Journal of Emergency Medicine, Trauma and Acute Care - 1 - Qatar Health 2022 Conference abstracts, January 2022

Background: Acute coronary syndrome (ACS) is one of the most common life-threatening diseases worldwide.¹ Early diagnosis, advanced cardiac life support, and rapid transportation to a cardiac center are essential to reduce mortality and morbidity. ST-segment elevation myocardial infarctions (STEMI) are life-threatening and are diagnosed with a 12-lead electrocardiogram (ECG). However, non-STEMI (NSTEMI) is not prioritized as a STEMI in the prehospital setting. Studies have confirmed that patients who are diagnosed with an ACS in the prehospital setting are more likely to survive.^2,3Method: A scoping review was conducted based on the above topic. Limited data is available on prehospital cardiac troponin tests for NSTEMI. Discussion: Paramedics from the national Ambulance Service in Qatar diagnose patients with ACS based on the findings of a 12-lead ECG, clinical presentation, abnormalities in vital signs, physical examination, and congruent history which is compatible with the American Heart Association and European Resuscitation Council recommendations. In a case of NSTEMI chest pain, the paramedic cannot rule out Acute Myocardial Infarction (AMI), yet the patient will be taken to the normal emergency department until further investigations are done.¹ ACS remains a challenge to diagnose in the prehospital setting as the diverse population in Qatar makes communication often difficult which would negatively impact the patient's assessment. Although the accuracy of prehospital Troponin tests done around 2010 was relatively encouraging², their sensitivity has now significantly improved and warrants further studies to highlight their benefit to patient care.³ The routing of patients with ACS (STEMI and NSTEMI) to the appropriate cardiac center is essential to assure they receive a rapid diagnosis and appropriate care. Conclusion: The enhanced diagnostic accuracy of ACS in the prehospital setting by using a rapid Troponin test is expected to accelerate the care of NSTEMI patients and should be explored in Qatar. This scoping review indicates that limited data is available on cardiac troponin tests for NSTEMI.

Background: Dapagliflozin has been shown to reduce the risk of heart failure hospitalization and cardiovascular mortality in patients with heart failure with reduced ejection fraction (HFrEF).^1,2 This work aims to determine the cost-effectiveness of dapagliflozin added to standard therapy versus standard therapy alone in patients with HFrEF, regardless of the presence or absence of type 2 diabetes mellitus (T2DM). Methods: A lifetime Markov model was constructed to compare the health outcomes and costs of dapagliflozin added to standard therapy versus standard therapy alone from a Qatari public healthcare perspective (Figure 1).² The cohort is comprised of HFrEF patients with left ventricular ejection fraction (LVEF) ≤ 40%, and New York Heart Association (NYHA) class II–IV with an average age of 65 years, based on Dapagliflozin and Prevention of Adverse-Outcomes in Heart Failure (DAPA-HF) trial (Table 1).^1,2 The model consisted of three health states: ‘stable’, ‘hospitalization for heart failure’, and ‘dead’. Clinical inputs were derived from the results of DAPA-HF trial and costs, and utilities were estimated from published sources as well as publicly available sources in Qatar.³ The main outcome was the incremental cost-effectiveness ratio (ICER) per quality-adjusted life-year gained (QALY). All outcomes and costs were discounted at a rate of 3% annually. Sensitivity analyses were conducted to confirm the robustness of the results. The study was based on published data; therefore ethics approval was not required. Results: Dapagliflozin added to standard care prevented 112 heart failure hospitalization and resulted in an additional cost of QAR 33,890 (USD 9,309). This equated to an ICER of QAR 101,763 (USD 27,951) per QALY gained, below the US willingness-to-pay threshold of USD 150,000 per QALY gained. Sensitivity analyses showed the findings to be robust. Conclusion: Dapagliflozin in addition to standard care appears to be a cost-effective strategy for patients with HFrEF, regardless of the presence or absence of T2DM.

