Corey B. Bills

Stories behind the symptoms: a qualitative analysis of the narratives of 9/11 rescue and recovery workers

A qualitative study of the experiences of rescue and recovery workers/volunteers at Ground Zero following the terrorist attacks of 9/11/01 is reported. Information was extracted from a semi-structured clinical evaluation of 416 responders who were the initial participants in a large scale medical and mental health screening and treatment program for 9/11 responders. Qualitative analysis revealed themes that spanned four categories— occupational roles, exposures, attitudes/experiences, and outcomes related to the experience of Ground Zero. Themes included details regarding Ground Zero roles, grotesque experiences such as smells, the sense of the surreal nature of responding, and a turning to rituals to cope after leaving Ground Zero. These findings personalize the symptom reports and diagnoses that have resulted from the 9/11 responders’ exposure to Ground Zero, yielding richer information than would otherwise be available for addressing the psychological dimensions of disasters. This work shows that large scale qualitative surveillance of trauma-exposed populations is both relevant and feasible.

The Academic Health Center in Complex Humanitarian Emergencies: Lessons Learned From the 2010 Haiti Earthquake

On January 12, 2010, a 7.0-magnitude earthquake struck Haiti. The event disrupted infrastructure and was marked by extreme morbidity and mortality. The global response to the disaster was rapid and immense, comprising multiple actors-including academic health centers (AHCs)-that provided assistance in the field and from home. The authors retrospectively examine the multidisciplinary approach that the University of Chicago Medicine (UCM) applied to postearthquake Haiti, which included the application of institutional structure and strategy, systematic deployment of teams tailored to evolving needs, and the actual response and recovery. The university mobilized significant human and material resources for deployment within 48 hours and sustained the effort for over four months. In partnership with international and local nongovernmental organizations as well as other AHCs, the UCM operated one of the largest and more efficient acute field hospitals in the country. The UCMs efforts in postearthquake Haiti provide insight into the role AHCs can play, including their strengths and limitations, in complex disasters. AHCs can provide necessary intellectual and material resources as well as technical expertise, but the cost and speed required for responding to an emergency, and ongoing domestic responsibilities, may limit the response of a large university and hospital system. The authors describe the strong institutional backing, the detailed predeployment planning and logistical support UCM provided, the engagement of faculty and staff who had previous experience in complex humanitarian emergencies, and the help of volunteers fluent in the local language which, together, made UCMs mission in postearthquake Haiti successful.

Characteristics and outcomes of women using emergency medical services for third-trimester pregnancy-related problems in India: a prospective observational study

Objectives Characterise the demographics, management and outcomes of obstetric patients transported by emergency medical services (EMS). Design Prospective observational study. Setting Five Indian states using a centralised EMS agency that transported 3.1 million pregnant women in 2014. Participants This study enrolled a convenience sample of 1684 women in third trimester of pregnancy calling with a ‘pregnancy-related’ problem for free-of-charge ambulance transport. Calls were deemed ‘pregnancy related’ if categorised by EMS dispatchers as ‘pregnancy’, ‘childbirth’, ‘miscarriage’ or ‘labour pains’. Interfacility transfers, patients absent on ambulance arrival and patients refusing care were excluded. Main outcome measures Emergency medical technician (EMT) interventions, method of delivery and death. Results The median age enrolled was 23 years (IQR 21–25). Women were primarily from rural or tribal areas (1550/1684 (92.0%)) and lower economic strata (1177/1684 (69.9%)). Time from initial call to hospital arrival was longer for rural/tribal compared with urban patients (66 min (IQR 51–84) vs 56 min (IQR 42–73), respectively, p<0.0001). EMTs assisted delivery in 44 women, delivering the placenta in 33/44 (75%), performing transabdominal uterine massage in 29/33 (87.9%) and administering oxytocin in none (0%). There were 1411 recorded deliveries. Most women delivered at a hospital (1212/1411 (85.9%)), however 126/1411 (8.9%) delivered at home following hospital discharge. Follow-up rates at 48 hours, 7 days and 42 days were 95.0%, 94.4% and 94.1%, respectively. Four women died, all within 48 hours. The caesarean section rate was 8.2% (116/1411). On multivariate regression analysis, women transported to private hospitals versus government primary health centres were less likely to deliver by caesarean section (OR 0.14 (0.05–0.43)) Conclusions Pregnant women from vulnerable Indian populations use free-of-charge EMS for impending delivery, making it integral to the healthcare system. Future research and health system planning should focus on strengthening and expanding EMS as a component of emergency obstetric and newborn care (EmONC).

