Global Health in EM Section Project Grants

Principal Investigator: Anna Q. Yaffee, MD

• Trained 140 emergency care providers in trauma care, with a focus on teamwork
• Trained 19 local CATC trainers who will be able to expand the course in other locations
• Strengthened Emory Department of Emergency Medicine’s relationship with the Department of Emergency Medicine at TASH
• Created opportunity for trilateral partnership with The Indus Hospital (Karachi, Pakistan), Emory, and TASH

Trauma globally represents an overwhelming burden of morbidity and mortality, especially in low- and middle-income countries (LMIC). Effective management with trauma teams has proven to reduce time to resuscitation and definitive care leading to decreased mortality and length of stay of trauma patients. Tikur Anbessa Specialized Hospital (TASH) is a 700 bed hospital and the largest tertiary care hospital in Ethiopia, the emergency department (ED) serves over 20,000 patients per year. A recent study showed incidence of road traffic injury in patients in ED at TASH to be 36.8% of all injuries, with 74.4% of these patients having moderate severity of injury and 11.6% of trauma patients requiring admission. This high burden of injury indicates need and opportunity for coordinated trauma care improvement. Building upon our previous partnership we undertook to implement and evaluate the Collaborative Advanced Trauma Care (CATC) training program at TASH. CATC is a collaborative, multidisciplinary trauma team training program for emergency medicine (EM) physicians, surgeons, and nurses, previously implemented in other LMIC settings but never before implemented in Ethiopia. 

A total of 140 participants were trained in CATC. The breakdown of participants included 72 EM resident physicians, 57 emergency nurses, 8 surgeons, 2 anesthesiologists, and 1 family medicine physician. Of these participants, 19 were selected for the TOT course, including 12 emergency nurses and 7 EM physicians.

These courses represent the first efforts to establish a team-based, systematic approach to trauma patient care at TASH. The outcomes in teamwork and leadership were impressive and consistent with CATC courses in other settings. Now with a cadre of trainers trained, we hope that this represents the first of many courses to improve team-based trauma care in Ethiopia, and the beginnings of a strengthened partnership between Emory, TASH, and TIH, leading to a future with bilateral exchange and sustainable educational initiative, with the ultimate goal of improved trauma patient care.

Principal Investigators: Ziad Kazzi, MD, Emily Kiernan DO, Aynur Sahin MD, Jonathan De Olano MD, and Brent Morgan MD

Impact on patients who are poisoned or exposed to chemicals, toxicants, and toxins in Turkiye

• This intervention has established collaboration between Emory University Department of Emergency Medicine and Karadeniz Technical University (KTU) in Trabzon, Turkiye
• This intervention has provided valuable telephonic clinical advice to physicians at KTU’s Farabi Hospital during their management of patients with toxicological exposure in their emergency department or inpatient units
• This project has led to a better understanding of the epidemiology of toxicological exposure in the region served by KTU’s Farabi Hospital
• The project has led to the drafting and publication of several case reports and studies related to the technical clinical consultations
• This collaboration has led to the organization of a conference held in Trabzon and that was attended by greater than 200 physicians from Turkiye
• The grant awarded by Emory’s Department of Emergency Medicine has led to continued collaboration with KTU since November 2022 and plans to expand the collaboration to Basaksehir Cam and Sakura Hospital in Istanbul, Turkiye
• The project has led to the involvement of Emory University Department of Emergency Medicine faculty members in the organization of the Turkish Foundation of Emergency Medicine conference planned in Antalya, Turkiye from November 5-8, 2023

Poisonings and chemical exposures cause a large number of deaths and injuries around the world with a disproportionately greater impact in low- and middle-income countries like Turkiye. The Karadeniz Technical University (KTU) Farabi Hospital in Trabzon, Turkiye has on staff the only trained medical toxicologists in the country. The hospital includes an emergency medicine residency program and a newly established inpatient medical toxicology unit. Due to limited resources, the Turkish National Poison Center in Ankara and the KTU Department of Emergency Medicine do not systematically collect sufficient data regarding these toxicological exposures. The Emory University Department of Emergency Medicine Toxicology Section (EU) is a leader in global toxicology and has provided telephonic toxicology consultation to the American University of Beirut Medical Center (AUBMC) since 2015.

