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Table of Content

    15 September 2018, Volume 9 Issue 3
    Original Articles
    Pre-recorded instructional audio vs. dispatchers’ conversational assistance in telephone cardiopulmonary resuscitation: A randomized controlled simulation study
    Alexei Birkun, Maksim Glotov, Herman Franklin Ndjamen, Esther Alaiye, Temidara Adeleke, Sergey Samarin
    2018, 9(3):  165-171.  doi:10.5847/wjem.j.1920-8642.2018.03.001
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    BACKGROUND: To assess the effectiveness of the telephone chest-compression-only cardiopulmonary resuscitation (CPR) guided by a pre-recorded instructional audio when compared with dispatcher-assisted resuscitation.
    METHODS: It was a prospective, blind, randomised controlled study involving 109 medical students without previous CPR training. In a standardized mannequin scenario, after the step of dispatcher-assisted cardiac arrest recognition, the participants performed compression-only resuscitation guided over the telephone by either: (1) the pre-recorded instructional audio (n=57); or (2) verbal dispatcher assistance (n=52). The simulation video records were reviewed to assess the CPR performance using a 13-item checklist. The interval from call reception to the first compression, total number and rate of compressions, total number and duration of pauses after the first compression were also recorded.
    RESULTS: There were no significant differences between the recording-assisted and dispatcher-assisted groups based on the overall performance score (5.6±2.2 vs. 5.1±1.9, P>0.05) or individual criteria of the CPR performance checklist. The recording-assisted group demonstrated significantly shorter time interval from call receipt to the first compression (86.0±14.3 vs. 91.2±14.2 s, P<0.05), higher compression rate (94.9±26.4 vs. 89.1±32.8 min-1) and number of compressions provided (170.2±48.0 vs. 156.2±60.7).
    CONCLUSION: When provided by untrained persons in the simulated settings, the compression-only resuscitation guided by the pre-recorded instructional audio is no less efficient than dispatcher-assisted CPR. Future studies are warranted to further assess feasibility of using instructional audio aid as a potential alternative to dispatcher assistance.

    The effect of wilderness and medical training on injury and altitude preparedness among backcountry hikers in Rocky Mountain National Park
    Michael D.T. Yue, David W. Spivey, Daniel B. Gingold, Douglas G. Sward
    2018, 9(3):  172-177.  doi:10.5847/wjem.j.1920-8642.2018.03.002
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    BACKGROUND: The purpose of this study was to document the correlation between medical and wilderness training with levels of preparedness for acute mountain sickness (AMS), illness, and injury among backcountry hikers.
    METHODS: We conducted a cross-sectional, convenience survey in Rocky Mountain National Park in July and August 2015. The study group consisted of 380 hikers who completed a written survey that collected information about demographics, wilderness experience, altitude experience, hiking equipment, communications devices, and trip planning.
    RESULTS: Factors such as wilderness training (wilderness first aid [WFA], wilderness first responder [WFR], or wilderness emergency medical technician [WEMT]), wilderness experience, and altitude experience all affected hikers’ emergency preparedness. Respondents with medical training were more prepared to avoid or respond to AMS (62.3% vs. 34.3% [P<0.001]). They were also more prepared to avoid or manage injury/illness than hikers without medical training (37.7% vs. 20.7% [P=0.003]). Participants with wilderness training were more likely to be prepared to avoid or respond to AMS (52.3% vs. 36.8% [P=0.025]) but not significantly more likely to be prepared to manage illness/injury (31.8% vs. 22.0% [P<0.11]). Adjusting for experience, wilderness training, age, and gender, we found that medical training was associated with increased preparedness for AMS (OR 2.72; 95% CI 1.51-4.91) and injury/illness (OR 2.71; 95% CI 1.5-4.89).
    CONCLUSION: Medically trained hikers were more likely to be prepared to avoid or manage AMS, medical emergencies, and injuries than their non-medically trained counterparts. Wilderness training increased hikers’ preparedness for AMS but did not significantly alter preparedness for illness/injury.

