bluuebunny/crossref_metadata_2025 huggingface dataset:
Providing mental health services in a multi-cultural emergency setting: Challenges and opportunities
Authors: Zaraa Adel
Published: May 2017

Developing cultural competency in mental health provision became an imperative skill in the age of globalization. This involves the enhanced knowledge and attitudes of care givers (NKI). We will review the geodemographic, religious, linguistic, and family structure in the Middle East so we can understand some of the special approaches needed to achieve our goal. We evaluate the common pitfalls and caveats of our own practices starting with our formal western curriculum, the types of therapeutic approaches that we have gathered and learned, our biases and prejudices and all our educational, cultural, and life experience baggage. Also, we will go over the difficulty of applying diagnostic criteria applicable in the west to Middle Eastern pathologies, where albeit they carry the same name, the presentations are very different. A literature review of many documented experiences and research into the same issue was conducted, and we are including the most relevant findings and solutions to approach these practices. Many earnest efforts have been invested in building educational edifices and branches of international colleges in the Middle East that produce highly-educated and skillful professionals, yet the problem is the same for the curriculum that was given, as it was still a western plan tailored to a different society and culture.

Conclusion: Although it is a slow process, we have been able to identify some of the differences and as we go, we are applying the appropriate changes (Ex. Validated diagnostic scales, modified interviewing questions and better understanding the cultural idioms of complaints).
Validation of the pre-hospital Qatar Early Warning Score (QEWS) to determine transport priority
Authors: Campbell Craig , Al Shaikh Loua , Saifeldeen Khalid , Bowen James , Pap Robin , Alinier Guillaume , Meyer John , Naidoo Vernon
Published: May 2017

Background: Ambulance Paramedics are dispatched to all calls while Critical Care Paramedic (CCP) units only attend potentially “life threatening” cases (Priority 1). Ambulance Paramedics (AP) triaged patients based on clinical judgment and experience creating a risk of Priority 1 under or over-triage. QEWS was designed to supplement priority decision-making process based on physiological values used as a trigger to identify patients with a potential risk of deterioration. The objective of this study was to undertake a comparison of the QEWS score calculated from retrospective vital signs data to that of the priority decision-making by ambulance crews.

Methods: In our retrospective study, data entered into the Ambulance Service clinical database over a nine-month period before QEWS implementation was analysed for comparison of the priority decision made by the crew for each patient versus the calculated QEWS value based on the first set of six relevant vital signs (Heart rate, Respiratory rate, Systolic blood pressure, Temperature, Oxygen saturation, AVPU). Only cases with patients over 18 years old were included.

Results: Of 34,908 retrieved cases, 27,915 (79.97%) had sufficient data to retrospectively determine QEWS. The mean age was 38.62 (+15.84) years and 21,453 (76.85%) were male patients. Priority decision-making correlated in 25,850 cases (92.6%), with 286 (1.11%) Priority 1 and 25,564 (98.89%) Priority 2 patients. In 1,662 cases (5.95%), QEWS retrospectively triaged patients higher and in 1.44%, QEWS triaged patients lower.

Conclusions: Physiological variables are an established predictor of risk regarding a patient's condition. Hospital-based early warning scores have been validated and implemented successfully. Only one published pre-hospital scoring system has been validated for triage. Under-triage appears to be a common problem in medical patients. QEWS potentially could address this under-triage issue and appears to be a valid scoring system to implement for prioritising patients to routine or urgent transport, or CCP intervention.
Perception of emergency nurses on electronic health record (Cerner) in acute-care setting
Authors: Macatangay Gloria Culla , Caritativo Ma. Teresita , Mestarihi Hashem , Dela Paz Grethel , Torkzi Ahmed
Published: May 2017

Background: The introduction of electronic health record (Cerner) in Qatar's public health system aimed to bridge the disparities in documenting patient's official health record. It is essential to recognize nurses' viewpoint in using this technology. As it embarks on the two emergency walk-in-clinics, we attempted to identify its impact to ER nurses in terms of coordination of care, documentation skills and staff productivity.

Methods: The study is conducted in 2 Walk-in Clinics under Hamad General Hospital- Emergency Department, namely Al Gharaffa and Al Shahaniya. Questionnaires were given to a convenience sample of emergency nurses, asking about new opportunities EHRs created in work outcomes in the 2 walk-in-clinics. A 3-point Likert-type scale was used for the survey. Results were dichotomized (respondents indicated that they agree, neutral or disagree) for analysis.

Results: More than half of the respondents (68.4%) worked in HMC for more than 10 years. Nurses believed that the use of electronic health records enable them to streamline the patient flow in the walk-in-clinics (92% reported better coordination of care). Most nurses agreed that their productivity increased after using EHR increased after using EHR. Likewise, most of the nurses (96%), expressed that accessibility to patient's health record and that their documentation skills improved.

