Journal of Emergency Medicine, Trauma and Acute Care - 2 - International Conference in Emergency Medicine and Public Health-Qatar Proceedings, October 2016

Background: Measles is a highly contagious respiratory disease caused by a virus that can be serious in all age groups. However, measles complications more like to occur in children younger than five years and adult older than 20 years. Qatar is one of the Eastern Mediterranean (EMR) countries that are committed to achieving measles elimination target by 2015. However, Qatar has been experiencing a measles outbreak mainly due to a unique population characteristic, which includes highly transient expatriate population.

Objectives: To describe the incidence and morbidity to measles outbreak among the Pakistani community living in Abu Hamour area in spring 2015.

Methods: Data collection was done through the system of mandatory notification of the Health Protection and communicable disease control department (HP&CDC). All notified cases were interviewed with standardized questionnaire that are distributed to the families during the vaccination campaign. The information about disease complications was obtained from Health care facilities. Clinical case definition was adopted from world health organization (WHO).

Results: A total of 36 cases were diagnosed with measles from mid-March until end of April 2015. The index case was traveled recently to Pakistan, hence this outbreak was associated with the imported virus. Most of cases were from Pakistani community living in Abu Hamour area and the age distribution of cases was more of younger age groups (especially the 1–4 year group). Concerning measles vaccination history, all reported cases never vaccinated before. Conjunctivitis (36.1%) followed by gastroenteritis (30.6%) were the most common complications.

Conclusion: An accumulation of non-immune individuals led to this outbreak. Catch-up vaccination campaigns targeting a younger age group of a particular immigrant community are needed to close critical immunity gaps.

Background: Ambulance Paramedics are dispatched to all calls while Critical Care Paramedic (CCP) units only attend potentially “life threatening” cases (Priority 1). Ambulance Paramedics (AP) triaged patients based on clinical judgment and experience creating a risk of Priority 1 under or over-triage. QEWS was designed to supplement priority decision-making process based on physiological values used as a trigger to identify patients with a potential risk of deterioration. The objective of this study was to undertake a comparison of the QEWS score calculated from retrospective vital signs data to that of the priority decision-making by ambulance crews.

Methods: In our retrospective study, data entered into the Ambulance Service clinical database over a nine-month period before QEWS implementation was analysed for comparison of the priority decision made by the crew for each patient versus the calculated QEWS value based on the first set of six relevant vital signs (Heart rate, Respiratory rate, Systolic blood pressure, Temperature, Oxygen saturation, AVPU). Only cases with patients over 18 years old were included.

Results: Of 34,908 retrieved cases, 27,915 (79.97%) had sufficient data to retrospectively determine QEWS. The mean age was 38.62 (+15.84) years and 21,453 (76.85%) were male patients. Priority decision-making correlated in 25,850 cases (92.6%), with 286 (1.11%) Priority 1 and 25,564 (98.89%) Priority 2 patients. In 1,662 cases (5.95%), QEWS retrospectively triaged patients higher and in 1.44%, QEWS triaged patients lower.

Conclusions: Physiological variables are an established predictor of risk regarding a patient's condition. Hospital-based early warning scores have been validated and implemented successfully. Only one published pre-hospital scoring system has been validated for triage. Under-triage appears to be a common problem in medical patients. QEWS potentially could address this under-triage issue and appears to be a valid scoring system to implement for prioritising patients to routine or urgent transport, or CCP intervention.

Background: The handover process is meant to ensure patient safety and maintain continuity of care through endorsement of critical patient information. This study evaluates staff's perceptions about the current patient handover process effectiveness between Ambulance Service (AS) and Emergency Department (ED) clinicians. It may help identify barriers and contributing factors to an effective patient handover.

Methods: An electronic questionnaire was circulated to all ED doctors/nurses and AS staff (Estimated N = 1,000). 400 questionnaires were completed of which 92 did not meet the inclusion criteria. Respondents were 43% AS staff, 29% ED nurses, and 28% ED doctors. A 4-point Likert scale (1 = strongly disagree-4 = strongly agree) was used. The mean was calculated for every variable to determine each group perception. One-way ANOVA tested the relationship between demographics and perceptions’ variables.

Results: Although 62% of respondents believe the current handover process is safe and 65% believe AS staff report all critical information, 70% of respondents think that it causes AS/ED staff conflicts, and 72% believe the current handover process needs changing. ANOVA test revealed significant differences in the mean between study groups’ handover safety perceptions. Interestingly, ED nurses expressed more safety concern (2.43) than ED doctors (2.58) and AS staff (2.82) with p-value < 0.05. The main perceived barriers to effective handover were: Lack of handover protocol (89%); Lack of a standardized handover tool (89%); Fragmented communication (85%); and Frequent interruptions (82%). 93% of the respondents believe the use of a standardized handover tool will improve the patient handover process despite 67% of them not knowing any standardized handover tool.

Conclusion: The lack of handover protocol and a standardized tool leads to significant variation and is a patient safety concern due to potential loss of critical information. We believe that a mutually agreed standardized handover tool such as ISBAR would reduce handover variation and ensure quality.

Background: The ambulance patient compartment is a working environment where paramedics provide care to patients at times of distress. It needs to meet a number of functional requirements under various conditions whilst being practical and safe for its occupants. Their design varies greatly internationally and often nationally. This study aims to review the current design of Qatar's ambulances to ensure the safe journey of its users whilst making it very appropriate for patient care delivery during transport.

Methods: This study was ethically approved as a quality improvement project. The literature was extensively reviewed with regards to patient compartment design. Three focus groups sessions were organised each with 8 experienced participants out of a total population of 800–900 paramedics, to examine the current ambulance patient compartment layout.

Results: The focus group sessions conducted with a total of 24 paramedics, each with over a year of experience as independent practitioner, identified that improvements can be made to the current ambulance design for patient care and paramedic safety, including the different positioning of consumables and equipment, altered seat design, modified storage cabinets, and the use of better passenger restraints. It was also identified that improving the quality of driving skills through training and education will also have a positive impact on safety and comfort.

Conclusions: It has been recognised that current practitioners' (users) involvement, as opposed to managers, is critical to the appropriate design of the ambulance patient's compartment. They have valuable feedback to provide on the current design from a practical aspect but do not always have their own safety in mind. Based on our study findings the recommendations are to introduce a structured driver-training programme and begin a process of redesigning the patient compartment to test the above recommendations using prototyping and simulation techniques to minimise costs and maximise benefits.

Background: The introduction of electronic health record (Cerner) in Qatar's public health system aimed to bridge the disparities in documenting patient's official health record. It is essential to recognize nurses' viewpoint in using this technology. As it embarks on the two emergency walk-in-clinics, we attempted to identify its impact to ER nurses in terms of coordination of care, documentation skills and staff productivity.

Methods: The study is conducted in 2 Walk-in Clinics under Hamad General Hospital- Emergency Department, namely Al Gharaffa and Al Shahaniya. Questionnaires were given to a convenience sample of emergency nurses, asking about new opportunities EHRs created in work outcomes in the 2 walk-in-clinics. A 3-point Likert-type scale was used for the survey. Results were dichotomized (respondents indicated that they agree, neutral or disagree) for analysis.

Results: More than half of the respondents (68.4%) worked in HMC for more than 10 years. Nurses believed that the use of electronic health records enable them to streamline the patient flow in the walk-in-clinics (92% reported better coordination of care). Most nurses agreed that their productivity increased after using EHR increased after using EHR. Likewise, most of the nurses (96%), expressed that accessibility to patient's health record and that their documentation skills improved.

Conclusion: The introduction of electronic health record (Cerner) has a positive impact to emergency nurses. It is possible that after a year of use, the perception to EHR use will change. As such, this study may assist in determining if the system is meeting the expectation of emergency nurses in Qatar.

Background: Benign paroxysmal positional vertigo (BPPV) is a common medical condition. According to recent literature, it is prevalent in about 28% of the head injury patients. BPPV can be easily diagnosed in the Emergency Department (ED) by a simple bedside Dix-Hallpike test, in which patients experience vertigo and nystagmus as observed by the physician. It can be treated effectively in the ED by the Epley maneuver. In 2014, over 3,000 patients presented the ED at Hamad General Hospital with a head injury. Hospital guidelines often do not explicitly include BPPV symptoms as a possible complication of head injury. This may result in the physician being unable to manage BPPV, leading to longer sufferings for the patients.

Objectives: The purpose of this study was to evaluate current practice amongst physicians in a tertiary care hospital when managing BPPV in head injury patients.

Methods: Physicians working in Emergency Medicine, neurosurgery, trauma, and orthopaedics were asked to complete a paper based question survey.

Results: A total of 91 physicians completed the survey. 95.5% (n = 85) specified that they manage head injuries in their clinical practice. Only 29.6% (n = 27) indicated that they routinely investigate the possibility of BPPV in head injury patients. 73.6% (n = 67) stated lack of knowledge of BPPV and training in management to be the main reasons for not exploring BPPV. 91.1% (n = 83) stated willingness to receive further training in the management of BPPV.

Conclusion: In this study, physicians, when dealing with head injuries, were found not routinely diagnosing and managing BPPV. Lack of knowledge and training about this condition has been stated as the most common reasons for not exploring possibility of BPPV in head injury patients. The study confirms the need for training of physicians in managing this important condition early to prevent further disability in patients.