296 patients required the toxicological consultation between 11/1/2021 and 10/30/2022 (women 53%). Most exposures were intentional (56%) followed by unintentional (39%). The 4 most common pharmaceutical product categories involved in the exposures were analgesics, antidepressants, sedative/hypnotic/antipsychotics, and cardiovascular drugs. The 4 most common non-pharmaceutical product categories were alcohols, plants/mushrooms, fumes/gas/vapors, and pesticides. 44% were discharged from the ED, 31% were admitted, 8% were transferred to another hospital, and 16% left against medical advice. There were 2 deaths in this cohort of patient visits (0.7%).

Gastric lavage was performed in 24% of cases and was done using a nasogastric tube instead of the Ewald device. Antidotes were administered in 19% of cases and included (bicarbonate, folic acid, thiamine, ethanol for methanol toxicity, benzodiazepine, N-acetylcysteine, atropine, flumazenil, calcium gluconate, insulin, digoxin-immune fragments, naloxone, silibinin, and levocarnitine). 6% of patients required hemodialysis with the major indication of methanol toxicity.

Implementation of a telephonic technical consultation on toxicological exposures managed at Farabi Hospital in Turkey has expanded the local capacity to provide expert toxicological care and benefited the healthcare providers who manage these patients. The project has also improved understanding of the epidemiology of these exposures and has created opportunities for interventions and preventive public health strategies.

Principal Investigator: Prem Menon, MD

This GHEMS grant was originally awarded for a qualitative emergency needs assessment regarding the state of emergency care in the country of Liberia. Given EMS in Liberia is rapidly developing, and one of our primary contacts in the country (Mark Luke) is the director of Liberia EMS, we investigated monthly dispatch summaries to get a better understanding of the utilization of EMS in the country. 

This project was presented as an oral presentation at the AfCEM Conference in Ghana (November 2022). This project was also presented as a poster presentation at SAEM2023 in Austin, TX (May 2023)

Impact to EM Capacity and Preparedness:

• Through this grant, a collaboration with the Liberia Ministry of Health and Emory Emergency Medicine was established. This collaboration will lead to further opportunities for both Liberia and Emory EM
• This is the first retrospective review of EMS in the country of Liberia, the results of this study were done in conjunction with the director of EMS in Liberia and thus evidence-based interventions can now be instituted
• This study was presented at national and international conferences increasing awareness of the needs in Liberia and further contributing to the collaboration opportunities
• Future studies can now be directed by Emory or other organizations to further investigate needs and patterns of the EMS system in Liberia

In recent decades, Liberia has undergone civil wars and an Ebola virus outbreak. Prior to the Ebola outbreak, pre-hospital needs were assessed with various government-sanctioned projects. Post-Ebola, these operations were shut down. While the concept of prehospital emergency care has existed for decades in the developed world, the implementation of a formal prehospital care & transport system is very new to Liberia, with its introduction first occurring in 2019 when the Liberian Ministry of Health created The Division of Emergency Medical Services. The Liberia EMS system serves the entire nation, spanning 15 counties and utilizing over 350 trained staff members and 55 transport vehicles. Given its very recent creation, no previous published studies have explored the nature of EMS runs in Liberia.  

Over nearly two years, Liberia EMS responded to 4,494 calls. Of these, 4,014 (89.3%) calls resulted in a patient being lifted to a healthcare facility. The largest category of calls resulted from obstetric-related conditions (N = 1,553; 34.6%) followed by medical calls (N = 1,280; 28.5%). There was seasonality in all calls such that the highest call volume occurred between February and April of each year (Figure 2). The most likely age range demographic for patients that use the EMS service is 16-35 (N = 2,343; 52.1%), followed by 36 – 45 year olds (N = 855; 19.0%), >46 year olds (N = 826; 18.4%), and 0 – 15 year olds (N = 470; 10.5%). The majority of calls (N = 2,694; 59.9%) related to female patients. Trauma (N = 885; 19.7%) and surgical calls (N = 79; 1.8%) comprised a smaller portion of the total calls. OBG calls were most commonly due to prolonged labor (N = 284), malpresentation/obstructed labor (N = 228), or general labor (N = 213). Within medical cases, the most common category was a sick person not otherwise specified (N = 182), followed by hypertension (N = 137), and respiratory distress (N = 117). Trauma cases were most commonly related to road traffic accidents (N = 306), head injuries (N = 115), and fractures (N = 92). Within surgical cases, the most common category was acute abdominal distress (N = 25), followed by bowel obstruction (N = 12), appendicitis (N = 11), and hernias (N = 11). Lifted cases were most commonly received in the Common Wealth Health District (N = 1,388; 34.6%). This was followed by Central Monrovia (N = 747; 18.6%), Somalia Drive (N = 387; 9.6%), Bushrod Island (N = 373; 9.3%), Caresburg (N = 101; 2.5%), St. Paul (N = 52; 1.3%), and Todee (N = 23; 0.6%). 943 (23.5%) call were received in one of the other districts.