Conclusion: The introduction of electronic health record (Cerner) has a positive impact to emergency nurses. It is possible that after a year of use, the perception to EHR use will change. As such, this study may assist in determining if the system is meeting the expectation of emergency nurses in Qatar.
Do physicians who manage head injuries also diagnose and treat benign paroxysmal positional vertigo (BPPV) in patients with head injuries?
Authors: Khalid Muhammad Masood , Bashir Khalid , Zayed Sameh , Farook Saleem
Published: May 2017

Background: Benign paroxysmal positional vertigo (BPPV) is a common medical condition. According to recent literature, it is prevalent in about 28% of the head injury patients. BPPV can be easily diagnosed in the Emergency Department (ED) by a simple bedside Dix-Hallpike test, in which patients experience vertigo and nystagmus as observed by the physician. It can be treated effectively in the ED by the Epley maneuver. In 2014, over 3,000 patients presented the ED at Hamad General Hospital with a head injury. Hospital guidelines often do not explicitly include BPPV symptoms as a possible complication of head injury. This may result in the physician being unable to manage BPPV, leading to longer sufferings for the patients.

Objectives: The purpose of this study was to evaluate current practice amongst physicians in a tertiary care hospital when managing BPPV in head injury patients.

Methods: Physicians working in Emergency Medicine, neurosurgery, trauma, and orthopaedics were asked to complete a paper based question survey.

Results: A total of 91 physicians completed the survey. 95.5% (n = 85) specified that they manage head injuries in their clinical practice. Only 29.6% (n = 27) indicated that they routinely investigate the possibility of BPPV in head injury patients. 73.6% (n = 67) stated lack of knowledge of BPPV and training in management to be the main reasons for not exploring BPPV. 91.1% (n = 83) stated willingness to receive further training in the management of BPPV.

Conclusion: In this study, physicians, when dealing with head injuries, were found not routinely diagnosing and managing BPPV. Lack of knowledge and training about this condition has been stated as the most common reasons for not exploring possibility of BPPV in head injury patients. The study confirms the need for training of physicians in managing this important condition early to prevent further disability in patients.
Organophosphorus toxicity awareness among Emergency Department healthcare providers in Tertiary Care Hospital, Qatar
Authors: Awad Waleed , Abbasy Mohamed E. , Ebrahim Ahmed Hai , Gaffer Rana , Khan Saad Salahuddin
Published: May 2017

Background: Organophosphorus poisoning is a global public health problem. Annually, approximately 200,000–300,000 individuals die worldwide from Organophosphorus poisoning with the majority of deaths occurring in developing countries. In many countries in the Middle East, legislation is inflexible and unable to cope with new challenges. Often standards are not consistent with international and national needs. Hamad General Hospital (HGH) is the main tertiary care hospital in Qatar with its Emergency Department (ED) sees in access of 1500 patients in a 24 hour period. Anecdotally, there is a wide variation in practice of Organophosphorus toxicity management at HGH ED. The aim of this study is to check the knowledge and practice of the healthcare workers involved in managing such cases regarding decontamination, use of PPE and management.

Methods: This is a cross sectional survey using a pre developed questionnaire collected from a representative sample of 280 physicians of different grades and nurses in HGH ED.

Results: Till date collected data from 156 nurses and 66 emergency physicians showed failure of recognition of correct indication of atropine use in 47% of nurses (73 out of 156) and in (15%) of physicians (10 out of 66). Wearing appropriate respiratory and skin protective equipment while attending to patients with suspected Organophosphorus poisoning was up to the desired standard in 54% of nurses (85 out of 156) and 97 % of physicians (64 out of 66). The more years of experience the more safety awareness.

Conclusion: Junior staff knowledge about anti dote indications and diagnosis is the best. However the seniors are more aware about protective measures. We recommend the introduction of standardized Evidence based clinical algorithm and developing of educational sessions aiming to increase awareness about organophosphorus toxicity management. A secondary audit is necessary following the above intervention to measure the awareness improvement.
Diabetic muscle infarction with pelvic vein thrombosis - An uncommon presentation to the Emergency Department
Authors: Varadarajulu Suresh , Pathan Sameer
Published: May 2017

Background: DMI itself is a benign condition unless complicated by compartment syndrome or superadded infection. However, coexistence of extensive DVT may have serious complications such as pulmonary embolism. We report 2 cases of DMI with iliac vein thrombosis presented to our ED.

Case presentation: Case 1 A 40-year-old lady with diabetes, presented with a swollen and painful left leg for a day. A bedside Doppler ultrasound confirmed the presence of weak pulsation in the dorsalis pedis and posterior tibial arteries. Orthopedic and vascular teams were consulted as the patient continued to have pain despite repeat IV analgesia, raising the possibility of compartment syndrome. The vascular surgeons requested a CT angiogram to exclude extension to the pelvic vessels. The CT angiogram report revealed delayed filling below the knee compared to the right side. Following admission to the medical ward, MRV examination was performed. The MRI findings were suggestive of DMI. Case 2 A 58-year-old man presented with a swollen and painful left lower limb for 12 hours. Compartment syndrome was excluded by measuring bedside compartment pressure. The ultrasound examination was suboptimal due to extensive swelling in the muscles of the thigh. CT angiogram reported thrombosis of the iliac veins with grossly edematous left thigh muscles. The MRV was reported as diffuse enlargement of the lower limb muscles associated with edema in the fascia and subcutaneous tissue and was compatible with the muscle infarction. The muscle swelling and bullae resolved slowly and the patient was discharged after three weeks with an optimum INR.

