Heike Geduld

Validation of weight estimation by age and length based methods in the Western Cape, South Africa population

Objective To evaluate four paediatric weight estimation methods (APLS, Luscombe and Owens, Best Guess and Broselow tape) in order to determine which are accurate for weight estimation in South African children. Method From a database of 2832 children aged 1–10 years seen at Red Cross Hospital in Cape Town, measured weight was compared to estimated weights from all four methods. Results APLS formula and the Broselow Tape showed the best correlation with measured weight. Mean error was 3.3% for APLS (for 1–10-year olds) and 0.9% for Broselow tape (children <145 cm length and <35 kg). Both the Best Guess and Luscombe and Owens formulae tended to overestimate weight (15.4% and 12.4%, respectively). Conclusion The Broselow tape and APLS estimation methods are most accurate in estimating weight in the Western Cape paediatric population, even though they have a small tendency to underestimate weight. Clinicians need to bear in mind that none of the formulae are infallible and constant reassessment and clinical judgement should be used, as well as a measured weight as soon as possible in an emergency situation.

Taxi driver training in Madagascar: the first step in developing a functioning prehospital emergency care system

Background Prehospital care in developing countries is severely lacking. Few countries can afford the relatively expensive formalised Western model of a prehospital emergency medical system. The WHO has highlighted the development of layperson first responder programmes as the most basic step in the development of a functioning prehospital system. Aim To describe the first training programme of its kind, run in Mahajanga, Madagascar. The faculty was invited by Mahajanga Medical School. Methods and Results Local input was taken into account in developing the curriculum. 26 taxi drivers were invited to attend in cooperation with the local municipality. The faculty consisted of five instructors from the Division of Emergency Medicine and EMSSA, plus local doctors from University Hospital Mahajanga. The 1-day course included workshops on prehospital scene management, bleeding and broken bones, immobilisation and patient movement, and labour and delivery. The workshops made use of commonly available items only including packets, string and towels; French and Malagasy translators were available throughout. Conclusions Both faculty and candidates deemed the course a success and plans for formal evaluation of knowledge and skill retention are underway. Future plans are to continue the training using local instructors and in rural districts.

An analysis of the clinical practice of emergency medicine in public emergency departments in Kenya

Objectives To describe the case mix, interventions, procedures and management of patients in public emergency departments (ED) in Kenya. Methods An observational study over 24 h, of patients who presented to 15 public ED during the 3-month period from 1 October to 31 December 2010. The study was conducted across Kenya in two national referral hospitals, five secondary level hospitals and eight primary level hospitals. All patients presenting alive to the ED during the 24-h study period that were seen by a doctor or clinical officer were included in the study. A data collection form was completed by the primary investigator at the time of the initial ED consultation documenting patient demographics, presenting complaints, investigations ordered, procedures done, initial diagnosis and outcome of ED consultation. Results Data on 1887 patient presentations were described. Adults (≥13 years) accounted for the majority (70%) of patients. Two peak age groups, 0–9 and 20–29 years, accounted for 27% and 25% of patients, respectively. Respiratory and trauma presentations each accounted for 21% of presentations, with a wide spread of other presentations. Over half (58%) of the patients were investigated in the department. 385 patients received immediate treatment in the ED before discharge. Fewer than one in three patients admitted or transferred to specialist units received any therapy in the ED. Conclusions ED in Kenya provide care to an undifferentiated patient population yet most of the immediate therapy is provided only to patients with minor conditions who are subsequently discharged. Sicker patients have to await transfer to wards or specialist units to start receiving treatment.

Africa's First Emergency Medicine Training Program at the University of Cape Town⁄Stellenbosch University: History, Progress, and Lessons Learned

Africas first residency training program in emergency medicine (EM) was established at the University of Cape Town (UCT)/Stellenbosch University (SUN) in 2004. There have since been four classes for a total of 29 graduates from this program who are practicing, teaching, and leading EM. This article describes the structure of the program and discusses the history and major drivers behind its founding. We report major changes, cite ongoing challenges, and discuss lessons learned from the programs first 7 years that may help advise other nascent training programs in developing countries.

Door-to-needle time for administration of fibrinolytics in acute myocardial infarction in Cape Town

OBJECTIVES To determine the current door-to-needle time for the administration of fibrinolytics for acute myocardial infarction (AMI) in emergency centres (ECs) at three hospitals in Cape Town, and to compare it with the American Heart Association/American College of Cardiology (AHA/ACC) recommendation of 30 minutes as a marker of quality of care. METHODS A retrospective review of case notes from January 2008 to July 2010 of all patients receiving thrombolytics for AMI in the ECs of three Cape Town hospitals. The total door-to-needle time was calculated and patient demographics and presentation, physician qualification, clinical symptomology and reasons for delays in thromobolytic administration were analysed. RESULTS A total of 372 patients with acute ST elevation myocardial infarction (STEMI) were identified; 161 patients were eligible for the study. The median door-to-needle time achieved was 54 minutes (range 13 - 553 mins). A door-to-needle time of 30 minutes or less was achieved in 33 (20.5%) patients; 51.3% of the patients arrived by ambulance; 34% of patients had a pre-hospital 12-lead ECG; and 88.8% had typical symptoms of myocardial infarction. Medical officers administered thrombolytics to 44.7% of the patients. The predominant infarct location on ECG was inferior (55.9%). CONCLUSION A significant number of patients were not thrombolysed within 30 minutes of presentation. The lack of senior doctors, difficulty interpreting ECGs, atypical presentations and EC system delays prolonged the door-to-needle time in this study.