    Prevalence and associated factors of stress, anxiety and depression among emergency medical officers in Malaysian hospitals
    Siti Nasrina Yahaya, Shaik Farid Abdull Wahab, Muhammad Saiful Bahribin Yusoff, Mohd Azhar Mohd Yasin, Mohammed Alwi Abdul Rahman
    2018, 9(3):  178-186.  doi:10.5847/wjem.j.1920-8642.2018.03.003
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    BACKGROUND: Demanding profession has been associated with poor psychological health due to multiple factors such as overworking hours and night shifts. This study is to determine prevalence and associated factors of depression, anxiety and stress among medical officers working at emergency department in Malaysian hospitals.
    METHODS: A cross-sectional study was conducted on 140 emergency department medical officers working at general hospitals from seven Malaysia regions. They were randomly selected and their depression, anxiety and stress level were measured by the 21-item Depression, Anxiety, Stress Scale.
    RESULTS: The highest prevalence was anxiety (28.6%) followed by depression (10.7%) and stress (7.9%). Depression, anxiety and stress between seven hospitals were not significantly different (P>0.05). Male medical officers significantly experienced more anxiety symptoms than female medical officers (P=0.0022), however depression and stress symptoms between male and female medical officers were not significantly different (P>0.05). Depression, anxiety and stress were not associated with age, working experience, ethnicity, marital status, number of shifts and type of system adopted in different hospitals (P>0.05).
    CONCLUSION: The prevalence of anxiety was high, whereas for depression and stress were considerably low. Gender was the only factor significantly associated with anxiety. Other factors were not associated with depression, anxiety and stress. Future research should aim to gain better understanding on unique factors that affect female and male medical officers’ anxiety level in emergency setting, thus guide authorities to chart strategic plans to remedy this condition.

    Emergency medicine residencies structure of trainees’ administrative experience: A cross-sectional survey
    Kelly Williamson, Jeremy Branzetti, Navneet Cheema, Amer Aldeen
    2018, 9(3):  187-190.  doi:10.5847/wjem.j.1920-8642.2018.03.004
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    BACKGROUND: While the Accreditation Council for Graduate Medical Education (ACGME) mandates that emergency medicine residencies provide an educational curriculum that includes administrative seminars and morbidity and mortality conference, there is significant variation as to how administrative topics are implemented into training programs. We seek to determine the prevalence of dedicated administrative rotations and details about the components of the curriculum.
    METHODS: In this descriptive study, a 12-question survey was distributed via the CORD listserv; each member program was asked questions concerning the presence of an administrative rotation and details about its components. These responses were then analyzed with simple descriptive statistics.
    RESULTS: A total of 114 of the 168 programs responded, leading to a 68% response rate. Of responders, 73% have a dedicated administrative rotation (95% CI 64.0 to 80.4). The content areas covered by the majority of programs with a dedicated program include performance improvement (n=68), patient safety (n=64), ED operations (n=58), patient satisfaction (n=54), billing and coding (n=47), and inter-professional collaboration (n=43). Experiential learning activities include review of patient safety reports (n=66) and addressing patient complaints (n=45). Most of the teaching on the rotation is either in-person (n=65) and/or self-directed reading assignments (n=48). The most commonly attended meetings during the rotation include performance improvement (n=60), ED operations (n=59), and ED faculty (n=44).
    CONCLUSION: This paper provides an overview of the most commonly covered resident administrative experiences that can be a guide as we work to develop an ideal administrative curriculum for EM residents.

    Assessment of toxicology knowledge in the fourth-year medical students: Three years of data
    Jennie Buchanan, Daniel Windels, Jeffrey Druck, Kennon Heard
    2018, 9(3):  191-194.  doi:10.5847/wjem.j.1920-8642.2018.03.005
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    BACKGROUND: Pharmacology and toxicology are core content knowledge for physicians. Medical students should demonstrate understanding of general pharmacology and basic treatment of poisoning. The objective of this study was to measure the knowledge of the 4th-year medical students (MS4) on these topics over 3 years.
    METHODS: A multiple-choice exam (15 questions) was administered to MS4 students in spring of 2010, 2011, and 2012. Questions were developed by medical toxicologists to evaluate basic knowledge in three areas: pharmacologic effects (PE), treatment of poisoning (TOP), and pharmacokinetics (PK). The students were grouped by intended specialties into pharmacologic intense (anesthesia, emergency medicine, internal medicine, pediatrics, and psychiatry), less pharmacologic intense specialties (dermatology, OB/GYN, ophthalmology, pathology, physical medicine and rehabilitation, radiology, and surgery) and by completion of a pharmacology or toxicology elective. Mean group scores were compared using ANOVA.
    RESULTS: Totally 332 of 401 (83%) students completed the survey. Mean scores were stable over the three years, higher for students completing a toxicology rotation and for students entering a pharmacologically intense specialty.
    CONCLUSION: The external validity is limited to a single medical school with incomplete participation and content was limited by the survey length. Consistent results over the three-year period and correlation of performance with completing a toxicology rotation and intent to enter a pharmacology intensive specialty suggest this survey may correlate with toxicology knowledge. Implementation of required core courses focused on toxicology may improve core content knowledge in fourth year medical students.