Discussion: Diabetic muscle infarction may be associated with pelvic vein thrombosis. Possible differential diagnoses may include venous thrombosis of lower limbs, myositis, pyomyositis, muscle hematoma, neoplasm, necrotizing fasciitis, and osteomyelitis. Contrast magnetic resonance imaging (MRV) is ideal for making the diagnosis.
Dieting – a very risky business? Simultaneous determination of anti-diabetic and weight-loss agents in herbal and dietary supplements
Authors: Azimi Salman
Published: May 2017

The presence of undeclared pharmaceuticals, including drugs that have been withdrawn from the market, in anti-diabetic and weight-loss herbal and dietary supplements can pose a serious health risk to consumers; they also undermine confidence in legitimate products. To protect consumers from potentially harmful products that are marketed as dietary supplements, the Drug QC Laboratory, Qatar is involved in the testing of herbal and dietary products. Traditionally this testing has required a combination of several analytical methods which presents a substantial investment of time and resources. To improve laboratory efficiency a single UPLC-MS/MS method was developed for the supplement screening followed by a confirmatory method based on multiple reaction monitoring (MRM) analysis. Screening analysis comprised LC/MS with automated searching against an in-house generated MS spectral library. Confirmation and quantification was performed by MRM analysis. The developed method was applied to 654 supplements submitted to our laboratory in 2014-15. Analysis revealed that 42 herbal anti-diabetic and weight lost products were tainted with undeclared registered or banned drugs, namely sibutramine (n = 30), phenolphthalein (n = 21), glibenclamide (n = 4), metformin (n = 4), phenformin (n = 2), pioglitazone (n = 1), fluoxetine (n = 2), orlistat (n = 1), methylephedrine (n = 1) and methamphetamine (n = 2). Five hot beverages tea and coffee were found to contain a combination of sibutramine and phenolphthalein.
A comprehensive UPLC-MS(/MS) based approach for screening and confirmation of illegally added erectile dysfunction (ED) drugs in natural health products
Authors: Azimi Salman
Published: May 2017

The adulteration of herbal/dietary supplements with erectile dysfunction (ED) drugs and their analogues is reported worldwide and is an increasing problem. The sale of so-called 100%, ’all-natural’ products has become a highly profitable business for online pharmacies, however these products can pose a serious threat to consumers owing to the undisclosed presence of approved/prescription drugs or the unknown safety and toxicity profile of unapproved ED drugs. The Drug QC Laboratory, Qatar, has been involved in the testing of adulterated and counterfeit products for a number of years. A simple and rapid UPLC-MS/MS procedure for the analysis of 42 synthetic ED compounds in herbal supplements is presented. A spectral library for the compounds and their analogues was generated from reference standards for automated routine analysis. Full scan MS analysis was performed simultaneously in both positive and in high energy negative ESI modes; In addition a MS/MS method was developed for confirmation and quantification of compounds. The method was applied to 87 suspected dietary products which were received to our laboratory. Twenty three were found to be adulterated: 11 with sildenafil, four with thiodimethylsildenafil/thiosildenafil, two with dapoxetine and five contained a combination of verdenafil, tadalafil, aminotadalafil, hydroxthiohomo sildenafil. One sample contained unknown analogue named as propoxyphenyl thiohomosildenafil. Developed method is a novel screening method that is suitable for both the detection of known and unknown ED drugs and their analogues. This is the first description of a single analytical method with this capability.
A case of brain abscess in a child following trivial head injury
Authors: Mathai Anup , Joseph Prakash , Parath Arif Nelliyulla
Published: May 2017

Introduction: Brain abscess is caused by inflammation and collection of infected material, coming from local or remote infectious sources, within the brain tissue. The infection may also be introduced via a breach in the skull following head trauma or surgical procedures. Brain abscess may also be associated with congenital heart disease in the young children. Here we would like to describe a case of brain abscess secondary to seemingly trivial head injury.

Case presentation: A 12 years old boy presented with left forehead and periorbital swelling for one week with fever, vomiting and headache. Parents added the history of confusion. No history of seizures or LOC was recorded. There was history of minor scalp trauma to the forehead 10 days prior. Examination reveals a febrile child with GCS of 13. Rest of systemic examination was unremarkable. Local examination showed warm tender fluctuant swelling. CT examination was ordered and it revealed, frontal subgaleal collection involving the frontal sinus and extending into intracranial portion. He was admitted for decompressive craniotomy and evacuation of intracranial empyema. The patient's condition improved gradually and was discharged with full recovery after 15 days post-admission.

Discussion: Minor scalp trauma serving route of intracranial infection is a rare complication documented in the literature. Detailed history is important as patient or family may not remember it.
A study to assess the compliance rate with pain assessment and reassessment by nurses in ED, HGH - A quality improvement initiative
Authors: Mazara Leila , Zareei Maryam Abdullah , Gharib Ahmed , Aljazzazi Hani Shahir
Published: May 2017

Background: One of the most common reasons why patients visit the Emergency Department is with the complaints of pain. The compliance rate of pain assessment and reassessment by the nurses in ED is far from expectation. This results in delayed disposition, increased re admission and poor patient satisfaction. As pain is exclusively a subjective experience, accurate documentation of patient pain assessment is critical in the management of pain.