Of the 4,494 total calls, 480 calls were not transported to a healthcare facility. The primary reason was that the call was cancelled (N = 201; 41.9%). This was followed by on-scene treatment (N = 114; 23.8%), patient was dead on arrival (N = 76; 15.8%), patient was transported in a private vehicle (N = 48; 10%), patient refused treatment (N = 30; 6.3%), and the transport vehicle lacked fuel (N = 11, 2.3%).

This is the first review of EMS data from Liberia. We will use these analyses to guide development of a database to collect data that can be used in formal statistical analysis to address future research hypotheses and inform EMS development.

Principal Investigator: Liang Liu, MD

Impact to EM Capacity and Preparedness

• This intervention has established collaboration between Maputo Central Hospital Emergency Medicine Residency (HCM) and the Department of Emergency Medicine’s Ultrasound Section and further strengthened the pre-existing relationship amongst the two programs
• This intervention introduces a much needed (and often only available) imaging modality which broadens the diagnostic capabilities of our Mozambiquan providers
• This has allowed for the first in the country use of ultrasound guidance for procedures which improves patient safety and allows for troubleshooting of procedures
• Throughout the year, HCM has provided numerous case reports of patients receiving diagnosis that would otherwise been delayed including ectopic pregnancy, bladder outlet obstruction, abdominal masses, pericardiocentesis, pregnancy, etc.

Point of care ultrasound (POCUS) has been shown to have beneficial applications internationally, especially in resource-limited settings where access to advanced imaging modalities can be challenging. It is a low-cost and efficient imaging modality that assists in the diagnosis and management of many conditions while also reducing the risks of procedural complications. POCUS improves time to diagnosis and can improve overall patient care. This is particularly important in countries like Mozambique. Coupled with limited access to emergency care is the challenge of expanding training opportunities due to limited funding and number of local physician teachers. In 2017, the country’s first EM training program, Maputo Central Hospital Emergency Medicine Residency (HCM), was founded to address this disparity. The program has graduated six specialists and currently includes nine resident physicians at different stages in the four-year training program. While studies have demonstrated the value of POCUS in resource-limited settings and there is a demonstrated need at HCM, there is currently little published guidance on how to establish effective and sustainable distance-based POCUS programs. The implementation of such a program in Mozambique is described and the results and lessons learned can serve as a template for the development of other areas of distance-based medical education in low-resource settings.

Three of five specialist and all nine residents completed the initial needs assessment. All respondents have used ultrasound to some extent in their clinical practice. Amongst the specialists, two had performed over 100 independent ultrasound exams while one specialist reported performing less than 50 exams. Amongst the residents, all had performed less than 10, if any, exams independently. All residents and all but one specialist were comfortable with only the EFAST or trauma ultrasound exam. The two barriers cited by all who participated in the needs assessment were lack of instruction and lack of equipment. After one year of intervention, 649 total ultrasound exams were independently performed by HCM residents and specialists. These exams include pelvic, EFAST, renal, cardiac and many other modalities.

During the in-country boot camp, OSAUSs were assessed on all five specialists and nine residents. The majority of specialists and learners were ranked at “can perform with guidance” and “can independently perform” on each of the subcompetencies of the EFAST, cardiac and ultrasound guided peripheral IV exams after the Boot Camp. The month of dedicated echocardiography teaching was provided in March of 2022 prior to the scheduled boot camp. 

Implementation of a mostly virtual curriculum can be effective in improving technical skills, image interpretation, and clinical application of ultrasound. The curriculum was augmented by providing resources in Portuguese, near-peer mentorship, image review and the longitudinal nature of the curriculum established. That said, image review and teleguidance amongst faculty were both time intensive and difficult to implement, whereas WhatsApp communications and near-peer teleguidance opportunities were more successful. These findings are important in informing future implementation of similar curricula and continued relationship with HCM.