Background: Organophosphorus poisoning is a global public health problem. Annually, approximately 200,000–300,000 individuals die worldwide from Organophosphorus poisoning with the majority of deaths occurring in developing countries. In many countries in the Middle East, legislation is inflexible and unable to cope with new challenges. Often standards are not consistent with international and national needs. Hamad General Hospital (HGH) is the main tertiary care hospital in Qatar with its Emergency Department (ED) sees in access of 1500 patients in a 24 hour period. Anecdotally, there is a wide variation in practice of Organophosphorus toxicity management at HGH ED. The aim of this study is to check the knowledge and practice of the healthcare workers involved in managing such cases regarding decontamination, use of PPE and management.

Methods: This is a cross sectional survey using a pre developed questionnaire collected from a representative sample of 280 physicians of different grades and nurses in HGH ED.

Results: Till date collected data from 156 nurses and 66 emergency physicians showed failure of recognition of correct indication of atropine use in 47% of nurses (73 out of 156) and in (15%) of physicians (10 out of 66). Wearing appropriate respiratory and skin protective equipment while attending to patients with suspected Organophosphorus poisoning was up to the desired standard in 54% of nurses (85 out of 156) and 97 % of physicians (64 out of 66). The more years of experience the more safety awareness.

Conclusion: Junior staff knowledge about anti dote indications and diagnosis is the best. However the seniors are more aware about protective measures. We recommend the introduction of standardized Evidence based clinical algorithm and developing of educational sessions aiming to increase awareness about organophosphorus toxicity management. A secondary audit is necessary following the above intervention to measure the awareness improvement.

Background: As one of the leading causes of death and disability in the world, human trauma and injury disproportionately affects individuals in developing countries. During initial program development, senior MOHP physicians stated there was a critical need for a portable and flexible educational course on the clinical care of injured patients. To meet the need for improved trauma care in Egypt, the Sequential Trauma Emergency/Education ProgramS (STEPS) course was created through the collaborative effort of Egyptian and US expert physicians. The objective of course development was to create a high-quality, modular, adaptable, and sustainable trauma care course that could be readily adopted by a lower- or middle-income country.

Methods: We describes the course development from 2006 to 2015, highlighting the challenges and solutions of creating a successful, flexible and sustainable in-country trauma care training program that suits low and middle-income countries.

Results: STEPS was developed at the University of Maryland, based in part on World Health Organization's Emergency and Trauma Care materials, and introduced to the Egyptian Ministry of Health and Population and Ain Shams University in May 2006. The program is designed to adapt low cost and limited resources with maintaining high fidelity and unified standard. In 2008, the course transitioned completely to the leadership of Egyptian academic physicians. To date, more than 700 physicians from 8 countries have taken the course through the Ministry of Health and Population or public/governmental universities. For the first time the course will be held in Sudan on January 2016.

Conclusion: STEPS has rapidly become a desired trauma care training program proved by sustainability based on 7 years of course conduct. Success of this collaborative educational program is demonstrated by the numbers of physicians trained, and program continuance after transitioning to in-country leadership and trainers.

Background: DMI itself is a benign condition unless complicated by compartment syndrome or superadded infection. However, coexistence of extensive DVT may have serious complications such as pulmonary embolism. We report 2 cases of DMI with iliac vein thrombosis presented to our ED.

Case presentation: Case 1 A 40-year-old lady with diabetes, presented with a swollen and painful left leg for a day. A bedside Doppler ultrasound confirmed the presence of weak pulsation in the dorsalis pedis and posterior tibial arteries. Orthopedic and vascular teams were consulted as the patient continued to have pain despite repeat IV analgesia, raising the possibility of compartment syndrome. The vascular surgeons requested a CT angiogram to exclude extension to the pelvic vessels. The CT angiogram report revealed delayed filling below the knee compared to the right side. Following admission to the medical ward, MRV examination was performed. The MRI findings were suggestive of DMI. Case 2 A 58-year-old man presented with a swollen and painful left lower limb for 12 hours. Compartment syndrome was excluded by measuring bedside compartment pressure. The ultrasound examination was suboptimal due to extensive swelling in the muscles of the thigh. CT angiogram reported thrombosis of the iliac veins with grossly edematous left thigh muscles. The MRV was reported as diffuse enlargement of the lower limb muscles associated with edema in the fascia and subcutaneous tissue and was compatible with the muscle infarction. The muscle swelling and bullae resolved slowly and the patient was discharged after three weeks with an optimum INR.

Discussion: Diabetic muscle infarction may be associated with pelvic vein thrombosis. Possible differential diagnoses may include venous thrombosis of lower limbs, myositis, pyomyositis, muscle hematoma, neoplasm, necrotizing fasciitis, and osteomyelitis. Contrast magnetic resonance imaging (MRV) is ideal for making the diagnosis.

The presence of undeclared pharmaceuticals, including drugs that have been withdrawn from the market, in anti-diabetic and weight-loss herbal and dietary supplements can pose a serious health risk to consumers; they also undermine confidence in legitimate products. To protect consumers from potentially harmful products that are marketed as dietary supplements, the Drug QC Laboratory, Qatar is involved in the testing of herbal and dietary products. Traditionally this testing has required a combination of several analytical methods which presents a substantial investment of time and resources. To improve laboratory efficiency a single UPLC-MS/MS method was developed for the supplement screening followed by a confirmatory method based on multiple reaction monitoring (MRM) analysis. Screening analysis comprised LC/MS with automated searching against an in-house generated MS spectral library. Confirmation and quantification was performed by MRM analysis. The developed method was applied to 654 supplements submitted to our laboratory in 2014-15. Analysis revealed that 42 herbal anti-diabetic and weight lost products were tainted with undeclared registered or banned drugs, namely sibutramine (n = 30), phenolphthalein (n = 21), glibenclamide (n = 4), metformin (n = 4), phenformin (n = 2), pioglitazone (n = 1), fluoxetine (n = 2), orlistat (n = 1), methylephedrine (n = 1) and methamphetamine (n = 2). Five hot beverages tea and coffee were found to contain a combination of sibutramine and phenolphthalein.

Background: The ambulance service communication center is the first access point of the public to the health care services in the state of Qatar. It's receiving between 400 and 600 emergency calls per day which are processed through a very robust and consistent workflow, for the aim to triage the emergency incidents and distinguish high and low acuity patients and send an adequate response. Within these emergency calls there are cases that will be recognized as associated with communicable diseases where the healthcare responders are at high risk of exposure.

Aims: Protecting healthcare workers from infectious diseases and controlling exposure by implementing an attentive communication network.

Methods: HMC-AS communications center implemented a communicable disease screening procedure for calls coming from Primary health centers, Hospitals and community. To identify potential infectious patients and PRE-NOTIFY: The responding crew and prompt the use of proper Personal Protective Equipment; The receiving facility to activate their procedure.

Summary of results: The Screening procedure played an important role in minimizing the exposure of the pre-hospital care responders and improved the hospital preparedness in receiving infectious patients.

Conclusion: The communication officer's compliance to the screening criteria showed an improvement and this ensured that the PRE-NOTIFICATION is done properly in a timely manner.

Background: Although Emergency Medicine has existed as a recognized specialty in Alexandria University since 1970 a recent shining as a highly competitive specialty since 2003 through an Egyptian Fellowship Training program granting a professional and not an academic degree. Emergency Medicine is still in its development phase as a practice. Five public universities are offering postgraduate degrees in Emergency Medicine. These degrees when obtained by trainees, in addition to a varying number of years of experience, enable doctors to climb up the medical hierarchical ladder, which begins with a resident post till Senior consultant one.

Methods: We describe the development of Emergency Medicine as a separate specialty in Egypt highlighting the history, challenges we faced, collaborations and recommendations for future improvement of Emergency Medicine training in Egypt.

Results: As of August 2015, there are five Emergency Medicine educational programs in Egypt, which are primarily based upon the British model of obtaining a masters or higher degree. The largest of these, the Egyptian Fellowship program, is supported by the Ministry of Health and Population (MOHP) and is the country's most formalized and acknowledged training program. Currently, there are more than 300 specialists graduated with 32 registered consultants. However, the majority of the qualified graduated physicians capable of leading the field of Emergency Medicine had left Egypt due to financial, social and economic stresses.

Conclusion: Although, the fast developing field of Emergency Medicine, Egypt still need an urgent well-structured system supported by Ministry of Health and population. There needs to be creation of an Emergency Medicine committee by Egyptian board certified emergency physicians to monitor and improve the training and exams done by universities, and holding of regional conferences to enhance Emergency Medicine in Egypt and the Middle East region.

Objective: Since 1998 seasonal epidemic meningitis has been a recurrent problem in Sudan with a variation in the severity between seasons. Mass vaccination campaign with conjugated vaccine (MenAfriVac) for Neisseria meningitidis A was implemented in Sudan since October 2012, since then case base surveillance of meningitis was implemented. The target age group was 1–30 years. Measuring of meningitis trends in three years pre and post the campaign against NmA is mandatory to assess the impact of introducing (MenAfriVac) vaccine.

Objective: To describe the epidemiological profile of NmA in Sudan, 2010–2015.

Methods: Descriptive study using data of notable suspected meningitis cases by national surveillance system.