Methods: The study was conducted in the Emergency Department of Hamad General Hospital. The prospective data was collected for a period of two months (January to February 2015) using a direct observation technique by the ED nurses and verified by the study observer for the accuracy of the data. Sample was collected from various sections of ED (Male triage area, Female triage area and short stay units). Both male and female patients were included in the sample.

Results: Male area The use of pain scale improved from 63% to 83%. Non-compliance to reassessment after intervention decreased from 58% to 32% which shows improvement 74% of the observation was not following the international timing of the reassessment after intervention then decreased to 73% Female area The use of pain scale improved from 80% to 90% Non-compliance to reassessment after intervention decreased from 93% to 4% which shows improvement 80% of the observation was not following the international timing of the reassessment after intervention then decreased to 32%.

Conclusions: An accurate assessment and reassessment of pain is critical in the management of pain. Meticulous teaching and following the hospital standard is important to achieve 100% compliance with pain assessment.
Effectiveness of double lumen CVC with extra port in preventing multiple CVC insertions in critically ill patients
Authors: Abdelrahim Magid
Published: May 2017

Critically ill shock patients presenting to the Emergency Department (ED) in Hamad General Hospital (HGH), Doha Qatar often needs central line when fluid resuscitation fails to improve their blood pressure (BP). Triple lumen central lines are used when vasopressor or inotropic support becomes necessary. In some of these patients, a double lumen dialysis line is later inserted (often in the femoral vein), when it becomes clearer that the patient will need urgent dialysis for worsening renal function or acid-base physiology. Another clinical scenario we often encounter is when patient admitted to the ED for emergency dialysis session. Some of these patients have borderline to low BP that become obvious during the dialysis, eventually needing some vasopressor support to enable the dialysis session to be continued. More than 2 years ago we introduced the use of dialysis line with extra port (Trilyse Expert by Vygon) in the Intensive Care Unit and now its use has spread to front line ED resuscitation room. Indications for Trilyse Expert insertion are: 1. Patients who needed vasopressor or inotropic support who may need dialysis, 2. Patients who needed dialysis with borderline to low BP who may need vasopressor support during dialysis, 3. Patients who needed both dialysis and vasopressor/inotropic support on presentation to ED. In this retrospective cohort we looked into the effectiveness of Trilyse Expert inserted in our ED resuscitation room in preventing the need of a second central line insertion. We also reviewed all relevant complications related to the device and its insertion. We also conducted a systematic literature review in the use of dialysis line with extra port in critically ill patients to support our findings. Results is shown in charts and tables. Concluding better outcome when using double lumen CVC with extra port.
Ebola epidemic 2014 preparedness and response in compliance with International Health Regulation (2005) Requirements, Sudan 2015
Authors: Mohamad Dina Abdulhammed , Khogali Hayat Khogali , Abdelgadir Deena Mohamad
Published: May 2017

Background: Ebola viral disease (EVD) outbreak 2014 in West Africa declared as Public Health Emergency of International Concern (PHEIC) according to IHR (2005), Sudanas member state committed to plan and respond to PHEIC. Sudan was in a great risk to be affected by EVD due to the previous history of EVD outbreaks in 1976, 2004 and 1979, long open borders with Limited resource and poor infrastructure, presence of united nation mission in Darfur (UNAMID) coming from all over Africa.

Objective: To assess preparedness and response of Sudan to EVD 2015 within the context of IHR 2005.

Methods: This descriptive cross-sectional assessment was conducted using; WHO checklist to evaluate Ebola preparedness in different sectors, reviewing Ebola committee's reports, and IHR focal points reports.

Results: According to the IHR Domains analysis; existing of coordination mechanism at all level and active participation of National Focal Point (NFP) was (92%) Surveillance core capacity (53%), surveillance system was sensitized and capacity-building for surveillance officers were achieved. However Event and community based surveillance were still lacking behind Response and preparedness core capacity (40%); national response plan in place, command center was identified; border states were classified as high risk states accordingly, rehabilitation of isolation centers were priority, although the Protocols, guidelines and case managements were available. Majority of IHR requirements for ground crossing (POEs) were not fulfilled, although the preparedness at Khartoum International Airport scored (60%) Risk communication core capacity (42%); Distribution of fact sheets, awareness raising sessions of different group conducted. Risk communication plan should be implemented.

Conclusion: Risk of importation of EVD cases is moderate. Strong political commitment exists, urgent coordination mechanize with neighboring countries needs to be activated. Appropriate training for staff in case management and IPC is needed. Sudan need to Enhance and implement Event base and community based surveillance.
Description of heat stroke outbreak and its associated pre-existing medical conditions in Northern State, Sudan 2015
Authors: Ali Youisf Abdallah , Alhussien Samah Ali , Mohamed Mohtadi Mohamoud , Alzain Mazza Abasher , Bashab Hind Mohammed , Mohammednour Salim Abdelrahman
Published: May 2017

Background: Heat stroke contributes considerably to cause morbidity and mortality during hot season. The main factors associated with severity and mortality of disease unclear. In Sudan heat stroke occurred mainly in Red Sea State during previous years. The purpose of this study is to assess association between heat stroke and pre-existing medical conditions in Northern State of Sudan.

