RESUMEN
OBJECTIVES: To present suggestions on planning for development of emergency medicine (EM) and out-of-hospital care in countries that are in an early phase of this process, and to provide basic background information for planners not already familiar with EM. METHODS: The techniques and programs used by the authors and others in assisting in EM development in other countries to date are described. CONCLUSIONS: Some aspects of EM system development have applicability to most countries, but other aspects must be decided by planners based on country-specific factors. Because of the very recent initiation of many EM system development efforts in other countries, to the authors' knowledge there have not yet been extensive evaluative reports of the efficacy of these efforts. Further studies are needed on the relative effectiveness and cost-benefit of different EM development efforts.
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Atención Ambulatoria/organización & administración , Servicios Médicos de Urgencia/organización & administración , Medicina de Emergencia , Salud Global , Planificación en Salud/métodos , Técnicos Medios en Salud/educación , Humanos , Desarrollo de Programa/métodosRESUMEN
This article presents information on considerations involved in setting up and conducting fellowship training programs in emergency medicine (EM) for physicians from other countries. General goals for these programs are to assist in providing physicians from other countries with the knowledge and skills needed to further develop EM in their home countries. The authors report their opinions, based on their cumulative extensive experiences, on the necessary and optional structural elements to consider for international EM fellowship programs. Because of U.S. medical licensing restrictions, much of the proposed programs' content would be "observational" rather than involving direct "hands-on" clinical EM training. Due to the very recent initiation of these programs in the United States, there has not yet been reported any scientific evaluation of their structure or efficacy. International EM fellowship programs involving mainly observational EM experience can serve as one method to assist in EM development in other countries. Future studies should assess the impact and efficacy of these programs.
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Curriculum , Medicina de Emergencia/educación , Becas , HumanosRESUMEN
Medical resources routinely used for intravenous hydration and resuscitation of critically ill patients may be limited in remote regions of the world. When faced with these shortages, physicians have had to improvise with the available resources, or simply do without. We report the successful use of coconut water as a short-term intravenous hydration fluid for a Solomon Island patient, a laboratory analysis of the local coconuts, and a review of previously documented intravenous coconut use.
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Cocos/uso terapéutico , Deshidratación/terapia , Infusiones Intravenosas/métodos , Fitoterapia , Cocos/química , Deshidratación/etiología , Países en Desarrollo , Humanos , Concentración de Iones de Hidrógeno , Masculino , Área sin Atención Médica , Melanesia , Persona de Mediana Edad , Concentración Osmolar , Accidente Cerebrovascular/complicacionesRESUMEN
Many developing countries are experiencing a greater need for prehospital systems because of urbanization and changing population demographics, leading to greater death rates from trauma and cardiac illnesses. While emergency medical services (EMS) systems may take a variety of forms, they usually contain some system components similar to those found in the United States. In evaluating EMS abroad, it may be useful to compare the developing system type to one of five models of EMS delivery: hospital-based, municipal, private, volunteer, and complex. Using community-based services and available health providers can enable a developing system to function within a primary health network without overtaxing scarce resources. Developing such an approach can lead to creative and effective solutions for prehospital care in developing countries.
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Países en Desarrollo , Servicios Médicos de Urgencia/organización & administración , Modelos Organizacionales , Estudios de Evaluación como Asunto , Humanos , Evaluación de Necesidades , UrbanizaciónRESUMEN
Interest in international emergency medicine (EM) has grown steadily over the last ten years. This growth has been fueled by increased demand for emergency services abroad and the proliferation of emergency physicians (EPs) working in international relief and development. As a response, several academic EM programs have developed international EM fellowships for the purpose of providing formal training to EPs interested in international health. Although there have been preliminary articles describing fellowship curricula, to the authors' knowledge no recommendations have been proposed by national consensus that suggest emphasis or required components of a fellowship program. Therefore, a group of EPs interested in fellowship training convened for the purpose of developing goals and objectives for a postgraduate training program in international EM. To that end, this article proposes guidelines for a fellowship training program for international EM.
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Medicina de Emergencia/educación , Becas/organización & administración , Objetivos Organizacionales , Curriculum , Servicios Médicos de Urgencia , Humanos , Cooperación Internacional , Guías de Práctica Clínica como Asunto , Desarrollo de ProgramaRESUMEN
The objective of this article is to identify and describe Chinese emergency medical services (EMS) components. Chinese EMS system development began in the 1980s with "importing" of EMS principles from other systems. China is now attempting to unify these principles. Chinese EMS systems are absent in most rural areas. Urban ambulance dispatch or "rescue" centers provide both transport and inpatient care. Ambulances are staffed with either a physician or a driver. There is not extensive overlap between hospital emergency physicians and ambulance physicians and no out-of-hospital providers at the paramedic or emergency medical technician level exist. Access to EMS is accomplished by dialing 1-2-0. Emergency calls go directly to the rescue center and a physician is dispatched. No on-line radio communication between hospitals and ambulances typically takes place. China has assimilated both traditional and unique EMS components and is undergoing development. It remains unclear whether a systematized EMS structure will emerge.