Perceptions of graduates from Africa's first emergency medicine training program at the University of Cape Town/Stellenbosch University

OBJECTIVE Africas first postgraduate training program in emergency medicine (EM) was established at the University of Cape Town/Stellenbosch University (UCT/SUN) in 2004. This study of the UCT/SUN EM program investigated the backgrounds, perceptions, and experiences of its graduates. METHODS This was a cross-sectional descriptive study. The study population was the 30 graduates from the first four classes in the UCT/SUN EM program (2007-2010). We employed a scripted interview with a combination of closed and open-ended questions. Data were analyzed using the thematic method of qualitative analysis. RESULTS Twenty-seven (90%) graduates were interviewed. Initial career goals were primarily (78%) to practice EM in a nonacademic clinical capacity. At the time of the interview, 52% held academic positions, 15% had nonacademic clinical positions, and 33% had temporary positions and were looking for other posts. The three most commonly cited strengths of their program were diversity of clinical rotations (85%), autonomy and procedural experience (63%), and importance of being pioneers within Africa (52%). The three most commonly cited weaknesses were lack of bedside teaching in the ED (96%), lack of career options after graduation (74%), and lack of preparation for academic careers (70%). CONCLUSIONS The lessons identified from structured interviews with graduates from Africas first EM training include the importance of strong clinical training, difficulty of ensuring bedside teaching in a new program, the necessity of ensuring postgraduation positions, and the need for academic training. These findings may be useful for other developing countries looking to start EM training programs.

Assessment of routine laboratory screening of adult psychiatric patients presenting to an emergency centre in Cape Town

Our study suggests that routine laboratory screening provides no additional information to that obtained from a thorough history and clinical examination in patients at high risk of having an underlying medical cause of presenting psychotic symptoms.

Attitudes of prehospital providers on transport decision-making in the management of patients with a suicide attempt refusing care: A survey based on the Mental Health Care Act of 2002

Background Given the frequency of suicidal patients making attempts prior to a completed suicide, emergency access to mental health care services could lead to significant reduction in morbidity and mortality for these patients. Aim To describe the attitudes of prehospital providers and describe transport decision-making around the management of patients with a suicide attempt. Setting Cape Town Metropole. Methods A cross-sectional, vignette-based survey was used to collect data related to training and knowledge of the Mental Health Care Act, prehospital transport decision-making and patient management. Results Patients with less dramatic suicidal history were more likely to be discharged on scene. Few respondents reported the use of formal suicide evaluation tools to aid their decision. Respondents displayed negative attitudes towards suicidal patients. Some respondents reported returning to find a suicidal patient dead, while others reported patient attempts at suicide when in their care. Eighty per cent of respondents had no training in the management of suicidal patients, while only 7.0% had specific training in the Mental Health Care Act. Conclusion A critical lack in the knowledge, training and implementation of the Mental Health Care Act exists amongst prehospital providers within the Western Cape. A further concern is the negative feelings towards suicidal patients and the lack of commitment to transporting patients to definitive care. It is essential to urgently develop training programmes to ensure that prehospital providers are better equipped to deal with suicidal patients.

Professional needs of young Emergency Medicine specialists in Africa: Results of a South Africa, Ethiopia, Tanzania, and Ghana survey

Introduction Emergency Medicine (EM) residency programmes are new to Africa and exist in only a handful of countries. There has been no follow up on faculty development needs nor training of these graduates since they completed their programmes. The African Federation for Emergency Medicine (AFEM) aims to explore the needs of recent EM graduates with respect to the need for resources, mentorship, and teaching in order to develop a focused African faculty development intervention. Methods As part of the AFEM annual survey, all those who have graduated since 2012 from a Sub-Saharan African EM residency programme were approached. These included Muhimbili University of Health and Allied Sciences (MUHAS) in Tanzania, Addis Ababa University (AAU) in Ethiopia, Komfo Anokye Teaching Hospital (KATH) in Ghana, the University of Cape Town (UCT) in South Africa, the University of Pretoria (UP) in South Africa, the University of Witswatersrand (Wits) in South Africa, and the University of KwaZulu-Natal (UKZN) in South Africa. Results The 47 respondents rated themselves as most confident medical experts in knowledge, procedural skills, and communication. Overall graduates felt least equipped as scholars and managers, and requested more educational materials. They reported that the best way for AFEM to support them is through emergency care advocacy and support for their advocacy activities and that their most critical development need is for leadership development, including providing training materials. Conclusion Recent graduates report that the best ways for AFEM to help new EM graduates is to continue advocacy programmes and the development of leadership and mentorship programmes. However, there is also a demand from these graduates for educational materials, especially online.