Results: EpiInfo 7 software used to analyze the data. 2010–2012 a total of 4273 suspected cases were reported (13.08/100,000 Attack Rate (AR)) with 185 deaths (4.35% Case Fatality Rate (CFR)). The most effected Age-Group was ( < 5) representing 62% of cases, 61% of cases were observed among males and 39% among female. The positivity rate of NmA was 4.2%. 2013–2015 After MenAfriVac® and case-based surveillance implementation; a total of 794 suspected cases were reported (4.5/100,000 AR) with 59 deaths (7.0% CFR), the most effected Age-Groups were (1–4) representing 40.3% of cases following by Age-Groups ( < 1) representing 39.7% of cases, 64% of cases among male and 36% among female. The positivity rate of NmA was 0%, no confirmed case of NmA was reported.

Conclusion: Introducing of MenAfriVac® proved to be an effective strategy contributed to decrease the overall number of meningitis suspected cases in Sudan.

The adulteration of herbal/dietary supplements with erectile dysfunction (ED) drugs and their analogues is reported worldwide and is an increasing problem. The sale of so-called 100%, ’all-natural’ products has become a highly profitable business for online pharmacies, however these products can pose a serious threat to consumers owing to the undisclosed presence of approved/prescription drugs or the unknown safety and toxicity profile of unapproved ED drugs. The Drug QC Laboratory, Qatar, has been involved in the testing of adulterated and counterfeit products for a number of years. A simple and rapid UPLC-MS/MS procedure for the analysis of 42 synthetic ED compounds in herbal supplements is presented. A spectral library for the compounds and their analogues was generated from reference standards for automated routine analysis. Full scan MS analysis was performed simultaneously in both positive and in high energy negative ESI modes; In addition a MS/MS method was developed for confirmation and quantification of compounds. The method was applied to 87 suspected dietary products which were received to our laboratory. Twenty three were found to be adulterated: 11 with sildenafil, four with thiodimethylsildenafil/thiosildenafil, two with dapoxetine and five contained a combination of verdenafil, tadalafil, aminotadalafil, hydroxthiohomo sildenafil. One sample contained unknown analogue named as propoxyphenyl thiohomosildenafil. Developed method is a novel screening method that is suitable for both the detection of known and unknown ED drugs and their analogues. This is the first description of a single analytical method with this capability.

The consumption of dietary supplements is widely spread and on the rise in Qatar market. Toxic metals like mercury, lead, cadmium and arsenic can be naturally present in dietary supplements and can pose harmful effects on human health. Pharmacy and Drug Control Department; SCH has been involved in proper counselling of these products before they are marketed to Qatar. In this study Two hundred and thirty five different dietary products (capsule, liquid or powder form) were analyzed which were submitted to our department for registration. Inductively Coupled Plasma-Mass Spectrometer (ICP-MS) and Mercury Analyzer are used to monitor toxic metals that exceed United States Pharmacopeia (USP) maximum limits. Samples were digested with HNO3+HCl (5:1) by utilizing closed vessel microwave system. The validity of the applied method was assessed by the analysis of standard reference material (SRM 1548a), and the recoveries were 100 ± 10% of the certified value for 4 metals. Among the 235 samples, 13 samples contained lead (Pb) exceed the USP limit while 2 samples with arsenic (As) above the limit. No sample contained Cd and Hg above the limits. Pharmacy and Drug Control Department is taking action and monitoring toxic levels of Hg, Pb, Cd and As in herbal and dietary supplements before they market in Qatar by using state of the art technology for the safety of public and for the better health of peoples living in Qatar.

Background: Dengue Fever constitutes a major international public health concern due to rapid expansion of geographic distribution of the virus and the mosquito vector of the disease. In this paper we aim to review the risk of Dengue Fever introduction to Qatar.

Methods: Review of the Literature for the factors responsible for the worldwide spread of dengue fever and assess these factors in Qatar.

Results: Internationally, the Global Climate Change is believed to be responsible of Dengue geographical expansion. High Temperature and humidity in Qatar are suitable climatic conditions for breeding of Dengue vectors Aedes aegypti and albopticus. The rapid urbanization in Qatar constitutes a favorable environment for breeding sites of Dengue vectors, as the mosquito prefers to breed in artificial containers such as discarded tires, drums, cans, buckets, flower pots, and vases. High number of international travelers, especially form dengue endemic countries to Qatar is a very important risk factor. The rapid human population growth in Qatar if combined with circulation of different dengue virus serotypes is an important risk factor for development of sever forms of Dengue Fever. Unspecific clinical presentation in addition to presence of asymptomatic dengue cases poses a challenge to the diagnosis capability of medical doctors in Qatar and hence to under reporting of dengue.

Conclusion: Dengue Fever is an imminent risk to Qatar. Entomological survey is needed to determine the presence, capacity and density of Dengue Vector in Qatar. Strengthen Dengue surveillance in international travelers will work as sentinel for dengue risk in Qatar.

Introduction: Brain abscess is caused by inflammation and collection of infected material, coming from local or remote infectious sources, within the brain tissue. The infection may also be introduced via a breach in the skull following head trauma or surgical procedures. Brain abscess may also be associated with congenital heart disease in the young children. Here we would like to describe a case of brain abscess secondary to seemingly trivial head injury.

Case presentation: A 12 years old boy presented with left forehead and periorbital swelling for one week with fever, vomiting and headache. Parents added the history of confusion. No history of seizures or LOC was recorded. There was history of minor scalp trauma to the forehead 10 days prior. Examination reveals a febrile child with GCS of 13. Rest of systemic examination was unremarkable. Local examination showed warm tender fluctuant swelling. CT examination was ordered and it revealed, frontal subgaleal collection involving the frontal sinus and extending into intracranial portion. He was admitted for decompressive craniotomy and evacuation of intracranial empyema. The patient's condition improved gradually and was discharged with full recovery after 15 days post-admission.

Discussion: Minor scalp trauma serving route of intracranial infection is a rare complication documented in the literature. Detailed history is important as patient or family may not remember it.

Background: Primary achalasia is a disease of unknown etiology in which there is a loss of peristalsis in the distal esophagus and a failure of lower esophageal sphincter to relax with swallowing. Typical Clinical manifestations including dysphagia for solids (91%) and liquids (85%) and regurgitation food (76 to 91%) are the most frequent symptoms in patients with achalasia. Regurgitation may also result in aspiration (8%). However, atypical presentation of achalasia may cause delayed diagnosis and mismanagement.

Objective: This case report presents atypical presentation of achalasia in which patients presenting primarily with prolonged cough. This case report discusses possible mechanisms explaining the atypical presentation of achalasia including chronic cough.

Methods: We report a 45-year-old female patient presented to Emergency Department at Al Wakra Hospital with a history of cough and shortness of breath for more than two weeks. Oxygen saturation was 90% on room air with no history of vomiting, fever, hemoptysis, hematemesis or weight loss. Additionally, there was no significant past medical history except for recent diagnosis with bronchial asthma. In ED, patient was managed as a case of bronchial asthma exacerbation and received beta-2 agonist nebulization, intravenous corticosteroid and oxygen mask. Minimal improvement in the her condition was noted after treatment. Initial investigations were conducted including complete blood count, comprehensive metabolic panel and chest X-Ray. A radiolucent space in upper mediastinum with a query of pneumomediastinum was determined. Further imaging was conducted using computed tomography which showed diffuse dilatation of the esophagus.

Conclusion: Chronic cough could be the only presentation in achalasia cardia.This a typical presentation may cause misdiagnosis or delayed treatment and should be considered in differential diagnosis.

Background: One of the most common reasons why patients visit the Emergency Department is with the complaints of pain. The compliance rate of pain assessment and reassessment by the nurses in ED is far from expectation. This results in delayed disposition, increased re admission and poor patient satisfaction. As pain is exclusively a subjective experience, accurate documentation of patient pain assessment is critical in the management of pain.

Methods: The study was conducted in the Emergency Department of Hamad General Hospital. The prospective data was collected for a period of two months (January to February 2015) using a direct observation technique by the ED nurses and verified by the study observer for the accuracy of the data. Sample was collected from various sections of ED (Male triage area, Female triage area and short stay units). Both male and female patients were included in the sample.

Results: Male area The use of pain scale improved from 63% to 83%. Non-compliance to reassessment after intervention decreased from 58% to 32% which shows improvement 74% of the observation was not following the international timing of the reassessment after intervention then decreased to 73% Female area The use of pain scale improved from 80% to 90% Non-compliance to reassessment after intervention decreased from 93% to 4% which shows improvement 80% of the observation was not following the international timing of the reassessment after intervention then decreased to 32%.

Conclusions: An accurate assessment and reassessment of pain is critical in the management of pain. Meticulous teaching and following the hospital standard is important to achieve 100% compliance with pain assessment.

Background: Clinical governance requires having a process for adverse incident review and management to ensure the organisation ‘learns from its mistakes’ to prevent repetition. How leadership implements this system may enhance learning and patient safety, or have the unintended consequence of raising alarm, possible demotivation, and staff becoming risk-averse. The impact of the existing Ambulance Service incident management process was assessed from an organizational culture aspect.

Methods: Action research uses iterative and collaborative cycles of study, action, and reflection to not only understand a complex situation by holding an attitude of inquiry but also to bring about positive change. Dialogue and narrative enquiry were used to collect data using a grounded theory approach for data interpretation. Dialogue was used both for reflection and for initiating change at various levels within the Service.