Global Health and Graduate Medical Education: A Systematic Review of the Literature

BACKGROUND Global health (GH) interest is increasing in graduate medical education (GME). The popularity of the GH topic has created growth in the GME literature. OBJECTIVE The authors aim to provide a systematic review of published approaches to GH in GME. METHODS We searched PubMed using variable keywords to identify articles with abstracts published between January 1975 and January 2015 focusing on GME approaches to GH. Articles meeting inclusion criteria were evaluated for content by authors to ensure relevance. Methodological quality was assessed using the Medical Education Research Study Quality Instrument (MERSQI), which has demonstrated reliability and validity evidence. RESULTS Overall, 69 articles met initial inclusion criteria. Articles represented research and curricula from a number of specialties and a range of institutions. Many studies reported data from a single institution, lacked randomization and/or evidence of clinical benefit, and had poor reliability and validity evidence. The mean MERSQI score among 42 quantitative articles was 8.87 (2.79). CONCLUSIONS There is significant heterogeneity in GH curricula in GME, with no single strategy for teaching GH to graduate medical learners. The quality of literature is marginal, and the body of work overall does not facilitate assessment of educational or clinical benefit of GH experiences. Improved methods of curriculum evaluation and enhanced publication guidelines would have a positive impact on the quality of research in this area.

Comparison of online and classroom-based formats for teaching emergency medicine to medical students in Uganda

Severe global shortages in the health care workforce sector have made improving access to essential emergency care challenging. The paucity of trained specialists in low‐ and middle‐income countries translates to large swathes of the population receiving inadequate care. Efforts to expand emergency medicine (EM) education are similarly impeded by a lack of available and appropriate teaching faculty. The development of comprehensive, online medical education courses offers a potentially economical, scalable, and lasting solution for universities experiencing professional shortages.

Global Health Education as a Translational Science in Graduate Medical Education

The emergence of global health as a core component of medical education is a relatively recent phenomenon.1 Over the last 20 years, graduate medical education (GME) has documented the growth, curriculum development, and trainee benefits of global health electives (GHEs).2 Scholarship, predominantly focused on evidence-based benefits and clinical outcomes of GHEs at the community level, has not occurred at the same pace. Efforts to standardize and understand benefits of a GHE curriculum should occur in parallel with the need to monitor and evaluate the effects of GHEs on clinical and public health outcomes. Viewed within the framework of a translational science, GHEs have the potential to (re)focus attention on improved clinical health outcomes in low-resource settings. The process of understanding (global) medical education as a translational science involves: rigorous study on clinical skill and knowledge (T1), the translation of said knowledge into the delivery of better health care (T2), and the study of improved patient or public health outcomes (T3).3 Current global health education and scholarship are primarily focused on academic understanding at the T1 and T2 levels but is most lacking at the T3 level. Both high-quality clinical health studies from global health settings4 and studies linking educational activities and health outcomes in the United States5 do exist. There is far less literature linking GHEs and clinical outcomes. The presence of visiting health workers is assumed to yield health benefits to local populations, but little explicit data exist beyond small descriptive studies.6,7

Reducing early infant mortality in India: results of a prospective cohort of pregnant women using emergency medical services

