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.