Background: Obesity is a chronic illness that affects a lot of health aspects¹. The general preparation for the bariatric surgery and the lengthy weight-loss time, particularly in individuals with many comorbidities, are challenging and a complex process². Successful control of such a process requires the integration of several domains of the healthcare system that includes surgical care, nutritional management³, social support, and medical management of such diseases. Thus, the present study was to identify the effect of the bariatric surgery on the absorption of various micronutrients. Method: This is an animal study on 20 albino rabbits sorted into control and experimental group (n = 10 each). All the rabbits followed the same diet, had the same living condition, and experienced physical activity opportunities. Then the blood samples were collected from all the rabbits after one month (each group) via the jugular vein. Also, several laboratory tests were performed (such as the levels of folate, iron, vitamins E, A, D, K, B-1, B-12, calcium, magnesium, and zinc). Results: The results showed that the percentage of the rabbits that had a deficiency in micronutrients after the bariatric surgery increased compared with the control group (Table 1). In addition, the mean laboratory results of micronutrients decreased in the rabbits after the bariatric surgery compared with the control group (Table 2). This was observed in folate (-0.023), vitamin D (-0.015), and zinc (-2.35) levels. Conclusion: Finally, the deficiency of the absorption of micronutrients resulted in a change in the anatomy of the gastrointestinal tract through the bariatric surgery, a surgery that altered the pH, changed the solubility, and caused the loss of some of the absorption transporters.

Background: The upper permanent canine tooth germ develops close to maxillary sinus (MS)¹ therefore, upper canine displacement and MS pneumatization may have a link.² This study aims to evaluate the MS dimensions, volume, and range of anterior and vertical MS pneumatization in bilaterally palatally (PDCs) and buccally displaced maxillary canine (BDCs) compared to normally erupted canine (NDCs) subjects. Methods: Cone-Beam-Computed-Tomography (CBCT) images of 167 patients (131 females/33 males, age averaged 18.88 ± 1.66 years) were included in the study. Maxillary canines were bilaterally displaced palatally in 60 patients, buccally in 57 patients, and normally erupted in 50 subjects. The following variables were measured: anterior, lateral, and vertical distance from canine cusp tip to MS wall, MS volume and dimensions, and MS anterior and inferior pneumatization. The paired sample t-test was applied to detect differences between the right and left sides. Differences between the three groups were assessed using Chi-square and ANOVA one-way analysis tests. Results: More anterior MS pneumatization was detected in maxillary displaced canines compared to NDCs’ subjects. MS was extended to the incisor region in 20%, 10%, and 4%, and to canine region in 10%,12%, and 24.5% in PDCs, BDCs, and NDCs subjects, respectively (X2 = 19.22, p = 0.014). Significant differences between the right and left sides were detected, subsequently, right and left sides values were averaged (Table 1). PDCs subjects had a smaller lateral distance from the canine tip to MS wall compared to BDCs subjects (p < 0.05) and a reduced average vertical position of the canine tip to MS compared to NDCs subjects (P < 0.001). BDCs subjects had a larger vertical distance from canine tip to MS (p < 0.001), an increased MS volume (p < 0.01), and a reduced MS width (p < 0.05). Conclusion: MS showed anterior pneumatization in subjects with maxillary displaced canines. In BDCs’ subjects, MS showed lateral pneumatization. MS width and volume were larger in BDCs subjects compared to PDCs and NDCs subjects.

Background: Following the World Health Organization (WHO) recommendations to seek efficiency in the learning process¹, the Primary Care Department of Paris-Est University (UPEC) has adopted a competency-based learning model. At the UPEC, clinical writing notes (CWN) are required from challenging clinical training situations faced by residents. This study aims to describe the relationship difficulties with the patients encountered by UPEC's Family Medicine residents, based on their CWN. Methods: This is a retrospective qualitative/quantitative study. The CWN of UPEC's Family Medicine residents of the same cohort (52 residents) were collected over their 3-year residency program in 6 different locations. At least two relationships difficulties notes for every 6 months of training were required by the residents. 734 notes of patient–resident relationship difficulties were analyzed. For each note, the main patient–resident relationship difficulty was identified and coded according to the French repository of 11 major families of clinical situations², then organized according to the encountered difficulties and training location. Results: The most frequent relational difficulty was related to the management of patients with unjustified requests. Request for prescription of sick leaves, antibiotics³, and investigations were frequently a source of relational difficulties (Table 1). The situations causing relational difficulties were facility-dependent. In the emergency department: inpatient patients and patients with non-urgent medical conditions. In inpatient department: workload and lack of supervision. In Ambulatory clinic: unjustified patients’ requests for prescription and patients questioning the legitimacy of the resident as a physician. Faced with their difficulties, the residents described 3 types of patients: introverts, extroverts, and uncivil. The residents adopted a two-step strategy: the involvement phase, and then in case of failure, the detachment phase (Table 2). Conclusion: The relational difficulties encountered by Family Medicine residents at UPEC with their patients are facility dependent and frequently related to patients’ unjustified requests.

