Frontiers in Emergency Medicine (E-Journal)
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Experiences of emergency medical services personnel about barriers and facilitators in prehospital childbirth missions in Iran: a qualitative study
Get PDFObjective: In Iran, the majority of emergency medical services (EMS) personnel are male; hence, one of their distinct and crucial missions is the prehospital childbirth mission, which might be significantly challenging for both personnel and patients. To obtain in-depth and authentic data, the present study was conducted to elucidate the barriers and facilitators of prehospital childbirth missions based on the experiences of EMS personnel. Methods: A qualitative study employing conventional content analysis was conducted in 2023. Participants were selected through purposive sampling from EMS personnel willing to participate in the study and who have experiences with missions leading to childbirth. Data saturation was reached through in-depth semi-structured interviews with 14 participants. Data accuracy and credibility were confirmed using the Lincoln & Guba criteria. Results: The results included two main themes including barriers and facilitators. Barriers were categorized into "gender-related barriers" and "personnel barriers." While "appropriate communication" and "efforts to preserve privacy" were the primary facilitator themes. Conclusion: The findings revealed that EMS personnel face considerable barriers in the process of these missions. Therefore, for optimal performance quality in this prominent mission, it is recommended that clinical and educational policymakers consider actively recruiting female personnel, focusing on enhancing communication and practical skills and securing the patient's privacy. These approaches can result in childbirth missions with lower stress levels for patients, families, and personnel who provide the service
Trauma fellowship for emergency physicians: a necessity or demand?
Get PDFDue to the concerning rate of motor vehicle collisions and consequent significant morbidity and mortality in Iran, higher-quality trauma care than currently available is needed. These alarming statistics argue for establishing trauma-specific diagnostic and treatment protocols and presence of a dedicated trauma team.It has been well documented that the presence of a trauma team has led to significant improvement in trauma care. The trauma team leadership is a “model of practice” of specifically trained team leaders in the emergency department (ED). The timely presence, interpersonal communication, and leadership capabilities of trauma team leaders (TTLs) improve team performance, time to diagnostic imaging, and faster transfer to hemorrhage control.
In this regard, the largest retrospective study which assessed TTL implementation, included 20,193 patients with injury severity score (ISS) ≥12 from 3 Canadian Level-1 trauma centers from 2003 to 2017. They concluded that TTL implementation did not lead to admission delays from the ED. In addition, several studies addressed the efficacy and performance of different disciplines as TTLs. In a study performed by Taylor et al. on 12,961 major trauma adults presenting to trauma bays during trauma activations, data was recruited from provincial trauma registries at six level 1 trauma centers across Canada over 10 years. They assessed risk-adjusted in-hospital mortality for trauma patients receiving initial care from surgeons versus non-surgeon TTLs and concluded comparable outcomes among varying specialties. Although this study was underpowered to assess the outcome in the sickest and most unstable patients.In this context, a systematic review and meta-analysis of observational studies reported similar results assessing survival, missed injuries, and length of stay. They suggested the fact that resuscitation in the trauma bay can be effectively and timely performed by TTLs other than surgeons.Various specialist registrars who have completed local trauma team leader (TTL) development programs played the team leadership role including surgeons, emergency department (ED) consultants, intensivists, and anesthesiologists according to previous studies in North America and Europe.Thus, trauma fellowship for emergency physicians has been known for years in developed countries and graduated trainees improve the level of care for non-accidental and accidental injuries including mass casualty incidents. Today, despite the overwhelming situation of injured patients in EDs in Iran, only general surgeons have the chance to be trained in this fellowship, while most of them are involved in the operating rooms and cannot play role as the first line physicians to visit critically ill trauma patients. Therefore, there is no specialized and determined trained service in the EDs to take care of this major group of patients all over the country whereas the worldwide trend now is toward trauma care optimization.Since time is key in trauma management, there is an increasing necessity to change policies to decrease the present high mortality rate and to improve multidisciplinary care, specifically designed with the critical role of trauma team leaders in the EDs.On the other hand, the development of emergency medicine (EM) fellowships and subspecialties will shed light on the desire for continuing education among this specialty graduates in Iran. The safety of workplace, appropriate payments, and support for physicians’ rights by authorities and insurances are also determinants and necessities that result of and lead to the successful implementation of emergency medicine fellowships and its success in Iran
Navigating perils at the US-Mexico border: an illustrated exploration of trauma among southern border migrants
Get PDFThe number of migrants seeking refuge and asylum in the United States continues to increase yearly, exacerbated by the recent Coronavirus disease 2019 (COVID-19) pandemic. The total number of U.S border patrol encounters has now exceeded 2.7 million in 2022, which is a more than 5-fold increase from 2017. Current published literature suggests that most border-related injuries are related to boarder-wall crossing, fleeing, and motor vehicle collisions (MVCs). Our institution is near a large portion of the border, and we treat a high number of migrants who sustain injuries while attempting to cross the border. In addition to categorizing these injuries by organ-based system, we classify these injuries as relating to desert crossing, border wall crossing, fleeing (which includes MVCs), and traveling on trains. In this pictorial essay, we present imaging and clinical findings of traumatic and non-traumatic injuries related to border crossing event
Does a given abbreviated injury scale value in different body regions contribute to the same risks of in-hospital mortality and ICU admission in trauma patients?