Objectives To describe the demographic characteristics and clinical outcomes of neonates born within 7 days of public ambulance transport to hospitals across five states in India. Design Prospective observational study. Setting Five Indian states using a centralised emergency medical services (EMS) agency that transported 3.1 million pregnant women in 2014. Participants Over 6 weeks in 2014, this study followed a convenience sample of 1431 neonates born to women using a public-private ambulance service for a ‘pregnancy-related’ problem. Initial calls were deemed ‘pregnancy related’ if categorised by EMS dispatchers as ‘pregnancy’, ‘childbirth’, ‘miscarriage’ or ‘labour pains’. Interfacility transfers, patients absent on ambulance arrival, refusal of care and neonates born to women beyond 7 days of using the service were excluded. Main outcome measures: death at 2, 7 and 42 days after delivery. Results Among 1684 women, 1411 gave birth to 1431 newborns within 7 days of initial ambulance transport. Median maternal age at delivery was 23 years (IQR 21–25). Most mothers were from rural/tribal areas (92.5%) and lower social (79.9%) and economic status (69.9%). Follow-up rates at 2, 7 and 42 days were 99.8%, 99.3% and 94.1%, respectively. Cumulative mortality rates at 2, 7 and 42 days follow-up were 43, 53 and 62 per 1000 births, respectively. The perinatal mortality rate (PMR) was 53 per 1000. Preterm birth (OR 2.89, 95% CI 1.67 to 5.00), twin deliveries (OR 2.80, 95% CI 1.10 to 7.15) and caesarean section (OR 2.21, 95% CI 1.15 to 4.23) were the strongest predictors of mortality. Conclusions The perinatal mortality rate associated with this cohort of patients with high-acuity conditions of pregnancy was nearly two times the most recent rate for India as a whole (28 per 1000 births). EMS data have the potential to provide more robust estimates of PMR, reduce inequities in timely access to healthcare and increase facility-based care through service of marginalised populations.

Comparing Teaching Methods in Resource-Limited Countries

In Reply: As Dr. Al-Musawi states, hands-on clinical experience is an invaluable component of medical education. Our intention was not to suggest that online education can wholly replace hands-on learning, but rather should be seen as a viable method of augmenting and sustaining emergency care education worldwide. Our study conclusively demonstrated that classroom-based learning and online learning were equivalent in terms of knowledge acquisition by participating students. These results suggest that effective, online, core curriculum can serve as a scaffolding for an adjunct applied clinical curriculum, thus enabling countries with severely limited numbers of trained faculty to concentrate those human resources on leading hands-on workshops, simulation exercises, and emergency care drills, as well as engaging students in clinical bedside instruction. By designing a locally adaptable, online program, we can jumpstart knowledge acquisition, build partnerships, and enhance the pace of emergency care development in resource-limited settings.

Acute Care Referral Systems in Liberia: Transfer and Referral Capabilities in a Low-Income Country

Introduction Following two decades of armed conflict in Liberia, over 95% of health care facilities were partially or completely destroyed. Although the Liberian health system has undergone significant rehabilitation, one particular weakness is the lack of organized systems for referral and prehospital care. Acute care referral systems are a critical component of effective health care delivery and have led to improved quality of care and patient outcomes. Problem This study aimed to characterize the referral and transfer systems in the largest county of Liberia. METHODS A cross-sectional, health referral survey of a representative sample of health facilities in Montserrado County, Liberia was performed. A systematic random sample of all primary health care (PHC) clinics, fraction proportional to district population size, and all secondary and tertiary health facilities were included in the study sample. Collected data included baseline information about the health facility, patient flow, and qualitative and quantitative data regarding referral practices. RESULTS A total of 62 health facilities-41 PHC clinics, 11 health centers (HCs), and 10 referral hospitals (RHs)-were surveyed during the 6-week study period. In sum, three percent of patients were referred to a higher-level of care. Communication between health facilities was largely unsystematic, with lack of specific protocols (n=3; 5.0%) and standardized documentation (n=26; 44.0%) for referral. While most health facilities reported walking as the primary means by which patients presented to initial health facilities (n=50; 81.0%), private vehicles, including commercial taxis (n=37; 60.0%), were the primary transport mechanism for referral of patients between health facilities. CONCLUSION This study identified several weaknesses in acute care referral systems in Liberia, including lack of systematic care protocols for transfer, documentation, communication, and transport. However, several informal, well-functioning mechanisms for referral exist and could serve as the basis for a more robust system. Well-integrated acute care referral systems in low-income countries, like Liberia, may help to mitigate future public health crises by augmenting a countrys capacity for emergency preparedness. Kim J , Barreix M , Babcock C , Bills CB . Acute care referral systems in Liberia: transfer and referral capabilities in a low-income country. Prehosp Disaster Med. 2017;32(6):642-650.