Study: Descriptive analysis of Heat Stroke outbreak at Northern State of Sudan.

Methods: Analysis of secondary data of diseases surveillance system was used. The pattern of the outbreak was described and other risk factors were studied to assess their associated with Heat stroke in Northern State of Sudan 2015.

Results: Northern State was reported 44 probable cases of Heat stroke with case fatality (CFR) 72.3% (32 deaths), among them 64% were males and 36% were female. Halfa locality was reported 82% of cases due to decreased of humidity. The majority of the cases (81.8%) were represented in age groups more than 45 years. Majority of reported deaths had chronic illness and significant statistical association with their age group. All deaths were complained from high grade fever, hypotension (65.5%) and unconsciousness (46.9%) while the alive cases were complained from high grade fever and hypotension. Seventy eight percent of deaths occurred in the age group more than 45 years.

Conclusion: Northern State experienced a climatic change during last two year and heat waves became more augmented lead to heat related illness in the area. Elderly, chronic medical condition and humidity were found to be the main risk factors associated with deaths.
A security survey of Emergency Department Hamad General Hospital
Authors: Malik Waseem Ahmad , Shujaa Asaad Suliman , Younis Moataz Abdelmonem , Bhat Imran Nazir , Christoffel Wepener Jacob Gert , Adly Mohammed Hay , Kallangat Mohammed Kabeer , Qureshi Raheel Sharfeen , Aguilar Errol , Sharma Yogdutt , Pathan Sameer
Published: May 2017

A security Survey of Emergency Department Hamad General Hospital Background The problem of Emergency Department (ED) violence is a worldwide issue, and a systematic approach to mitigating the threat to our colleagues and patients is fundamental to the advancement of Emergency Medicine (EM). One of the important step to this is to assess and improve knowledge of the staff on workplace violence and how to react to it. Aim of this survey was to assess staff knowledge about measures against workplace violence.

Methods: We conducted a survey between, July 2015 to August 2015, in Hamad General Hospital Emergency Department (HGH-ED). Doctors and non-doctors health professionals working in the HGH-ED were asked to fill a paper survey. Data was collected and analyzed anonymously. The categorical outcomes are presented in proportions and continuous outcomes as mean with SD.

Results: A total of 180 staffs were approached to fill this survey. 61.1% was the response rate. Of 110 who completed the survey, 68 (61.8%) were doctors working as ED physicians, and 42 (38.2%) were nurses and clerks. The male proportion was 62.27%. Median age category was 30-39 years with work experience less than five years. Only 24 out of 110 responders (21.8%) were aware about HMC policy dealing with workplace violence. 56 (50.9%) of the staff members were not sure about how to deal with if the incidence happen involving them or their colleague. Non-doctor staff was found to have higher percentage of feeling unsafe at work.

Conclusion: We found poor knowledge about workplace violence policy and how to deal with it in the ED staff. Dedicated efforts are needed to make the staff aware and prepare for such situations.
The Syrian civil war: Impact of on-going violence on Syrian children's social, educational and health status
Authors: Elsaeidy Abdallah Mohamed Elsafti , Van Berlaer Gerlant , Al Safadi Mohammad , Pathan Sameer A. , Redrawn Atef
Published: May 2017

Background: The Syrian civil war since 2011 is one of the most complex humanitarian emergencies in history. This protracted disaster has but negative aspects, especially on living, educational and health care infrastructure and services. The goal of this study is to document the impact of four years of war on Syrian children's social, educational and health status.

Methods: A cross sectional observational study was conducted in May 2015. Health care workers, especially trained for this study, visited home by home in four Syrian governorates with a prospectively designed questionnaire.

Results: Of 1080 filled-out questionnaires, 1001 were complete and included in this study. Most lived in the Aleppo governorate (n = 413; 41%), 359 in Idleb (36%), 147 in Hamah (15%) and 82 in Lattakia (8%). Median age was 6 years (IQR; 0-15), most were male (n = 611; 61%). Almost 20% of all children were Internally Displaced Persons (n = 196), 45 lost their father (5%) and 41 (4%) had their father missing, 19 (2%) lost their mother and of 27 (3%) the mother was missing. Of all, 855 (86%) had access to safe drinking water, and 775 (77%) could access appropriate sanitation. About 16% (n = 156) had interrupted access to nutrition. Almost 27% suffered from diseases related to malnutrition. Access to specific health care providers was disturbed in 64% (n = 646), and only 28% had an updated vaccination status. Of all school-aged children, 450 (51%) had no access to education at the time of the study. Most children suffered from respiratory (29%), neurological (19%) or digestive (17%) diseases, 4% was victim of injury or violence, and 2% suffered from mental problems.