Get PDFObjective: We aimed to investigate the hypothesis that identical abbreviated injury scale (AIS) scores may lead to varying risks of in-hospital mortality and admission to the intensive care unit (ICU) depending on the specific body region affected. Methods: This study focused on hospitalized trauma patients with moderate to serious injuries (AIS=2, 3). The final sample was stratified based on the injured body regions. To determine the impact of these injuries on mortality and ICU admission, we conducted binary logistic regression after adjusting for confounding factors. Results: Overall, 16,040 trauma patients with moderate injury (AIS=2) and 1,338 trauma patients with serious injury (AIS=3) were included in this study. When comparing outcome of trauma patients in different body region, there was no significant difference in the odds of two main outcomes in various injury sites, except for extremities (P values>0.05). When the AIS=2 patients were controlled for confounding factors, the adjusted odds of mortality were significantly higher for head, face, and neck injuries, as well as spine/back, thoracic, and abdominal injuries, compared to extremity injuries (adjusted odds ratio (aOR)s=9.81,8.78, 8.11, and 3.96, respectively; P-values<0.05). Among those with AIS=3, the odds of mortality were significantly greater for abdominal (aOR=7.05, P-value=0.009) and head, face, and neck injuries (aOR=2.73, P-value=0.001) than for extremity injuries. Conclusion: Injuries with the same AIS (=2, 3) value almost indistinguishably confer the same mortality risk and ICU admission, except for extremities. The unique AIS value assigned to various body sites almost consistently indicate the same likelihood of negative outcome
Intravascular volume status in patients with moderate to severe COVID-19: a case series
Get PDFCoronavirus disease 2019 (COVID-19) is a transmissible disease instigated by the coronavirus (SARS-CoV-2) which has been identify for few years. Patients with COVID-19 may present with hypovolemia due to vomiting, anorexia, or diarrhea. However, treatment guidelines recommend a “conservative” fluid administration strategy with dynamic measuring parameters to assess fluid response. Since physical examination has a limited ability to predict volume status, other non-invasive methods such as point-of-care ultrasound (POCUS) have been extensively used for this purpose in other diseases. In this case series, we describe intravascular volume status in patients with moderate to severe COVID-19 as measured by inferior vena cava (IVC) calibre and distensibility
A rare case of emphysematous cystitis
Get PDFEmphysematous cystitis is a rare complication that can occur as a result of a lower urinary tract infection. Diabetic patients are at a heigh risk of developing emphysematous cystitis due to their susceptibility to urinary infections caused by gas-producing bacteria. The recommended diagnostic test for this condition is a computed tomography (CT) scan, which is effective in identifying gas buildup in the bladder wall and lumen. The prognosis of this condition depends on how quickly it is treated. In this report, we describe a woman with diabetes mellitus type-2 presented with emphysematous cystitis. Fortunately, she was treated with a combination of antibiotics, insulin therapy, and bladder drainage
case of faecopneumothorax resulting from a delayed diagnosis of traumatic diaphragmatic injury
Get PDFDiaphragmatic hernia is a rare condition that can result from blunt or penetrating trauma. It is often asymptomatic for years, making diagnosis challenging. In fact, up to 66% of diaphragmatic ruptures can go unnoticed at the time of trauma. Delayed diagnosis can lead to complications, including faecopneumothorax. We report the case of a 15-year-old Iranian female who had a history of a motor vehicle accident 1 year prior to being referred to our center. She presented with tension faecopneumothorax, which occurred due to the incarceration and strangulation of the large bowel in the thoracic cavity. the patient was urgently transferred to the operating room for exploratory surgery. In patients presenting with symptoms of pulmonary or intestinal obstruction and a history of thoracoabdominal injury, the clinician should consider diaphragmatic hernia as a potential diagnosis. Prompt recognition of this condition is crucial as complications can significantly increase morbidity and mortality rates
Diagnostic test performance of Amsterdam wrist rules in diagnosing wrist fracture in adults with wrist trauma
Get PDFObjective: Wrist trauma is a common chief complaint in emergency departments and radiography is used to make the diagnosis. Excessive usage of radiographs would utilize resources, exert risk of radiation exposure, and overcrowding. Amsterdam wrist rules (AWR) have been proposed as a tool for clinical decision-making regarding the need for wrist fracture diagnosis. This study assessed the diagnostic test performance of this rule in wrist trauma for wrist fracture. Methods: All patients over 18 years old with the chief complaint of acute wrist trauma were included. They were excluded if Glascow coma scale (GCS) was below 15, needed emergency surgery without an X-ray, and had a history of wrist fracture in the past 3 months. Anteroposterior and lateral radiographs were obtained and the AWR predictors were assessed before going to the radiology unit. The presence of a fracture of the distal