Background: Clinical reasoning is described as a reflective process that enables health care practitioners to collect data, solve problems, and make decisions and judgments to enhance patient outcomes and patient safety ¹. To avoid practice mistakes, healthcare professionals should possess or develop effective clinical reasoning skills. To develop effective clinical reasoning skills, enough exposure to various experiences is required. Practicing and developing clinical reasoning skills can be achieved in both clinical and simulated settings ². Using structured clinical reasoning models could enhance effective clinical reasoning development ³. This review aims to explore the current clinical reasoning models. Methods: A scoping review was undertaken to answer the question; what are the best available clinical reasoning models to enhance clinical reasoning in clinical and simulated settings? The following sources were searched: Medline; Scopus; Education Research Complete, and Google Scholar to identify relevant recent primary research conducted on this topic published in 2000 onwards. The search included [MeSH] topics of; “Clinical reasoning” and “Clinical Reasoning Models”. The inclusion criteria were primary studies that described the use of clinical reasoning models in clinical and simulated settings. Two independent researchers agreed on the inclusion of the identified papers for full-text review. This review followed the review guidelines of the Joanne Briggs institute. Results: There are valid clinical reasoning models to be used for clinical and simulated settings which are; TANNER, DML, clinical Reasoning Model (CRM), Outcome-Present State Test (OPT), and Self-Regulated Learning (SRL) model (Table 1). However, the validity of these models needs to be tested considering different health care specialties, the scope of practice, complexity, and seniority levels. Conclusion: Considering the importance of clinical reasoning skills in health care practices, using structured models could enhance the clinical reasoning process, however, despite the availability of clinical reasoning models, additional validation for these models is still required.

Background: A high level of emergency medical care is now expected from paramedics dealing with the sick and injured, including pediatric patients.^1,2 Very little is known of the paramedics’ perception of competency and of pediatric prehospital education and training, which is so critical to improve a paramedics’ knowledge and performance of important skills.^2,3 The purpose of this study was to determine if pediatric training resulted in a change in knowledge among paramedics from Hamad Medical Corporation Ambulance Service (HMCAS). Methods: A mixed-methods research approach was adopted to explore diverse perspectives. A comparison of all pre and post-test results for a pediatric Continuing Professional Development (CPD) course was conducted during the study period to determine whether knowledge was gained by paramedics. A survey was also used to conduct a retrospective analysis of the paramedics’ perception of pediatric training and to review their perceived level of competency. Results: The pediatric CPD course (Table 1) was conducted 33 times between January and November 2019. The average score difference between the pre and post-test indicates a gain in knowledge post-training across the participants (n = 51). The survey results (n = 33) revealed that there was an overall positive perception of the CPD course by paramedics and the impact it had on their learning and learning styles. Active learning strategies and hands-on practice were the recommended modalities by participants. The key findings are presented in Figure 1. Conclusion: HMCAS paramedics provided positive feedback on their pediatric training opportunities. Evaluating the effectiveness of all training provides valuable insight towards the improvement of the activity. Educators should have a fair knowledge and understanding of adult learning principles and the application of effective teaching and learning strategies when developing any CPD activity. Lastly, continual advances in patient care need to be reflected in all training programs.

Background: Qatar's National Health Strategy focuses on delivering care outside institutional settings in homes and communities. To successfully accomplish this, it is crucial to shift patient populations from being passive recipients of healthcare advice to active individuals taking control of their health.¹ This work describes Qatar's initial steps to measure and enhance patient activation. Methods: A two-phased approach was adopted as follows:

• Phase 1: Assessment

The Patient Activation Measure (PAM)^©2, a 13-question behavioral survey licensed through Insignia Health, was used to assess patient activation and ability to self-manage. A cross-sectional survey approach was adopted, in which 3,255 patients receiving governmental healthcare services were surveyed for the first time in Qatar between May 2020 and April 2021. • Phase 2: Enhancement

Clinical Health Coaching^©3, an innovative approach grounded in motivational interviewing delivered by the Iowa Chronic Care Consortium, was used to transform the nature of the conversation between healthcare providers and patients. Two rounds of training were conducted with over 70 healthcare professionals successfully completing a two-month training program finishing in November 2021.

Results: Being the first of its kind to be conducted in Qatar, the study found:

• Phase 1: Assessment

The PAM^© survey revealed that 21% of the patients were categorized as “feeling overwhelmed” (Level 1). 23% were “becoming aware” but still struggling (Level 2), 44% were categorized as “taking action” (Level 3) and 22% were categorized as “maintaining behaviors” (Level 4). • Phase 2: Enhancement

Training participants, to date, reported gaining practical skills to engage with patients to affect behavior change. Other key competencies gained included patient-centric care planning and building self-care skills. Conclusion: Patient activation is a critical factor in the successful delivery of healthcare services, particularly for patients with chronic or multiple chronic conditions. Measuring and improving patient activation has significant benefits to patients, providers, and health systems.