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Servicios Médicos de Urgencia , China , Servicios Médicos de Urgencia/historia , Servicios Médicos de Urgencia/organización & administración , Historia del Siglo XX , HumanosRESUMEN
BACKGROUND: Despite using different electrode positions, "conventional" external DC cardioversion in patients with atrial fibrillation is ineffective in 6%-50% of cases. An alternative when DC cardioversion is not successful is low energy internal cardioversion, which is performed at increased risk. We tested the hypothesis that optimization of electrode pad position under fluoroscopy to encompass as much atrial muscle as possible might improve the success rate of external cardioversion and thus minimize the need for internal cardioversion. METHODS: Fifteen (9 males, 6 females) patients (age: 54 +/- 15 years, weight: 124 +/- 35 kg) with chronic atrial fibrillation (> 8 weeks) who had undergone unsuccessful conventional external cardioversion entered the study. Repeat conventional external cardioversion with electrodes in standard (right anterior and left posterior) positions was followed by "optimized" external cardioversion by positioning electrodes under fluoroscopy (using metallic markers). In case of failure, internal cardioversion was performed. RESULTS: All 15 patients had undergone unsuccessful conventional external cardioversion with 360-J shocks. Eight patients (group A) reverted to sinus rhythm with one or two 360-J shocks using fluoroscopy-guided pad placement (53%). Six of the remaining 7 (86%) patients (group B) had successful internal cardioversion with biphasic shocks (12 +/- 3 J). The body weight and body mass index were statistically lower in group A vs group B (106 +/- 27 vs 145 +/- 33 kg, p = 0.03 and 35 +/- 8 vs 45 +/- 8 kg/m2, P = 0.48, respectively). There was no statistically significant in age, height, body surface area, duration of atrial fibrillation, amiodarone therapy, ejection fraction, or underlying heart disease. CONCLUSION: Unsuccessful external DC cardioversion, in some patients, is in part due to suboptimal conventional positioning of electrode pads that can be improved under fluoroscopic guidance by achieving the best possible vector encompassing the right and left atria. The optimized external cardioversion technique may minimize the need for internal cardioversion, which remains an effective approach when external cardioversion fails.
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Fibrilación Atrial/terapia , Desfibriladores Implantables , Cardioversión Eléctrica/métodos , Atrios Cardíacos/diagnóstico por imagen , Adolescente , Adulto , Anciano , Amiodarona/uso terapéutico , Antiarrítmicos/uso terapéutico , Fibrilación Atrial/diagnóstico por imagen , Fibrilación Atrial/fisiopatología , Cateterismo Cardíaco/métodos , Femenino , Fluoroscopía , Estudios de Seguimiento , Atrios Cardíacos/fisiopatología , Frecuencia Cardíaca , Humanos , Masculino , Persona de Mediana Edad , Factores de Riesgo , Volumen Sistólico , Resultado del TratamientoRESUMEN
Emergency medicine is growing rapidly as a specialty and is beginning to be recognized as an essential component of medicine in China. Traditional Chinese medicine and modern technology exist together. A description of the US authors' experience as consultants at a new emergency department and in establishing an emergency medicine residency program in Hangzhou, China is provided. A total of 7 months were spent in the observation, identification, and development of a basic framework of emergency care at a new hospital. The practice of emergency medicine in China was researched by direct observation at several Chinese cities and by literature review. China is taking the parts of the Western system it can use and implementing its own methods in the overall practice of emergency medicine.
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Servicios Médicos de Urgencia/organización & administración , Medicina de Emergencia/educación , Cooperación Internacional , China , Servicio de Urgencia en Hospital/organización & administración , Humanos , Intercambio Educacional Internacional , Triaje , Estados UnidosRESUMEN
OBJECTIVE: To evaluate the safety profile of ketamine when used to facilitate surgical procedures in the less controlled setting of developing world, rural hospitals. METHODS: A survey addressing clinical experience with ketamine in the developing world was administered to a convenience sample of missionary physicians. Descriptive statistics are reported. RESULTS: Of the 172 surveyed physicians, 122 (71%) responded; 55 reported experience with ketamine. These physicians estimated a total of 12,844 administrations. The format of one procedural physician and a second trained anesthesiologist/anesthetist was unavailable in the practice of 59% of the responding physicians, and 34% routinely performed procedures while simultaneously supervising ketamine administration and monitoring its clinical effect. Pulse oximetry was used "often" or "always" by only 10% of the physicians. Cardiac monitoring and intermittent vital signs were used in only 19% and 45%, respectively. One unexplained pediatric death occurred during an unmonitored, unobserved ward recovery. An adult suffered cardiac arrest after a failed intubation attempt. Seventeen other complications possibly related to ketamine were apnea (n = 10), laryngospasm (n = 6), and aspiration (n = 1), all of which were transient and without sequelae. Physicians believed that recovery hallucinations and agitation were frequent in adults and unusual in children. CONCLUSIONS: Death and other serious complications were rare in this survey reporting > 12,000 estimated ketamine administrations in the developing world. Although the limitations of survey data are recognized, the margin of safety with ketamine appears to be high, even when administered by non-anesthesiologists in settings lacking basic mechanical monitoring. These findings have important implications for the use of ketamine outside the controlled operating room environment in developed countries.