Results: Initial data indicated a moderate fear culture in the Service, with staff becoming risk averse in the clinical environment due to concerns of being called for investigation. Dialogue sessions were held with key role players highlighting the experiences of staff. The impact of these conversations were reflected on and the outcomes of this reflection was used to frame further dialogue. Narrative (stories) of staff experiences were collected and used in the dialogue to highlight the impact of the adverse incident review system on staff morale. Based on these conversations, leadership made changes, including developing new incident review process with peer involvement, changing leaders of the process and an increased focus on communicating feedback to staff. As one staff member noted the mood in the corridors is much lighter.

Conclusion: Action research provides an effective method for leaders, working in the real world environment, in dealing with the complex issues to bring about positive change, both in quality and patient safety, and staff satisfaction point of view.

Background: There are cases of ED visits with chief complaints of Shortness of Breath which are managed as a Case of Bronchial Asthma, URTI or Cardiac Origin with the total number of 13047 ED visits in Female Urgent Area in December 2014, random sample of 180 patients with complaints of SOB and diagnosed as BA, 90% were given nebulization therapy without measuring PEFR. There is 0% compliance of PEFR measurement of the staff.

Methods: Retrospective data was collected from patient's record who presented with shortness of breath from 01 December 2014 to 30 December 2014 at Emergency Department, Hamad General Hospital. Data was analyzed to find out the compliance rate of peak flow measurement. Vigorous teaching was carried out among the staff nurses in Emergency Department to improve the awareness of the peak flow measurement as a standard of care for all Asthma patients. Prospective data was collected to compare the compliance rate of post-educational period.

Results: The 50 patients who received nebulization in ED (MST, FST) were reviewed to identify the compliance rate of PEFR measurement Before, After and In-between the nebulization. Retrospective data of pre implementation phase showed poor compliance rate. (Eighteen percentage (18%) before nebulization, six percentage (6%) after nebulization and zero (0%) in between nebulization's. Prospective data of post-implementation showed tremendous improvement. The compliance rate of PEFR measurement before nebulization increased to seventy six percentage (76%), after nebulization to seventy two percentage(72%) and in between nebulization monitoring to 10%.

Conclusions: The implementation of the Peak flow project made a tremendous improvement in the staff compliance in measuring PEFR which can lead to better care and management Bronchial Asthma patients. Meticulous teaching is required to improve PEFR monitoring in between the nebulization in order to achieve 100% compliance.

Critically ill shock patients presenting to the Emergency Department (ED) in Hamad General Hospital (HGH), Doha Qatar often needs central line when fluid resuscitation fails to improve their blood pressure (BP). Triple lumen central lines are used when vasopressor or inotropic support becomes necessary. In some of these patients, a double lumen dialysis line is later inserted (often in the femoral vein), when it becomes clearer that the patient will need urgent dialysis for worsening renal function or acid-base physiology. Another clinical scenario we often encounter is when patient admitted to the ED for emergency dialysis session. Some of these patients have borderline to low BP that become obvious during the dialysis, eventually needing some vasopressor support to enable the dialysis session to be continued. More than 2 years ago we introduced the use of dialysis line with extra port (Trilyse Expert by Vygon) in the Intensive Care Unit and now its use has spread to front line ED resuscitation room. Indications for Trilyse Expert insertion are: 1. Patients who needed vasopressor or inotropic support who may need dialysis, 2. Patients who needed dialysis with borderline to low BP who may need vasopressor support during dialysis, 3. Patients who needed both dialysis and vasopressor/inotropic support on presentation to ED. In this retrospective cohort we looked into the effectiveness of Trilyse Expert inserted in our ED resuscitation room in preventing the need of a second central line insertion. We also reviewed all relevant complications related to the device and its insertion. We also conducted a systematic literature review in the use of dialysis line with extra port in critically ill patients to support our findings. Results is shown in charts and tables. Concluding better outcome when using double lumen CVC with extra port.

MERS-COV is an emerging zoonotic disease primarily originated in Arabian Peninsula, where camel industry and trade are part of the local culture and economy. Camels were proposed to be the possible reservoir. A convenient sample of 78 camel owners were interviewed through a structured questionnaire to assess their risk perception and practices. All were males, mean age of 42.5 ± 12.7 years. Most of camel owners were Qatari (94.9%), working with camels for 10 years or more (85.8%). Most of the owners are aware about the disease (93.6%), mostly from T.V (75.6%). However, only 37% of them know that the disease can be transmitted from camel to human or from human to human. The majority of owners (79.5%) had low to moderate knowledge score regarding MERS-COV. More than half of them had low perceived susceptibility to catch the disease. Perceived reasons for susceptibility were being in close contact with camels (82.2%) or exposure to camel products (76.7%). The majority (74%) feel to be protected from the disease, mostly because their farms are clean (78.1) or due to long history of working with camels without catching disease (69.9%). More than half of owners (54.8%) had high perceived severity score, and thought it can lead to hospitalization (86.3%) or death (69.9%). The most perceived protective measures were washing hands with soap and water (84.9%) and keeping away from sick people (78.1%). The most perceived barriers to using protective measures were being unavailable (56.2%), or unpractical (43.8%). Sixty percent of owners have high self -efficacy score, however, very low percentages were using protective measures (4–12%). Health education sessions should be conducted to camel owners in Qatar to increase their awareness and risk perception about MERS-COV.

Despite substantial progress emergency public health and medicine, there is no doubt that recent European Union (EU) migration crisis has provide a new dimension and complexity in public health and lives of millions are in peril, while international aid organizations are unable to effectively deal with associated emergencies. Health risks related to migration process associated with emergency or crises situations are not fully studied despite the growing number and intensity of such events. In globalization and health systems are increasingly becoming topical issues due to range of risks diseases vulnerability challenges irrespective of race, ethnic and gender across all levels of the society. The paper aimed at examining the quality of care and effectiveness of emergency public health services delivery in contemporary Mediterranean, Balkans and Africa to EU migration crisis. Our finding showed that the quality of care of migrants in emergency situations varied considerable from one entry points to another and limited optimal Emergency public health engagement and responsibility of EU members' countries. Barriers and challenges to quality care included limited health access to traveller preventive services such as vaccines, essential medicines, and basic health care, chaotic over-crowding, long queue of asylum claims, linguistics, social exclusion, limited emergency local and humanitarian staff availability, police barricades, detentions centers, culture and limited protection against pathogens dynamics, infectious diseases and importation vulnerability. In addition to decreased hygiene, unsanitary conditions, and exposure to disease vectors, increased risk of physical and sexual violence, mental distress, and scarcity of food and water. The quality care index was highly compromised particular methodological strengths and weaknesses in most camps and transitory shelters centers. In conclusion, practical and efficient evidence-based emergency public health policies, services delivery quality and effectiveness metrics in preventing human suffering are crucial in upholding the common moral imperatives and responsibility to global health security.

Background: Each hospital in the UK has a hospital trauma team which includes a multi-disciplinary team. However, the use of such team for minor trauma can lead to inappropriate use of healthcare resources. Thus, an “Emergency Department (ED) trauma team” including only ED staff was developed. The 2 teams together form the 2-tiered trauma system. Each team has its own activation criteria. Its effectiveness in the UK still requires further evaluations. Thus, an evaluation of its effectiveness is important. Only a few UK hospitals adopt this system. St Helier Hospital (SHH) is one of them.

Objectives: Our aim is to evaluate the effectiveness of new service which has been implemented in the Trauma Unit and its impact on the trauma care and service delivery.

Methods: Patients who activated the ED trauma system at SHH from 01/11/2014 to 30/04/2015 were included. This is a retrospective work, clinical notes were reviewed against two tiered trauma calls using SHH database.

Results: A total of 103 ED trauma calls were recorded. 65 cases (63.1%) should have been managed using the hospital team but were not. Overall, patient care was not adversely affected. In most cases, guidelines on “initial assessors”, “primary survey” and “fast scans” were followed. The survival rate was 100% with 55.3% home discharges. Injury mechanism was looked at to explain for the deviation. The “2 or more systems involved” sub-criterion was activated the most and could be argued to bring about most over-triage cases if trust trauma calls had been used.

Conclusions: The ED team at SHH have managed its patients safely and effectively despite a high guideline non-adherence rate. Improvements of the 2-tiered system effectiveness need an increase in the system awareness and a review of the system activation criteria.

Background: There appear to be variations in the time of presentation patients with ACS around the world. The working days and weekends differ in Qatar from the Western world.

Methods: In 1846 patients admitted with ACS, 721 had Primary PCI for STEMI and 1125 had Non-ST Elevation ACS (NSTE-ACS). The days and time of onset of symptoms, Door to Balloon Time (DBT) and Out of Hospital Delay were compared in different time periods in relation to the weekend (Friday/Saturday), and 2-days before (B-WKE), or 2-days after (A-WKE). The intra-day variation was compared in day time (6AM-6PM), and night time (6PM-6AM).