Discussion and conclusion: After four years of civil war in Syria, children have lost parents, live in substandard life quality circumstances, and are at risk for outbreaks because of worsening vaccination status and specific healthcare provider attention.
Descriptive case study - Interventions to minimize faculty dropouts in the Emergency Medicine Residency Training Program weekly teaching activity
Authors: Anjum Shahzad , Gafoor Biju , Farook Saleem , Khan Saad Salahuddin
Published: May 2017

Background: Managing a weekly educational planner for an Emergency Residency can be a challenging task in a busy Department due to shift pattern of work, personal development and travelling issues. In this descriptive case study, we outline the challenges and solutions to facilitate this issue. We found that key interventions in the form of timely reminders to instructors and faculty, prospectively consulting them before topic allocation and timely reminders and backup plans helps in reducing drop outs.

Methods: In this quality improvement study, we describe the interventions undertaken to ensure 100% compliance by the faculty for the teaching schedule for the year 2015/2016. We demonstrated a reduction of the dropouts to almost zero despite significant external pressures. An initial scoping exercise revealed that in the 2014/2015 planner 68.75% presentations were conducted as per the planner where as 31.25% did not follow the planner. The reasons included apologies to present (10%), eleventh hour swapping because presenter was not ready or available in country (12.5%) and non-availability of presenter (8.75%) due to leave issues. An initial questionnaire survey was undertaken to elucidate the factors that were disruptive to the faculty and the planner. We also sought ideas to help improve to the planner. A tentative planner for the year 2015/2016 was announced in advance to the whole department and all the staff and faculty were consulted to send the topics of their interest as well as their dates of annual leaves and holidays. Each presenter was called individually to confirm their availability and topics were assigned to them.

Results: We compared the first four month educational planer starting from July 2015 till October 2015 and found the compliance 100% with zero drop outs.

Conclusion: Proactive measures in making educational planner always help in maintaining compliance of the planner and reducing drop outs.
Is hyponatraemia a major or a trivial issue in endurance sports?
Authors: Rekik Raouf Nader
Published: May 2017

Exercise-associated hyponatraemia (EAH) is a potentially serious and occasionally fatal outcome in marathons and other long duration events. In the last 30 years, there have been more than 500 publications on hyponatraemia and exercise. Some studies, who point to the fatalities that have occurred, consider this as a major concern while others dismiss it as a rare and unimportant condition. This work critically assessed and summarized the main evidence on the prevalence and aetiology of the condition and on possible preventive measures. Hence, more than 400 relevant articles were identified by a search in PubMed and other secondary sources like NICE and 112 abstracts and 42 full text were reviewed. Level and strength of evidence supporting the conclusions were assessed by Strength of Recommendation Taxonomy (SORT). EAH is more frequently asymptomatic. If its frequency through finishers of an endurance event is estimated from 0 to 51%, the incidence of symptomatic EAH in marathon is estimated to less than 1% of all participants. Actual evidence correlates EAH incidence to 2 major etiologies: an overhydration by excessive fluid intake and a persistent secretion of arginine vasopressin. The prevention consists primarily of avoiding overdrinking. In this context, the key recommendation is to drink according to thirst to avoid dehydration and overhydration. To provide such prevention, besides educating athletes, education for the supporting event staff is recommended to avoid errors in fluid supplementation advices. Furthermore, the medical staff covering such events should be familiar with early recognition and diagnosis of EAH to avoid complications and improper real-time drink supplementation. In conclusion, EAH is a life threatening condition during endurance sport events. Besides a limited incidence, the increasing numbers of participants in events like marathons induce a higher rate of symptomatic EAH. It seems, according to actual evidence to be a serious concern in endurance sports.
Emergency Department overcrowding and increased length of stay: Identifying the causes in a secondary care general hospital
Authors: Elamir Hossam
Published: May 2017

Background: Emergency Department (ED) is amongst the most crucial departments in the hospital. It receives around 1000 patient/day. ED overcrowding (EDOC) and increased Length of Stay (LOS) are key global issues for more than 20 years, as they have serious repercussions. No measurements have been done to assess the situation nationally.

Methods: The paper used direct observation for seven days to collect patient flow data on ED patients at a secondary care hospital in Kuwait. It calculated wait times and services to identify the major causes of EDOC and increased LOS.

Results: A total number of 6383 patient visits were registered, 1750 of them were referred to the ED observation room. Among these, 210 patients stayed more than 6 hours as a total ED visit time. The aggregated time of the 210 patients was 1918.95 hours. Further analysis revealed that they spent 1078.98 hours as wasted waiting time. (Waiting for a vacant in-patient bed) constituted 52% of that time, (waiting for a consultation reply) constituted 13.3% and (waiting for a radiology request to be executed) constituted 13.29%.