Background: The Coronavirus Disease 2019 (COVID-19) pandemic has triggered a global emergency in all social realms, including but not restricted to the economy, health, and education. The health sector requires all healthcare professionals to be well-equipped with the latest advances in knowledge and research through Continuing Professional Development (CPD) and postgraduate training programs such as residencies and fellowships.¹ These educational endeavors have been severely affected and potentially compromised since they heavily rely on learning through face-to-face interactive activities.²Methods: This is a narrative review that discusses the utilization of distance learning in CPD and postgraduate training programs, and the potential for a more active utilization in the post- COVID-19 era as one of the effective tools to meet healthcare practitioners’ education, training, and professional development needs. Results: Through this review, we propose a shift towards a more active utilization of online tools for on-site and distance healthcare training and CPD activities, via online platforms that offer video and audio facilities. The advantages of this approach include the flexibility of using such methods, being more convenient, cost-effective, as well as promising continuity even in challenging situations like the current pandemic, aiming at equipping healthcare personnel with the necessary skills and knowledge to ensure safe and effective care for their patients. This is in consideration to several key features for effective distance learning platforms.³Figure 1 is a conceptual framework that summarizes this approach and addresses the problem, solutions, and challenges to overcome. Conclusion: The current traditional educational model of healthcare training, education, and CPD have been challenged in terms of its effectiveness and continuity, especially during complicated situations like the COVID-19 pandemic. Therefore, this model needs to evolve and utilize distance learning solutions in the era post-COVID-19, in order to guarantee its continuity to equip healthcare workers with the needful skills for safe and effective patient care.

Background: Failed intubation is the single most important cause of patient morbidity and mortality during anesthesia for surgery. The incidence of difficult intubation could be as high as 12% while failed intubation is around 0.5%.¹ Disaster and mass casualty management may increase this risk multi-fold due to the paucity of airway-trained medical personnel.² Automation of the entire procedure could potentially save lives particularly in situations where mass casualties could happen without the immediate availability of skilled airway specialists. Thanks to the combination of existing technology involving 3-D image capture, artificial intelligence (AI), machine learning (ML) for image analysis, and robotics, airway management could be revolutionized. Work is already underway in this domain, but many challenges still need to be overcome to make the technology more practical and user-friendly.³Methods: Experts in the above fields from Hamad Medical Corporation (Qatar), Qatar University (Qatar), and Teesside University (UK) were brought together to collaborate on this potentially game-changing technological solution. The team includes clinicians specialized in airway management, engineers with a very strong track record of accomplishments in artificial intelligence and computer algorithm-based software development. The team is regularly meeting online to discuss the integration of the various technologies to develop a prototype automated device. Recommendations: A concept model based on Clinical-Technology-Research integration was arrived at as illustrated in Figure 1. The team is presently seeking funding to start the development of a working prototype combining AI, ML, and robotics. The planned work packages are briefly presented in Table 1. Conclusion: This work has shown that an automated device to disrupt the practice in airway management is feasible and could save lives particularly in disaster management and in geographical areas with a lack of clinicians with expertise in airway management.

Background: Cardiovascular disease (CVD) is the leading cause of death worldwide.¹ Unfortunately, CVD risk assessment and management (RAM) services face many challenges and barriers in the community. Mobile technology offers the opportunity to empower patients and improve access to health prevention strategies to overcome these barriers.² The purpose of this study was to pilot test the Arabic and English versions of the EPIRxISK™ CVD risk calculator in the public sector. Methods: Pilot testing of an Arabic and English version of the online application EPIRxISK™ for CVDRAM (Figure 1) was done by potential users from a sample consisting of the general population and pharmacists attending community pharmacies. Participants’ feedback was gathered in a qualitative interview which was recorded and transcribed for quality assurance and review by the research team. Responses from all interviews were analyzed and recommendations were made to finalize the application before phase II of the study. In phase II, quantitative and qualitative methods will be utilized to assess the feasibility of implementing a community pharmacy-based CVD risk assessment program using the English and Arabic versions of the EPIRxISK™ online application. Results: In phase I, a total of 9 pharmacists from community pharmacies and 5 general participants from the general population were interviewed. As shown in Table 1, the analysis of the interviews resulted in themes related to five frameworks: engagement, functionality, aesthetics, information, and subjective quality. Overall, the themes demonstrated acceptance and satisfaction with the features of the application. Phase II is currently in progress. Conclusion: The overall results of this study are indicative that the use of the EPIRxISK™ application for CVDRAM may be of benefit in Qatar, considering it is the first available in the Arabic language. The tool is likely well equipped to support continuous and standardized CVDRAM in Qatar's primary care sector.³