radius was confirmed by treating emergency physician or radiologist. Results: 205 participants were recruited in this study, of which 6 patients (2.9%) were excluded due to missing data. The median age was 40 (IQR: 30-50) and 74 (37.2%) patients were female. There were 66 (33.2%) patients with a wrist fracture, which distal radius accounted for most of them. The AWR had sensitivity and specificity of 0.71 (95% CI: 0.49,0.87) and 1 (95% CI: 0.92,1), respectively. Although the negative likelihood ratio of AWR was 0.29 (95% CI: 0.16,0.54), the positive likelihood ratio was infinite. The positive predicted value was 1 (95% CI: 0.80,1), whereas the negative predictive value was 0.86 (95% CI: 0.74,0.94). Conclusion: The AWR showed great specificity and positive predictive. It had fair sensitivity, negative predictive value, and negative likelihood ratio for diagnosis of wrist fracture in patients with wrist trauma
Associated factors with intensive care unit (ICU) admission and mortality among road traffic accident victims in southern Iran: results from a trauma registry
Get PDFObjective: Road traffic crashes are a significant health problem worldwide, causing injury, disability, and death. This study aims to identify associated factors with intensive care unit (ICU) admission and mortality among road traffic accident victims using data from a trauma registry. Methods: This descriptive study examined 368 road traffic accident patients in the national trauma registry system fromMarch 2021 toMarch 2023. Following the objectives of the study, a checklist was created that included information on age, gender, marital status, level of education, injury severity score (ISS), Glasgow coma scale (GCS), and abbreviated injury scale (AIS). The factors associated with ICU admission and mortality among road traffic accident victims were found significant according to univariate andmultivariable logistic regression analyses results. Results: 87.8% of the 368 patients included in this study were men, with a mean age of 33.54±18.95 years. Ten patients (2.71%) of total died, and 46 (12.5%) needed to be admitted to the ICU. In-hospital mortality and gender were not significantly associated (P=0.081). However, univariate logistic regression revealed several factors significantly associated with in-hospital mortality, including GCS<8 (OR: 60.05, 95% CI: 11.67,309), ISS>16 (OR: 11.39, 95% CI: 2.67,48.55), ICU admission (OR: 5,01, 95% CI: 1.36,18.50), underwent surgery (OR: 0.055, 95% CI: 0.014,0.223), respiratory rate (OR: 0.726, 95% CI: 0.630,0.836), O2 saturation (OR: 0.906, 95% CI: 00.852,0.963), systolic blood pressure (OR: 0.910, 95% CI:0.865,0.957) and temperature (OR: 0.932, 95% CI: 00.891,0.975). Furthermore, the odds of ICU admission was found to be increased with an ISS>16 (OR: 2072.12, 95% CI: 17.29,50644.09), being a pedestrian (OR: 366.53, 95% CI: 31.44,389.85), GCS<8 on admission (OR: 87.64, 95% CI: 29.04,264.43), smoking (OR: 11.92, 95% CI: 1.45,97.64), drug usage before the accident (OR: 11.47, 95% CI: 7.09,18.56), being amotorcyclist (OR: 5.72, 95% CI: 1.06,29.22), age (OR: 1.19, 95% CI: 1.05,1.34) and the time duration between the event and admission (OR: 1.01, 95% CI: 1.003,1.02). Conclusion: This study underscores the critical role of timely and effective medical interventions, including surgical procedures, in improving the outcomes of road accident victims. It also highlights the need for targeted preventivemeasures and interventions for high-risk groups pedestrians and motorcyclists. Hospital Mortalit
Comparison of neutrophil/lymphocyte ratio, platelet/lymphocyte ratio , and red blood cell distribution width during the attack phase of familial Mediterranean fever with the silent phase of the disease in patients referred to the emergency department
Get PDFObjective: As patients with acute-phase familial Mediterranean fever (FMF) require prompt diagnosis for optimal management, we are conducting a study to compare inflammatory markers during the attack and silent phases in individuals referred to the emergency department. Methods: This case-control study involved 184 FMF patients under 16 years old, with data collected at Bo Ali Hospital's emergency department in Ardabil city throughout 2022. Patients in the attack phase were assessed by emergency medicine specialists, while those in the silent phase were recruited from the rheumatology clinic. Hematological parameters were obtained from venous blood samples, neutrophil-to-lymphocyte ratio (NLR), platelet-to-lymphocyte ratio (PLR) and red blood cell distribution width (RDW) were calculated. Statistical analyses included 1-Sample Kolmogorov-Smirnov, ANOVA, Tukey's-b post hoc, Independent Samples T-test, Kruskal-Wallis, and Pearson Chi-squared tests. Results: In the attack group, the NLR correlated with increased leukocytes (r=0.652, P<0.001) and RDW (r=0.310, P=0.003). The non-attack group showed a correlation between the NLR and higher leukocytes (r=0.384, P<0.001) and ESR (r=0.214, P=0.04). Additionally, the attack group exhibited a correlation between the PLR and higher leukocytes (r=0.711, P=0.009), and ESR (r=0.285, P=0.014) while no correlation was found in the non-attack group. Conclusion: Our study revealed that RDW levels were significantly higher in FMF patients, indicating clinical inflammation. During FMF attacks, NLR and PLR ratios were notably elevated, making them key markers for systemic inflammation in these patients