Conclusions: Around one-third of the ED design capacity was utilized by 12% of the ED patients. The wasted waiting time represents 56.2% of the aggregated LOS, and access block to inpatient wards was the primary cause of increased LOS and EDOC. A national-wide measurement project should be considered to assess the exact problem volume, its impact and test solutions, which should eliminate the waits before trying to reduce the service time.
Comparison of communication tools for recalling doctors in the Emergency Department in Hamad Medical Corporation
Authors: Al Jazairi Abdulnasir Falah , Altintas Hakan , Fahem Muhammed , Ahmad Saeed , Kamel Hany
Published: May 2017

Background: The conventional landlines and bleeps that are commonly used in recalling physicians during major casualty incident (MCI) have shown multiple defects. Despite the remarkable advancement of handheld devices, social media and short text messaging (SMS), only a few studies on the comparison between the conventional communication and the social media have been found in the literature. This research compares (1) bleeps, (2) SMS and (3) WhatsApp as communication tools for recalling doctors. These tools were selected because they are commonly used in our region.

Method: We selected two periods for communications: social-friendly (09:00–19:00) and anti-social (23:00–06:00) periods. A total of 120 emergency physicians from Hamad General Hospital were contacted by the three communication tools in the two selected periods. We investigated the percentage of the responders and the time of response because this is the first step to the MCI response.

Results: Bleep had the fastest response (mean 7.6 minutes in the social-friendly period and 9 minutes in the anti-social period), but with a least response of 10.8% and 3.0% for the social-friendly and anti-social periods, respectively. WhatsApp had the majority of responses (45.0% in the social-friendly period and 47.5% in the anti-social period, respectively). However, its response time was long (146 and 141 minutes), respectively. Therefore, it is not suitable for recalling doctors during MCI. In contrast, SMS showed a bizarre response, with a mean response time of 43 and 154 minutes for the social-friendly and anti-social periods, respectively. This showed a marked increase in response from 30.8% for the social-friendly period to 44.2% for the anti-social period.

Conclusion: At present, there is not even one satisfactory and reliable communication tool for recalling physicians during MCI. Unsatisfactory response may be due to human factors that can be improved by training to achieve optimal compliance in both percentage and response time. This could in turn help achieve the ultimate response in MCI. More research is needed in this field to obtain the best and most accurate communication tool.
Two cases of high-pressure injection injury – The importance of early, accurate, assessment and referral
Authors: Khan Keebat Mirdad , Bashir Khalid
Published: May 2017

Background: The emergency department physicians rarely see high-pressure injection injuries (HPI) to the hand. These work-related injuries can have a devastating effect on hand function, particularly if not treated early. These injuries are usually caused by the introduction of chemicals into the wound. Chemicals under high-pressure cause local tissue damage, ischemia, and acute and chronic inflammation. The initial assessment may suggest a trivial injury to the inexperienced physician. HPI should be considered as a surgical emergency. Wound exploration, cleansing, and decompression usually preserve the optimal functions. The prognosis of these HPI depends upon the time of presentation, the type of the fluid injected, the pressure, volume, site of injection and appropriate management.

Aim: We aim to highlight the importance of early recognition of HPI by the emergency physician.

Case presentations: We present two cases of HPI. Both of them presented with a small puncture wound on their hands within 1–2 hours of the injury. The first patient was treated with analgesia and antibiotics and was discharged home. He returned again to the Emergency Department after 24 hours with increased pain, swelling, and discoloration of the fingers. He was referred for surgical exploration but required amputation of the index finger. The second patient was immediately referred to the hand surgeon for surgical exploration. He was able to make a good functional recovery within 3 months of the accident.

Conclusion: These cases highlight the importance of early identification and referral by emergency physicians to ensure appropriate multidisciplinary treatment to prevent long-term disability.
Evaluation of the use of MOODLE-based e-learning for faculty development in Emergency Medicine
Authors: Qotb Mohamed Abdelkader , Farook Saleem
Published: May 2017

Background: Today, e-learning is of strategic importance to teaching and learning in Emergency Medicine (EM). We adopted an interactive e-learning platform based on the open source software called MOODLEa using a blended learning strategy to assist the implementation of a dedicated faculty development program known as the EM consolidation program. This 12-month program was designed to meet the developmental needs of 20 EM specialists who qualified from different parts of the world. The program is delivered through an innovative blend of workplace and simulation-based assessments, educational portfolio and individualized training in selected clinical areas. The e-learning platform was used by the program participants to share learning resources, communicate, and coordinate various educational activities over the last 6 months.

Methods: We sought feedback from the participants through a MOODLE-based online questionnaire to evaluate their satisfaction, usage patterns and feedback of their e-learning experience.

Results: Out of 20 participants, 90% (n = 18) completed the questionnaire. Two-thirds declared proficiency in computer skills and were enthusiastic about the technology. Their prior experience was related to certified courses rather than interactive forum-based e-learning. About their current experience with MOODLE, 86.7% of participants found it easy to use without any major technical problems. Most of them preferred to access the platform once or twice a week, with 20% accessing on a daily basis. Of the participants, 75% of them accessed MOODLE through their smartphones and 12.5 % through tablet devices. All areas of the e-learning course were found to be useful. The forum-based discussion area was highly rated. The overall learning material was perceived as appropriate and well designed. Among the participants, 62.50% liked the current methodology of blended learning, and 31.25% wished to replace traditional method with e-learning. Also 93.75% of the respondents stated that e-learning was time saving.