    Enoxaparin dosing errors in the emergency department
    Samantha P. Jellinek-Cohen, May Li, Gregg Husk
    2018, 9(3):  195-202.  doi:10.5847/wjem.j.1920-8642.2018.03.006
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    BACKGROUND: The study aimed to determine the frequency of enoxaparin dosing errors for patients who had a measured emergency department (ED) weight compared to those who did not have a measured ED weight, and to determine if demographic variables (e.g., weight, height, age, English-speaking, race) impact the likelihood of receiving an inappropriate dose.
    METHODS: This is a retrospective, electronic chart review of patients who received a dose of enoxaparin in the ED between January 1, 2008 and July 1, 2013. We identified all patients >18 years who received a dose of enoxaparin while in the ED, were admitted, and had at least one inpatient weight within the first four days of hospitalization. Patients were excluded if they received enoxaparin for prophylaxis or a dose of more than 1.25 mg/kg.
    RESULTS: A total of 1,944 patients were included. Patients were more likely to experience an error if they did not have a measured ED weight. Over-doses of >10 mg were more likely to occur in patients without a measured ED weight. Patients with no documented ED weight or with a staff-estimated ED weight were more likely to experience a dosing error than those with a patient-stated weight. Patients were more likely to experience an error if their first inpatient weight was more than 96 kg, they were more than 175-cm tall, or were English speaking.
    CONCLUSION: Dosing errors are more likely to occur when patients are not weighed in the ED. Modifications to current workflows to incorporate weighing those patients who receive weight-dosed medications may be warranted.

    Risk factors for ventilator-associated pneumonia in trauma patients: A descriptive analysis
    Suresh Kumar Arumugam, Insolvisagan Mudali, Gustav Strandvik, Ayman El-Menyar, Ammar Al-Hassani, Hassan Al-Thani
    2018, 9(3):  203-210.  doi:10.5847/wjem.j.1920-8642.2018.03.007
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    BACKGROUND: We sought to evaluate the risk factors for developing ventilator-associated pneumonia (VAP) and whether the location of intubation posed a risk in trauma patients.
    METHODS: Data were retrospectively reviewed for adult trauma patients requiring intubation for > 48 hours, admitted between 2010 and 2013. Patients’ demographics, clinical presentations and outcomes were compared according to intubation location (prehospital intubation [PHI] vs. trauma room [TRI]) and presence vs. absence of VAP. Multivariate regression analysis was performed to identify predictors of VAP.
    RESULTS: Of 471 intubated patients, 332 patients met the inclusion criteria (124 had PHI and 208 had TRI) with a mean age of 30.7±14.8 years. PHI group had lower GCS (P=0.001), respiratory rate (P=0.001), and higher frequency of head (P=0.02) and chest injuries (P=0.04). The rate of VAP in PHI group was comparable to the TRI group (P=0.60). Patients who developed VAP were 6 years older, had significantly lower GCS and higher ISS, head AIS, and higher rates of polytrauma. The overall mortality was 7.5%, and was not associated with intubation location or pneumonia rates. In the early-VAP group, gram-positive pathogens were more common, while gram-negative microorganisms were more frequently encountered in the late VAP group. Logistic regression analysis and modeling showed that the impact of the location of intubation in predicting the risk of VAP appeared only when chest injury was included in the models.
    CONCLUSION: In trauma, the risk of developing VAP is multifactorial. However, the location of intubation and presence of chest injury could play an important role.