Results: Overall, almost half ACS patients (both STEMI and NSTE-ACS) presented in 2 days After WKE (Sun & Mon), with 60% of these presenting on Sunday alone, compared to only 16% over WKE (Fri & Sat). This was true for males with both STEMI and NSTEMI and for females with NSTE-ACS. However, the pattern was reversed in females with STEMI, 39% presented during week days vs only 19% After WKE (Sun & Mon). For both sexes and all ages, most (58%) presented early day time with modal symptoms starting time around 4 AM. In Primary PCI patients, the DBT was longer (77.5 min) during the night vs (61 min) during day, but in both >90% were within 90 min. 66% of STEMI total occlusion (TIMI-0) during the night. TIMI-3 flow was achieved in 94% during the day vs (87%) at night. Out of Hospital Delay was longer at night (270 min) vs (200 min) during the day. However, in-hospital mortality and LV function was similar.

Conclusions: There are interesting variations diurnal and gender variation in time of presentation of ACS. However, this does not seem to make significant impact on in-hospital outcome in the Primary PCI, perhaps because majority achieved optimal Door to Balloon Time.

Background: Cerebrovascular Accident or stroke is a global health problem and is a leading cause of disability. It is one of the leading causes of mortality and morbidity worldwide.

Materials and methods: A retrospective case-control study carried out on stroke patients admitted to the main Ministry of Health hospitals from May to November 2014. The study consisted of 110 proved cases of stroke and 110 controls (selected from patients who attended the study hospital for conditions other than stroke). For each case of stroke, one control was selected. The controls matched to cases in respect to age ( ± 3 years), sex and locality. Analyses performed by calculation of Chi-Square test and confidence interval using SPSS program version 20.

Results: Out of 110 patients, (61.8%) were females and (38.2%) males. Mean age of cases was 65.80 years compared to 65.46 for controls. Most of them were living in Gaza city. The ischemic type found in 81.8% patients. The most important medical risk factors associated with CVA was diabetes mellitus and hypertension; which represent 61.9% diabetes mellitus among cases compared to 38.1% among controls (P-value < 0.001) and represent 61.4% among hypertension cases compared to 38.6% among controls (P-value < 0.001). For cardiac disorders, 60.3% of cases compared to 39.7% of controls have cardiac disorders (P-value < 0.021). For lifestyle risk factors, obese represent 56.9% among cases compared to 43.1% among controls (P-value < 0.010), smoking represent 63.6% among cases compared to 36.4% among controls (P-value < 0.001). Sedentary level represent 78.2% among cases compared to 21.8% among controls, (P-value < 0.001) and stress represent 83.8% among cases compared to 16.2% among controls, (P-value < 0.001).

Conclusion: Hypertension and diabetes are the biggest risk factors for stroke in, which can be controlled with appropriate medication and lifestyle changes.

Background: Ebola viral disease (EVD) outbreak 2014 in West Africa declared as Public Health Emergency of International Concern (PHEIC) according to IHR (2005), Sudanas member state committed to plan and respond to PHEIC. Sudan was in a great risk to be affected by EVD due to the previous history of EVD outbreaks in 1976, 2004 and 1979, long open borders with Limited resource and poor infrastructure, presence of united nation mission in Darfur (UNAMID) coming from all over Africa.

Objective: To assess preparedness and response of Sudan to EVD 2015 within the context of IHR 2005.

Methods: This descriptive cross-sectional assessment was conducted using; WHO checklist to evaluate Ebola preparedness in different sectors, reviewing Ebola committee's reports, and IHR focal points reports.

Results: According to the IHR Domains analysis; existing of coordination mechanism at all level and active participation of National Focal Point (NFP) was (92%) Surveillance core capacity (53%), surveillance system was sensitized and capacity-building for surveillance officers were achieved. However Event and community based surveillance were still lacking behind Response and preparedness core capacity (40%); national response plan in place, command center was identified; border states were classified as high risk states accordingly, rehabilitation of isolation centers were priority, although the Protocols, guidelines and case managements were available. Majority of IHR requirements for ground crossing (POEs) were not fulfilled, although the preparedness at Khartoum International Airport scored (60%) Risk communication core capacity (42%); Distribution of fact sheets, awareness raising sessions of different group conducted. Risk communication plan should be implemented.

Conclusion: Risk of importation of EVD cases is moderate. Strong political commitment exists, urgent coordination mechanize with neighboring countries needs to be activated. Appropriate training for staff in case management and IPC is needed. Sudan need to Enhance and implement Event base and community based surveillance.

Background: As part of improving the service in ED, we conduct Pharmacist-led Pharmacy round (PLPR) led by Pharmacist to ensure best patient care is provided by pharmacist.

Objective: No such experience was reported in the literature up to our knowledge so we decided to describe our experience, in the successful establishment of PLPR in ED and to identify whether implementing a pharmacy based round, provide better patients care in terms of finding more drug related problems and providing educations to all clinical pharmacists.

Methods: The PLPR started daily at 11 am by brief meeting to discuss any pharmacy related issue then the PRPR team start rounding according to a planned schedule. The PLPR often involves ED pharmacists of different levels of experience the ED pharmacy specialist, clinical pharmacists who have reviewed the patient's case, pharmacy fellows and medical and pharmacy students. During the round, the pharmacist assigned for the area present each case using the Care Plan Form (CPF) to review the suggested recommendations or interventions, further recommendations to the clinical pharmacist may be given if necessary. The extra recommendations or discussion (ERD) conducted during the PLPR are documented and analyzed to evaluate the impact of the pharmacy based round. For each intervention, the following data were documented: date, time, medication, types of intervention.

Results: A total of seventy five ERD were documented during this period. Interventions related to adding, initiating or selecting drug therapy were the most common performed 58 (77%), pharmacotherapy options were the second most common interventions done by the team 13 (17.3%), requesting laboratory tests to optimize pharmacotherapy management were made 7 (9%) followed by dosage adjustment 6 (8%).

Conclusion: Implementation of PLPR is an initiative to improve pharmaceutical care in ED and training among Clinical pharmacist at point of care.

Background: Heat stroke contributes considerably to cause morbidity and mortality during hot season. The main factors associated with severity and mortality of disease unclear. In Sudan heat stroke occurred mainly in Red Sea State during previous years. The purpose of this study is to assess association between heat stroke and pre-existing medical conditions in Northern State of Sudan.

Study: Descriptive analysis of Heat Stroke outbreak at Northern State of Sudan.

Methods: Analysis of secondary data of diseases surveillance system was used. The pattern of the outbreak was described and other risk factors were studied to assess their associated with Heat stroke in Northern State of Sudan 2015.

Results: Northern State was reported 44 probable cases of Heat stroke with case fatality (CFR) 72.3% (32 deaths), among them 64% were males and 36% were female. Halfa locality was reported 82% of cases due to decreased of humidity. The majority of the cases (81.8%) were represented in age groups more than 45 years. Majority of reported deaths had chronic illness and significant statistical association with their age group. All deaths were complained from high grade fever, hypotension (65.5%) and unconsciousness (46.9%) while the alive cases were complained from high grade fever and hypotension. Seventy eight percent of deaths occurred in the age group more than 45 years.

Conclusion: Northern State experienced a climatic change during last two year and heat waves became more augmented lead to heat related illness in the area. Elderly, chronic medical condition and humidity were found to be the main risk factors associated with deaths.

A security Survey of Emergency Department Hamad General Hospital Background The problem of Emergency Department (ED) violence is a worldwide issue, and a systematic approach to mitigating the threat to our colleagues and patients is fundamental to the advancement of Emergency Medicine (EM). One of the important step to this is to assess and improve knowledge of the staff on workplace violence and how to react to it. Aim of this survey was to assess staff knowledge about measures against workplace violence.

Methods: We conducted a survey between, July 2015 to August 2015, in Hamad General Hospital Emergency Department (HGH-ED). Doctors and non-doctors health professionals working in the HGH-ED were asked to fill a paper survey. Data was collected and analyzed anonymously. The categorical outcomes are presented in proportions and continuous outcomes as mean with SD.

Results: A total of 180 staffs were approached to fill this survey. 61.1% was the response rate. Of 110 who completed the survey, 68 (61.8%) were doctors working as ED physicians, and 42 (38.2%) were nurses and clerks. The male proportion was 62.27%. Median age category was 30-39 years with work experience less than five years. Only 24 out of 110 responders (21.8%) were aware about HMC policy dealing with workplace violence. 56 (50.9%) of the staff members were not sure about how to deal with if the incidence happen involving them or their colleague. Non-doctor staff was found to have higher percentage of feeling unsafe at work.

Conclusion: We found poor knowledge about workplace violence policy and how to deal with it in the ED staff. Dedicated efforts are needed to make the staff aware and prepare for such situations.

Background: The Syrian civil war since 2011 is one of the most complex humanitarian emergencies in history. This protracted disaster has but negative aspects, especially on living, educational and health care infrastructure and services. The goal of this study is to document the impact of four years of war on Syrian children's social, educational and health status.

Methods: A cross sectional observational study was conducted in May 2015. Health care workers, especially trained for this study, visited home by home in four Syrian governorates with a prospectively designed questionnaire.