Conclusion: Learners involved in this e-learning initiative were overall satisfied by the current implementation of MOODLE and with a third of users preferring e-learning to traditional learning. The use of smartphones and tablet devices was widespread in this small study and hence we recommend support for these devices in implementing similar e-learning initiatives.

Reference: [1] Cook DA, Yvonne S. Online learning for faculty development: A review of the literature. Med Teach. 2013;35(11):930–937.

a MOODLE – Modular Object Orientated Dynamic Learning Environment. http://moodle.org.
How can the practice and documentation of procedural sedation pre-assessment be improved in a high-volume tertiary care emergency department?
Authors: Bashir* Khalid , Alshinnawy Mohamed , Fawzy Mahmoud , Elmaasarawi Ahmad , Badawy Ehab , Abdeldayem Hossam
Published: May 2017

Background: Procedural sedation (PS) is commonly used in the Emergency Department (ED) to lessen pain, apprehension, and agony for patients during medical procedures. PS encompasses administering of sedative medications with or without the simultaneous delivery of analgesic agents. Safe and effective PS in the ED is a skill that is fundamental to practice of Emergency Medicine. Patients undergoing PS in ED should have a documented evidence of pre-sedation assessment, including prediction of difficulty in airway management, ASA physical status and fasting status.

Aim: The aim of this audit, as a part of a QIP, was to assess the current practice and documentation of PS pre-reassessment among the ED physicians.

Methods and settings: This was an electronic questionnaire survey sent to all ED physicians via their work e-mails. Sixty-seven emergency physicians took part in the survey; however, only 62 completed it. This is a high-volume ED in a large tertiary care hospital where up to 1,600 patients are seen daily and PS is practiced frequently.

Results: Sixty-two ED physicians completed the electronic survey. Only 33.33% (n = 21) stated that they document PS pre-assessment as a usual practice. Among the participants, 69.35% (n = 43) stated the lack of time as the commonest reason for not documenting the PS pre-assessment. And 79.03% (n = 49) admitted that availability of a PS pre-assessment form would improve practice and documentation.

Conclusion and recommendation: Only one-third of the physicians documented PS pre-assessment as a usual practice. The majority of the physicians indicated lack of time as the reason for not documenting the PS pre-assessment. There is a need for a simple assessment form with a checklist and regular training for all ED physicians in PS pre-assessment to practice safely and effectively.
Improving patients' flow in a busy emergency department by DPR (dedicated phlebotomy room) technique
Authors: Khalid Muhammad Masood , Ghafoor Biju , Eltayeb Yousif , Shukla Dharmesh , Shariff Mohamed Yousuf , Ali Amjad
Published: May 2017

Background: This study is a quality improvement project that aimed at improving patient flow in Male Urgent Area (MUA), one of the busiest areas in the largest emergency department in the state of Qatar.

Methods: The baseline process was designed by mapping and drawing a cause-and-effect diagram. Pre- and post-auditing was done after careful intervention of introducing a phlebotomy room in Male See and Treat area, the main feeder to MUA. The feeding areas to MUA and the daily flow of patients were studied in detail. Points of interest in the baseline process map were identified and targeted. Supporting data of about 398 patients helped in designing the process map and identifying the point of interest.

Results: Post-intervention analysis showed a remarkable improvement in time to phlebotomy in Hamad General Hospital Emergency Department. The proportion of patients moving to MUA and receiving phlebotomy increased from 48.6% to 84.1% in the first hour. Patients' hematological laboratory workup that helps MUA's physicians in decision making was readily available.

Conclusion: Patient flow and phlebotomy time can be significantly improved by introducing a dedicated phlebotomy room in a busy emergency department. It is concluded that identification and targeting of the main point of interest in baseline process mapping is crucial and of considerable importance in a quality improvement project.

Keywords: Emergency department, phlebotomy time, patient flow
Hamad Medical Corporation (HMC) ambulance service major incident response guide
Authors: Alshorman Sami Saleh , Almuhiarat Adel Misnad , Bruyn Philip , Khenissi Mohamad , Pullian Naven
Published: May 2017

Background: Qatar Hamad Medical Corporation Ambulance Service (HMCAS) major incident response guide is intended to address techniques in field operations that must be utilized in the event of a major incident. This guide standardizes operations during major incidents, regardless of what caused the incident, number of patients, severity of the injuries or the complexity of the incident.

Methods: This plan was tested and implemented across the ambulance service and Hamad International Airport (HIA) in collaboration with other agencies such as police, civil defense and HIA safety department through a full-day training program. Different training methods such as workshops, lectures and simulated exercises was conducted using different scenarios.

Results: This system was implemented for five real major incidents during 2014–2015 in Qatar. The average time for all units to be on scene was 20 minutes. The total units needed by this system were 33 units, approximately according to the predetermined attendance sheet (PDA). These units include all on-scene structure of command according to the HMCAS major incident response guide. The average time to transport the victims from the scene to the hospitals was 10 minutes or less. Three communication channels were established during the whole process.

Conclusion: The designed system is suitable for up to 100 patients in pre-hospital emergency care in case of a major incident. The system would need to be tested and evaluated regularly to ensure compliancy and understanding from all staff in HMCAS to ensure that they are ready at all times in the event of a major incident.