    Preventable readmission to intensive care unit in critically ill cancer patients
    Hai-jun Wang, Yong Gao, Shi-ning Qu, Chu-lin Huang, Hao Zhang, Hao Wang, Quan-hui Yang, Xue-zhong Xing
    2018, 9(3):  211-215.  doi:10.5847/wjem.j.1920-8642.2018.03.008
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    BACKGROUND: Readmission to intensive care unit (ICU) after discharge to ward has been reported to be associated with increased hospital mortality and longer length of stay (LOS). The objective of this study was to investigate whether ICU readmission are preventable in critically ill cancer patients.
    METHODS: Data of patients who readmitted to intensive care unit (ICU) at National Cancer Center/Cancer Hospital of Chinese Academy of Medical Sciences (CAMS) and Peking Union Medical College (PUMC) between January 2013 and November 2016 were retrospectively collected and reviewed.
    RESULTS: A total of 39 patients were included in the final analysis, and the overall readmission rate between 2013 and 2016 was 1.32% (39/2,961). Of 39 patients, 32 (82.1%) patients were judged as unpreventable and 7 (17.9%) patients were preventable. There were no significant differences in duration of mechanical ventilation, ICU LOS, hospital LOS, ICU mortality and in-hospital mortality between patients who were unpreventable and preventable. For 24 early readmission patients, 7 (29.2%) patients were preventable and 17 (70.8%) patients were unpreventable. Patients who were late readmission were all unpreventable. There was a trend that patients who were preventable had longer 1-year survival compared with patients who were unpreventable (100% vs. 66.8%, log rank=1.668, P=0.196).
    CONCLUSION: Most readmission patients were unpreventable, and all preventable readmissions occurred in early period after discharge to ward. There were no significant differences in short term outcomes and 1-year survival in critically ill cancer patients whose readmissions were preventable or not.

    Feasibility study of minimally trained medical students using the Rural Obstetrical Ultrasound Triage Exam (ROUTE) in rural Panama
    Annasha Vyas, Katherine Moran, Joshua Livingston, Savannah Gonzales, Marlene Torres, Ali Duffens, Carina Mireles Romo, Genevieve Mazza, Briana Livingston, Shadi Lahham, John Christian Fox
    2018, 9(3):  216-222.  doi:10.5847/wjem.j.1920-8642.2018.03.009
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    BACKGROUND: Maternal and infant mortality rates reported in rural Panama are greater than those in urban regions. Bocas del Toro is a region of Panama inhabited by indigenous people at greater risk for pregnancy-related complications and deaths due to geographic isolation and limited access to health care. Portable ultrasound training programs have recently been implemented in low-resource settings to increase access to diagnostic imaging. The goal of this study is to determine the feasibility of teaching first-year medical students the Rural Obstetrical Ultrasound Triage Exam (ROUTE) to help identify pathology in pregnant women of the Bocas del Toro region of Panama.
    METHODS: Eight first-year medical students completed ROUTE training sessions. After training, the students were compared to professional sonographers to evaluate their accuracy in performing the ROUTE. Students then performed the ROUTE in mobile clinics within Bocas del Toro. They enrolled women pregnant in their 2nd or 3rd trimesters and measured biparietal diameter, head circumference, amniotic fluid index, fetal lie and placental position. Any abnormal measurement would be further analyzed by the lead physician for a potential hospital referral.
    RESULTS: A total of 60 women were enrolled in the study. Four women were detected as having a possible high-risk pregnancy and thus referred to a hospital for further evaluation.
    CONCLUSION: Based on our data, first-year medical students with additional training can use the ROUTE to identify complications in pregnancy using ultrasound in rural Panama. Additional studies are required to determine the optimal amount of training required for proficiency.

    Case Letters
    Radial artery pseudoaneurysm diagnosed by point-of-care ultrasound five days after transradial catheterization: A case report
    Stephen Alerhand, Donald Apakama, Adam Nevel, Bret P. Nelson
    2018, 9(3):  223-226.  doi:10.5847/wjem.j.1920-8642.2018.03.010
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    Obstructive shock secondary to fungal prosthetic aortic valve endocarditis
    Emilio Rodriguez-Ruiz, Diego Iglesias-Alvarez, Carlos Peña-Gil
    2018, 9(3):  227-228.  doi:10.5847/wjem.j.1920-8642.2018.03.011
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    Instructions for Authors
    Instructions for Authors
    2018, 9(3):  229-232. 
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