Results: Of 1080 filled-out questionnaires, 1001 were complete and included in this study. Most lived in the Aleppo governorate (n = 413; 41%), 359 in Idleb (36%), 147 in Hamah (15%) and 82 in Lattakia (8%). Median age was 6 years (IQR; 0-15), most were male (n = 611; 61%). Almost 20% of all children were Internally Displaced Persons (n = 196), 45 lost their father (5%) and 41 (4%) had their father missing, 19 (2%) lost their mother and of 27 (3%) the mother was missing. Of all, 855 (86%) had access to safe drinking water, and 775 (77%) could access appropriate sanitation. About 16% (n = 156) had interrupted access to nutrition. Almost 27% suffered from diseases related to malnutrition. Access to specific health care providers was disturbed in 64% (n = 646), and only 28% had an updated vaccination status. Of all school-aged children, 450 (51%) had no access to education at the time of the study. Most children suffered from respiratory (29%), neurological (19%) or digestive (17%) diseases, 4% was victim of injury or violence, and 2% suffered from mental problems.

Discussion and conclusion: After four years of civil war in Syria, children have lost parents, live in substandard life quality circumstances, and are at risk for outbreaks because of worsening vaccination status and specific healthcare provider attention.

Background: Managing a weekly educational planner for an Emergency Residency can be a challenging task in a busy Department due to shift pattern of work, personal development and travelling issues. In this descriptive case study, we outline the challenges and solutions to facilitate this issue. We found that key interventions in the form of timely reminders to instructors and faculty, prospectively consulting them before topic allocation and timely reminders and backup plans helps in reducing drop outs.

Methods: In this quality improvement study, we describe the interventions undertaken to ensure 100% compliance by the faculty for the teaching schedule for the year 2015/2016. We demonstrated a reduction of the dropouts to almost zero despite significant external pressures. An initial scoping exercise revealed that in the 2014/2015 planner 68.75% presentations were conducted as per the planner where as 31.25% did not follow the planner. The reasons included apologies to present (10%), eleventh hour swapping because presenter was not ready or available in country (12.5%) and non-availability of presenter (8.75%) due to leave issues. An initial questionnaire survey was undertaken to elucidate the factors that were disruptive to the faculty and the planner. We also sought ideas to help improve to the planner. A tentative planner for the year 2015/2016 was announced in advance to the whole department and all the staff and faculty were consulted to send the topics of their interest as well as their dates of annual leaves and holidays. Each presenter was called individually to confirm their availability and topics were assigned to them.

Results: We compared the first four month educational planer starting from July 2015 till October 2015 and found the compliance 100% with zero drop outs.

Conclusion: Proactive measures in making educational planner always help in maintaining compliance of the planner and reducing drop outs.

Background: The tremendous increase in disasters in the Middle East whether natural or man-made is unforeseen in its characters and/or catastrophic effects to the communities and infrastructure, thus making public awareness is a mandate to plan, respond and mitigate the community.

Methods: We run Public Awareness program targeting non-medical university students, aiming at raising their knowledge about first aid and response during disasters by designing and conducting hands on First Aid and disaster preparedness course, pretest and post-test was done, graded from 0 to 10 for evaluation of the candidates and their level of knowledge, aiming at achieving 3 grades or above change in the candidates knowledge.

Results: Of 95 candidates attended the course, 84 pre and dost were complete and included in this study. More than half of them were male (n = 55; 65%). There was a significant difference in the candidates grades in the pre and post-test, with near 95% achieved the goal and almost 90% was satisfied by the program.

Discussion and conclusion: The surge in disasters over the last decades is unforeseen, in order to meet that threat national disaster plans should focus on effective disaster public awareness programs, targeting especially the most active and largest part of the community, which is university students.

Exercise-associated hyponatraemia (EAH) is a potentially serious and occasionally fatal outcome in marathons and other long duration events. In the last 30 years, there have been more than 500 publications on hyponatraemia and exercise. Some studies, who point to the fatalities that have occurred, consider this as a major concern while others dismiss it as a rare and unimportant condition. This work critically assessed and summarized the main evidence on the prevalence and aetiology of the condition and on possible preventive measures. Hence, more than 400 relevant articles were identified by a search in PubMed and other secondary sources like NICE and 112 abstracts and 42 full text were reviewed. Level and strength of evidence supporting the conclusions were assessed by Strength of Recommendation Taxonomy (SORT). EAH is more frequently asymptomatic. If its frequency through finishers of an endurance event is estimated from 0 to 51%, the incidence of symptomatic EAH in marathon is estimated to less than 1% of all participants. Actual evidence correlates EAH incidence to 2 major etiologies: an overhydration by excessive fluid intake and a persistent secretion of arginine vasopressin. The prevention consists primarily of avoiding overdrinking. In this context, the key recommendation is to drink according to thirst to avoid dehydration and overhydration. To provide such prevention, besides educating athletes, education for the supporting event staff is recommended to avoid errors in fluid supplementation advices. Furthermore, the medical staff covering such events should be familiar with early recognition and diagnosis of EAH to avoid complications and improper real-time drink supplementation. In conclusion, EAH is a life threatening condition during endurance sport events. Besides a limited incidence, the increasing numbers of participants in events like marathons induce a higher rate of symptomatic EAH. It seems, according to actual evidence to be a serious concern in endurance sports.

Introduction: Pre-hospital care professionals work outside or in confined spaces. Issues like population demography, cultural diversity, geography, roads, and climate regularly challenge them. Some of these factors might be overlooked by the hospital-based mentality of other clinicians. Providing them an opportunity to accompany paramedics in their own environment may help them better understand the paramedics' role and scope of practice, and improve the patient handover process between these two “alienated worlds” of medical professionals.

Methods: An Emergency Medicine Specialist spent 12 months within Qatar's national Ambulance Service. Regular rotations through its various departments were facilitated, including an 8-week ride along with a Rapid Response Vehicle (Delta unit) dealing with emergency calls. A daily journal was written to record the experiences and audit data was accessed to gain a deeper understanding of the Service.

Results: This experience was an eye opener. Delta officers are very experienced and can provide a global perspective of the operations. Their main focus is safety from a 360-degree scene perspective, team leadership, and communication. The type of calls and circumstances provided a unique view of the scene realities. Ambulance crews were observed dealing with difficult situations, assessing patients, and initiating treatment in challenging environments. Depending on the type of emergency, Ambulance Paramedics were joined by a Critical Care Paramedic who has more advanced skills and the ability to administer a broader range of medications.

Conclusion: This program has been effective at introducing a hospital-based clinician to the pre-hospital world and should be Considered to all Emergency Fellows. It highlighted the complexities of working in the community with limited resources and the importance of communication to ensure the provision of safe and effective care. Understanding the Ambulance Service staff's level of competency will also enhance the handover process and help build trust in the Paramedics.

Background: Globalization, increasing intense urbanization and climate changes has been linked to natural and man-made evolution and curiosity resulting in multiple threats and vulnerability. The degree, nature and extent community and household preparedness and resiliency programs and activities defined the robustness and effectiveness of local, national to regional EMRO timely response policy decision maker by policy makers, health planners and implementers.

Methods: This paper analyses existing community emergency preparedness and resilience implementation and translation challenges and bottlenecks against emerging natural and man-made threats and epidemics disaster in Saudi Arabia and other EMRO countries.

Results: Our results showed inefficiencies to identify, understanding and mapping of potential risks/threats and weak community early alarm and surveillance systems in threats or disaster occurrence. Also, showed that real time community-based programs are poorly interrelated and nurtured in most EMRO countries, and require fostering community guidelines and prevention and control activities. Such include social mobilization, health education in increasing alertness, awareness and community mass literacy outreach. Critically, adequate community knowledge and attitudes on preparedness and resilience on mass pilgrims influx during Hajj and Ramadan seasons, potential vulnerability to epidemics and floods indicates that policy planners and implementers could capitalize on these strengths and address the weaknesses in scaling up practical community and household emergency preparedness and management approach on and across borders populations for common beneficial expectations in upholding safety and security, healthy lives and well-being. In conclusion, we advocate that establishment of a comprehensive evidence-based local, national and regional laboratory and digital surveillance systems, community-based partnerships, investment projects and related preventive resilient measures are vital in revamping the evolving and future threats and disaster situations in Saudi Arabia and other EMRO countries in line with One Health Surveillance systems.

Introduction: A large number of patients present to the Emergency Department (ED) with sepsis, severe sepsis or septic shock. Septic shock is associated with 40% mortality risk and is the most common cause of death in the ICU. Moreover, survivors of septic shock are at risk of permanent organ dysfunction, prolonged hospital stay and long term institutionalization. Many of these complications can be minimized and may be avoided by prevention via public health improvement and education, early identification of sepsis, and timely effective intervention.

Methods: IHI quality improvement methodology applied to guide our work. The Quality Leaders from ED, ICUs and general wards were invited to participate and collaborate to develop and test the Sepsis 6 Pathway. From the data collected so far we noted the following: Sepsis patients ages range from as young as 19 to 89 years. The most common sepsis diagnoses are septic shock, pneumonia and urosepsis. For the initial management of sepsis patients 49% are managed in the ED. In August we started monitoring delays in time between the patient's admission and criteria met for sepsis diagnosis; and the time between criteria met for sepsis and referral to ICU. If the patient is admitted to the ward this can be as long as days. If the patient is admitted to MICU or ED it ranges from 0 minutes – 1 hrs. The time between criteria met for sepsis and treatment initiated is the most important indicator we are monitoring, which based on the data collected so far averages between 0 minutes – 1 day.

Conclusion: Sepsis causes avoidable and preventable patient harm. A multi-faceted approach may help reduce morbidity and mortality. Early implementation of the sepsis 6 pathway is underway in HMC across main acute care areas. Outcome measures will be collected and compared against international standards.