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Anestesia General , Anestésicos Disociativos/efectos adversos , Países en Desarrollo , Ketamina/efectos adversos , Salud Rural , Adulto , Sistemas de Registro de Reacción Adversa a Medicamentos , Hospitales Rurales , Humanos , Misioneros , Monitoreo Intraoperatorio , Misiones Religiosas , Factores de RiesgoRESUMEN
Emergency physicians (EPs) are increasingly participating in international medicine in regions that are chronically medically underserved. In August 1994, a ten-member emergency medicine team from the Loma Linda University School of Medicine staffed a 70-bed bush hospital in the primitive highlands of Papua New Guinea, providing both outpatient and inpatient medical care. Typhoid fever, malaria, polio, and numerous other infectious diseases were encountered. Rampant local tribal warfare resulted in regular penetrating injuries from arrows, spears, and machetes. The expedition was judged highly successful, in that 1) substantial medical service was provided to tribespeople accustomed to minimal care, 2) education was provided to local health care providers, and 3) team participants became adept at managing medical conditions uncommon in industrialized societies, and gained valuable ethical and utilitarian perspectives regarding health care delivery in underserved areas. In this article the objectives, organization, and experiences of the team members are described. This information may encourage other EPs to participate in medical expeditions to the developing world, and to provide general principles to assist in their organization and implementation.
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Países en Desarrollo , Medicina de Emergencia/tendencias , Expediciones/tendencias , Misiones Médicas/tendencias , Adulto , California , Niño , Curriculum/tendencias , Medicina de Emergencia/educación , Predicción , Humanos , Internado y Residencia , Área sin Atención Médica , Medicina Tradicional , Papúa Nueva Guinea , Grupo de Atención al Paciente/tendenciasRESUMEN
OBJECTIVE: It is frequently taught that lumbar puncture is a mandatory procedure in many or all children who have fever and a seizure, because the convulsion may represent the sole manifestation of bacterial meningitis. We attempted to determine the incidence of this occult manifestation of meningitis. DESIGN: Retrospective case series. SETTING AND PATIENTS: 503 consecutive cases of meningitis in children aged 2 months to 15 years seen at two referral hospitals during a 20-year period. MAIN OUTCOME MEASURES: Signs and symptoms of meningitis in patients having associated seizures. RESULTS: Meningitis was associated with seizures in 115 cases (23%), and 105 of these children were either obtunded or comatose at their first visit with a physician after the seizure. The remaining 10 had relatively normal levels of consciousness and either were believed to have viral meningitis (2) or possessed straightforward indications for lumbar puncture: nuchal rigidity (6), prolonged focal seizure (1), or multiple seizures and a petechial rash (1). No cases of occult bacterial meningitis were found. CONCLUSION: In our review of 503 consecutive children with meningitis, none were noted to have bacterial meningitis manifesting solely as a simple seizure. We suspect that this previously described entity is either extremely rare or nonexistent. Commonly taught decision rules requiring lumbar puncture in children with fever and a seizure appear to be unnecessarily restrictive.
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Meningitis Bacterianas/complicaciones , Convulsiones/etiología , Adolescente , Niño , Preescolar , Coma/epidemiología , Coma/etiología , Femenino , Humanos , Lactante , Masculino , Meningitis Bacterianas/epidemiología , Estudios Retrospectivos , Convulsiones/epidemiología , Punción Espinal , Factores de TiempoRESUMEN
The off-service rotation in Neurosurgery is included in some programs training emergency medicine residents. It may also be offered as an elective. The experience on this rotation can lack opportunity and educational content if structured guidance is not available. We have addressed this problem by developing a written curricula containing subject content listing, objectives, and references for the Neurosurgery off-service rotation for emergency medicine residents. This is the 23rd in a series of objectives for off-service rotations for emergency medicine residents.
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Curriculum , Medicina de Emergencia/educación , Internado y Residencia , Neurocirugia/educación , HumanosRESUMEN
Blue crabs clear foreign proteins from the circulation to the gills in a manner that can be explained by postulating the participation of a finite number of naturally occurring quasi-specific receptors. The rate of this clearance reaction is not increased by previous exposure to the foreign protein although recovery to the normal rate of clearance after high level blockade is quite rapid. The cleared foreign proteins are degraded in the gills in a relatively nonspecific fashion suggestive of a clear distinction between the clearance and degradation reactions. The results of perfusion experiments indicate that neither circulating hemocytes nor specific humoral factors are responsible for the foreign protein clearance reaction in blue crabs. Thus it is concluded that fixed cells, most likely in the gills, are responsible for this means of dealing with nonself proteins in blue crabs and possibly other crustaceae .