Background: The conventional landlines and bleeps that are commonly used in recalling physicians during major casualty incident (MCI) have shown multiple defects. Despite the remarkable advancement of handheld devices, social media and short text messaging (SMS), only a few studies on the comparison between the conventional communication and the social media have been found in the literature. This research compares (1) bleeps, (2) SMS and (3) WhatsApp as communication tools for recalling doctors. These tools were selected because they are commonly used in our region.

Method: We selected two periods for communications: social-friendly (09:00–19:00) and anti-social (23:00–06:00) periods. A total of 120 emergency physicians from Hamad General Hospital were contacted by the three communication tools in the two selected periods. We investigated the percentage of the responders and the time of response because this is the first step to the MCI response.

Results: Bleep had the fastest response (mean 7.6 minutes in the social-friendly period and 9 minutes in the anti-social period), but with a least response of 10.8% and 3.0% for the social-friendly and anti-social periods, respectively. WhatsApp had the majority of responses (45.0% in the social-friendly period and 47.5% in the anti-social period, respectively). However, its response time was long (146 and 141 minutes), respectively. Therefore, it is not suitable for recalling doctors during MCI. In contrast, SMS showed a bizarre response, with a mean response time of 43 and 154 minutes for the social-friendly and anti-social periods, respectively. This showed a marked increase in response from 30.8% for the social-friendly period to 44.2% for the anti-social period.

Conclusion: At present, there is not even one satisfactory and reliable communication tool for recalling physicians during MCI. Unsatisfactory response may be due to human factors that can be improved by training to achieve optimal compliance in both percentage and response time. This could in turn help achieve the ultimate response in MCI. More research is needed in this field to obtain the best and most accurate communication tool.

Background: Children cite needlesticks and invasive procedures as anxiety-provoking, which can have a negative impact on coping. This distress can lead to increased fear of medical settings and avoidance of care. Providing children with care that reduces the fear of pain associated with medical procedures can support positive experiences that can reduce anxiety. Thus, this will allow the child to better cope with and cooperate during medical procedures.

Methods: The available literature and the authors' professional experiences highlight the implementation and effectiveness of these approaches.

Results: Four main practices highlight a child-friendly approach: language, information, procedural support, and comfort positioning. Child-friendly language includes using a clear, concise, directed language. It avoids using confusing terms and focuses on the sensory experience of the child. Information is provided both in timing and content to children based on their developmental level and allows for the safe exploration of the equipment being used to promote mastery. Procedural support includes distraction, oral sucrose use, and encouraging positive coping skills such as breathing and imagery. Comfort positioning maintains access and safety for the healthcare professional while meeting the needs of the child to stay in proximity to its caregiver and not to lie on its back.

Conclusions: Child-friendly practices raise the standard of care for children in emergency settings. These practices can reduce procedural challenges for staff and improve the patient's experience. Implementation can be done across the provider spectrum and can be enhanced through the use of a child life specialist, a pediatric healthcare professional trained in supporting patients, families, and staff in the medical environment.

Introduction: Diagnosis of patients in a pre-hospital setting is a challenging process that depends primarily on clinical evaluation. The pre-hospital environment presents particular challenges such as scanty information and limited diagnostic tools. Nonetheless, accurate diagnosis is key to activate the appropriate cascade of management, level(s) of dispatch and disposition. This study aims to compare the ambulance paramedic diagnosis with that determined in the Emergency Department (ED).

Method: This is a multi-centered cohort prospective study comparing pre-hospital diagnosis with emergency physicians' primary diagnosis. We included all adult patients in the ED of Hamad General Hospital, Al Khor Hospital and Al Wakrah Hospital, but excluded all poly-trauma patients (trauma level 1). Pre-hospital diagnosis was reviewed from the ambulance patient care record and compared with documented primary diagnosis provided by ED physicians during August 2015.

Results: A total of 747 records were reviewed; of which, 154 records were excluded from the Study due to missing data. The comparison results showed that 389 files were congruent and 200 were non-congruent. They included common diagnoses such as trauma (9%), abdominal pain (12%) and renal colic (12%), and had concordance as high as 90.5%.

Conclusion: Pre-hospital diagnosis was congruent in 66% of the cases reviewed when compared with emergency physicians' provisional diagnosis. As the study did not include the final diagnosis, accuracy of diagnosis was not assessed for both the pre-hospital setting and ED physicians. The most common cause of incongruity was documenting a specific diagnosis instead of provisional diagnosis, which increases the risk of missing related differential diagnosis.

Recommendations: Such studies may help identify opportunities of improvement for healthcare providers to make optimal decisions. Therefore, further studies are required to reveal the areas of improvement.

Background: Despite the great success in controlling infectious disease in children, house accidents have increased, especially in developing countries, in the last years. WHO has reported that more than 20% of hospital cases involve children under 5 years of age and are caused by house accidents. Foreign body aspiration (FBA) is a preventable accident with a high risk of mortality. The objective of this study is to identify the epidemiology of FBA in children admitted to Al Bashir Hospital in 2011.

Methods: A retrospective cross-sectional study was conducted in 135 children who were admitted to the hospital and bronchoscopy was conducted for diagnosis and treatment. Data was collected from the files of those patients by using a questionnaire, which included variables (age, sex, type of foreign body, location of foreign body, main presenting symptoms, referred status). SPSS 17 used for analysis.

Results: A majority of the patients (63%) were between 1 and 3 years, mean age 3.2 years, (59% male, 41%female) with a M:F ratio 1.4:1. Bronchoscopy findings 113 out of 135 (84%) showed positive foreign bodies, Rt main bronchus is the common site 56% of the cases. Most of the foreign bodies were organic, seeds and peanuts (72%). The majority of the cases presented with cough (97%), choking (64%), and shortness of breathing (39%). Thirty percent of the cases were referred from peripheral hospitals. Mean hospital stay was 2.1 days. One patient developed cardiac arrest and convulsion occurred in one case. Chest infection was seen in 10 cases. No other complication was seen.

Conclusions: Detailed history from the parents about foreign body aspiration is important for diagnosis of FBA, when suspected prompt bronchoscopy should done to prevent further complication, the doctors should not depend exclusively on radiological examination for the diagnosis of FBA as most foreign bodies are radiopaque.

Background: The emergency department physicians rarely see high-pressure injection injuries (HPI) to the hand. These work-related injuries can have a devastating effect on hand function, particularly if not treated early. These injuries are usually caused by the introduction of chemicals into the wound. Chemicals under high-pressure cause local tissue damage, ischemia, and acute and chronic inflammation. The initial assessment may suggest a trivial injury to the inexperienced physician. HPI should be considered as a surgical emergency. Wound exploration, cleansing, and decompression usually preserve the optimal functions. The prognosis of these HPI depends upon the time of presentation, the type of the fluid injected, the pressure, volume, site of injection and appropriate management.

Aim: We aim to highlight the importance of early recognition of HPI by the emergency physician.

Case presentations: We present two cases of HPI. Both of them presented with a small puncture wound on their hands within 1–2 hours of the injury. The first patient was treated with analgesia and antibiotics and was discharged home. He returned again to the Emergency Department after 24 hours with increased pain, swelling, and discoloration of the fingers. He was referred for surgical exploration but required amputation of the index finger. The second patient was immediately referred to the hand surgeon for surgical exploration. He was able to make a good functional recovery within 3 months of the accident.

Conclusion: These cases highlight the importance of early identification and referral by emergency physicians to ensure appropriate multidisciplinary treatment to prevent long-term disability.

Introduction: Renal colic is one of the common abdominal emergency presentations to an ED. The cost of imaging, health care resources and time spent in the Emergency Department (ED) is huge. There is good evidence supporting the role of ED bedside ultrasound in detecting hydronephrosis.^1,2 We plan to study the role of bedside ultrasound in renal colic as a pilot audit for the QIP.

Method: A convenience sample was selected prospectively. In all patients, a bedside ultrasound was performed by emergency ultrasound fellow, focused to answer presence or absence of hydronephrosis was performed. The results of ultrasound were recorded using online Google docs. A CT-KUB scan was performed for all these patients as per departmental guidelines. The results of CT and USG finding, disposition, and timings for the registration, to perform USG, and to get CT reports were recorded and analyzed.

Results: A total of 24 patients aged between 18 and 65 years were included in the study. The average length of stay (LOS) in ED was 15.1 hours (3.7–60.3 hours). The mean time to perform bedside USG was 4.0 ± 2.4 hour. The average time to get the CT-KUB results was 6.0 ± 2.4 hours. The negative predicative value of bedside USG was 80%. None of the patients without hydronephrosis had obstructing stone or required admission. In patients without hydronephrosis, the average LOS of ED stay, in disposition based on CT results, was 2.08 hours higher than the disposition bedside USG results.

Conclusion: These observations are limited as part of small audit data. However, it could be future direction to explore, the role of bedside USG performed by ED physicians, in renal colic to decrease the ED LOS.

Background: Today, e-learning is of strategic importance to teaching and learning in Emergency Medicine (EM). We adopted an interactive e-learning platform based on the open source software called MOODLEa using a blended learning strategy to assist the implementation of a dedicated faculty development program known as the EM consolidation program. This 12-month program was designed to meet the developmental needs of 20 EM specialists who qualified from different parts of the world. The program is delivered through an innovative blend of workplace and simulation-based assessments, educational portfolio and individualized training in selected clinical areas. The e-learning platform was used by the program participants to share learning resources, communicate, and coordinate various educational activities over the last 6 months.

Methods: We sought feedback from the participants through a MOODLE-based online questionnaire to evaluate their satisfaction, usage patterns and feedback of their e-learning experience.

Results: Out of 20 participants, 90% (n = 18) completed the questionnaire. Two-thirds declared proficiency in computer skills and were enthusiastic about the technology. Their prior experience was related to certified courses rather than interactive forum-based e-learning. About their current experience with MOODLE, 86.7% of participants found it easy to use without any major technical problems. Most of them preferred to access the platform once or twice a week, with 20% accessing on a daily basis. Of the participants, 75% of them accessed MOODLE through their smartphones and 12.5 % through tablet devices. All areas of the e-learning course were found to be useful. The forum-based discussion area was highly rated. The overall learning material was perceived as appropriate and well designed. Among the participants, 62.50% liked the current methodology of blended learning, and 31.25% wished to replace traditional method with e-learning. Also 93.75% of the respondents stated that e-learning was time saving.

Conclusion: Learners involved in this e-learning initiative were overall satisfied by the current implementation of MOODLE and with a third of users preferring e-learning to traditional learning. The use of smartphones and tablet devices was widespread in this small study and hence we recommend support for these devices in implementing similar e-learning initiatives.

Reference: [1] Cook DA, Yvonne S. Online learning for faculty development: A review of the literature. Med Teach. 2013;35(11):930–937.

a MOODLE – Modular Object Orientated Dynamic Learning Environment. http://moodle.org.

Background: Procedural sedation (PS) is commonly used in the Emergency Department (ED) to lessen pain, apprehension, and agony for patients during medical procedures. PS encompasses administering of sedative medications with or without the simultaneous delivery of analgesic agents. Safe and effective PS in the ED is a skill that is fundamental to practice of Emergency Medicine. Patients undergoing PS in ED should have a documented evidence of pre-sedation assessment, including prediction of difficulty in airway management, ASA physical status and fasting status.

Aim: The aim of this audit, as a part of a QIP, was to assess the current practice and documentation of PS pre-reassessment among the ED physicians.

Methods and settings: This was an electronic questionnaire survey sent to all ED physicians via their work e-mails. Sixty-seven emergency physicians took part in the survey; however, only 62 completed it. This is a high-volume ED in a large tertiary care hospital where up to 1,600 patients are seen daily and PS is practiced frequently.

Results: Sixty-two ED physicians completed the electronic survey. Only 33.33% (n = 21) stated that they document PS pre-assessment as a usual practice. Among the participants, 69.35% (n = 43) stated the lack of time as the commonest reason for not documenting the PS pre-assessment. And 79.03% (n = 49) admitted that availability of a PS pre-assessment form would improve practice and documentation.

Conclusion and recommendation: Only one-third of the physicians documented PS pre-assessment as a usual practice. The majority of the physicians indicated lack of time as the reason for not documenting the PS pre-assessment. There is a need for a simple assessment form with a checklist and regular training for all ED physicians in PS pre-assessment to practice safely and effectively.

Background: Delays in clinical handover can compromise a patient's care. The handover is not the sole responsibility of the ambulance personnel or the emergency departments. Reducing delays requires the working together of the entire organization, as well as designing efficient emergency and ambulance departments.

Objectives: The study aims at exploring the quality of clinical handover between the emergency department personnel and the ambulance personnel at Hamad General Hospital.

Methods: This is a descriptive study using two kinds of anonymous questionnaire surveys to gauge the current opinion regarding patient handover. One was aimed at physicians, who are the hospital employees, and the second was intended for the ambulance personnel. The employees of the Emergency Department were asked to provide their opinion of the handovers that the ambulance employees provided in a given clinical situation. The clinical situations in question included: cardiac arrest, pediatric emergencies, sepsis, chest pain, head injury, and trauma.

Results: A total of 65 ambulance employees and 70 medical employees completed the survey. The findings of the study indicate that there is a formal training procedure for patient handover, and that, in general, the quality of communication of history, the general quality of handover, and the knowledge of vital signs reported were high. The ambulance personnel were satisfied with their quality of handover. However, the medical staff were less positive, particularly for sepsis and pediatric emergencies. The findings also indicate that the ambulance employees perceived a high level of delay regarding patient handover.

Conclusions: It was encouraging that both groups had a positive perception about the handover. The areas for improvement identified by the medical employees were sepsis and pediatric emergencies, while the ambulance employees perceived a significant delay in the handover. In conclusion, the study proposes the following recommendations as possible solutions: interdisciplinary training, addressing organizational culture, and flexibility in organizational processes.

Background: This study is a quality improvement project that aimed at improving patient flow in Male Urgent Area (MUA), one of the busiest areas in the largest emergency department in the state of Qatar.

Methods: The baseline process was designed by mapping and drawing a cause-and-effect diagram. Pre- and post-auditing was done after careful intervention of introducing a phlebotomy room in Male See and Treat area, the main feeder to MUA. The feeding areas to MUA and the daily flow of patients were studied in detail. Points of interest in the baseline process map were identified and targeted. Supporting data of about 398 patients helped in designing the process map and identifying the point of interest.

Results: Post-intervention analysis showed a remarkable improvement in time to phlebotomy in Hamad General Hospital Emergency Department. The proportion of patients moving to MUA and receiving phlebotomy increased from 48.6% to 84.1% in the first hour. Patients' hematological laboratory workup that helps MUA's physicians in decision making was readily available.

Conclusion: Patient flow and phlebotomy time can be significantly improved by introducing a dedicated phlebotomy room in a busy emergency department. It is concluded that identification and targeting of the main point of interest in baseline process mapping is crucial and of considerable importance in a quality improvement project.

Keywords: Emergency department, phlebotomy time, patient flow

Introduction: Sepsis is a major cause of hospitalization with a high mortality rate. Early recognition and management of sepsis have shown to improve mortality outcomes. A proactive alert system for improving the response of the interdisciplinary team may decrease the time to intervention and improve patient outcomes.

Objective: The study evaluated the impact of an early alert system, “CODE SEPSIS”, on adherence to the sepsis management bundle and time to intervention among patients at risk for sepsis.

Method: Patients presenting to the Emergency Department (ED) and meeting two or more criteria on the sepsis screening tool were intended to trigger an overhead alert known as CODE SEPSIS, which was activated based on the physician's decision. Data were retrospectively collected over a 3-month period for all hospitalized adult patients with confirmed sepsis (age above 18 years). We evaluated the time from ED presentation to diagnostic and treatment interventions. A data collection tool was designed to record information.

Results: A total of 36 sepsis patients were identified, among which 18 were classified as CODE SEPSIS and 18 were classified as non-CODE SEPSIS. We found that the CODE SEPSIS group showed greater improvement than the non-CODE SEPSIS group from ED presentation to intravenous catheter insertion (37.3 to 31.5 minutes, 15.6%), fluid administration (41 to 39 minutes, 4.9%), microbiological workup (91 to 33 minutes, 63.7%), lactate level (69 to 66 minutes, 4.3%), prescribing antimicrobial therapy (92 to 44 minutes, 52%), and administration of antimicrobial therapy (88 to 46 minutes, 47.7%). Patients in the non-CODE SEPSIS group showed a 1-day decrease in length of hospital stay.

Conclusion: The CODE SEPSIS alert system developed at Al Wakra Hospital promoted early and standardized management among patients at risk for sepsis, which may lead to improved patient outcomes.

Background: Rhabdomyolysis, which can be defined as a CPK level greater than five times the upper limit of normal, is related to muscle breakdown and hypovolemia in heat stroke patients.¹ CPK levels will likely be higher because of increased muscle breakdown in exertional heat stroke when compared with classic heat stroke.

Methods: We reviewed 50 patients who came into the Emergency Department of Hamad General Hospital during the months of July to September 2015, and who were diagnosed with exertional heat stroke.

Results: In 44 out of 50 heat stroke patients, the level of serum CPK was markedly elevated (mean 20,300 ± 25,500 U/l) compared with the elevated levels of other lab values (serum myoglobin 2500 ± 3000 ng/ml, creatinine 1.8 ± 2.4 mg/dL, BUN 90 ± 104 mg/dL, potassium 2.6 ± 3.6 mEq/L, sodium 135 ± 155 mEq/L) on admission. The repeated lab values after the 12th hour showed that the CPK rose further (28,500 ± 32,500 U/L) while the others (serum myoglobin 800 ± 1,200 ng/ml, creatinine 1.1 ± 1.4 mg/dl, BUN 35 ± 60 mg/dL, potassium 2.2 ± 3.4 mEq/L, sodium 110 ± 130 mEq/L) recorded a decrease.

Conclusion: In our cohort of patients, CPK levels were significantly high in the setting of exertional heat stroke. A possible relation to renal failure need to be explored in a prospective research design.

Keywords: exertional heat stroke, rhabdomyolysis, creatinine phosphokinase REFERENCE: [1] Santelli J, Sullivan J. An evidence based approach on emergency medicine. Emerg Med Prac. 2014;16:6–15.