Background: Internet of Medical Things (IOMT) has the potential to monitor health continuously and in real-time. One of the main issues that arise in IOMT is how securely the data can be transmitted to the clinical team. In this project, biometric Identity-based encryption was utilized using the Fuzzy-IBE (Identity-based encryption) scheme that uses face features of the clinicians to create the public key. Figure 1 shows the testbed setup designed to improve the privacy and security of the patients’ healthcare data. Methods: The testbed comprises an ESP32 platform sensing and encrypting data, the Nvidia Jetson Nano for data collection and decryption, and the Thingsboard online platform for vital information visualization. Fuzzy Identity-Based Encryption (FIBE)^1–3 uses legitimate users’ facial features. The encrypted vital information is transmitted to the Edge-device (Jetson Nano) through BLE/Wi-Fi. On the edge-device of the healthcare system, the face authentication mechanism verifies the user's (clinician) legitimacy to assess the data. Upon user authentication, their facial features will be used to generate a private decryption key that can decrypt the received encrypted data. The data is further sent to the core cloud (Thingsboard) for storage and visualization. To secure the data on the cloud, we deployed an Intrusion Detection System (IDS) model using deep learning to identify the inter-domain stream of malicious traffic. Results: The face authentication testing using Fuzzy Identity-based Cryptography relied on a public data set. The execution time was calculated for Encryption (time to encrypt the patient's vital data using a public key of health physician's facial features) and decryption (time to match at least d components of the ciphertext and perform message decryption). The experimental results are reported in Table 1. Conclusion: In today's age of advanced telecommunication technology, cyber security is a very important factor. The designed testbed setup in this work showcases how healthcare data can be secured against malicious attacks.

Background: Effective communication among physicians and nurses in in-patient settings is associated with better patient care¹, increased teamwork, and job satisfaction², however, no literature has addressed the concern of the gap in perception of communication between physicians and nurses.³ this study aims to explore the perceptions of physicians and nurses toward proper communication and collaboration before and after an intervention. The study period encompassed before and during the COVID-19 pandemic. Methods: A cross-sectional pilot survey was administered in September-November 2015 in pediatrics in-patient wards at Hamad Medical Corporation (Doha, Qatar) followed by a post-intervention program survey in November-December 2020. The interventions included establishing a multidisciplinary unit-based council involving physicians and nurses, and a communication skills course for physicians. The questionnaire included details of demographics, perceptions towards proper communication, and collaboration in daily clinical practice. Questions used a 3-point Likert scale. Result: 124 responses (66% physician/44% nurses) were obtained in 2015 and 83 responses (51% physician/49% nurses) in 2020. The physicians’ reported perceptions improved for nearly all survey questions, often in a statistically significant way, but it was not the case for their enjoyment of collaboration which was reduced by 10% points (p = 0.01) (Table 1). The enjoyment of collaborating with the other professions declined for the physicians (p = 0.01) whereas it improved for the nurses, but it was not statistically significant (p = 0.06). For the nurses, their perception improved across all items, but less often in a statistically significant manner. In general, nurses had higher levels of satisfaction regarding communication and team collaboration (Figure 1). Conclusions: Our study showed that physicians and nurses’ perceptions improved post-interventions. Nurses seemed to be more affected by the interventions. The biggest effect was in decision sharing as both had almost a similar improvement. Promoting communication and collaboration in a complex clinical environment is paramount. Interventions such as multidisciplinary rounds and adapting structured communication tools improve organizational culture.

Background: Methanol, ethylene glycol, diethylene glycol, propylene glycol, and isopropanol are common alcohols, whose consumption can lead to toxicity and significant morbidity and mortality^1,2. Clinicians must often rely on clinical features and laboratory values to determine the possible causative agent. Annually, almost 95,000 people die due to alcohol and it is the third leading cause of preventable deaths in the United States of America³. Case presentation: A 53-year-old male patient reported to the Emergency Department with vomiting, severe chest, and abdominal pain for one day. He looked unwell and was unstable. The blood gases showed metabolic acidosis with lactate of 10-mmol/L. Investigations on the line of Acute Mesenteric Ischemia, Pulmonary Embolism, and Aortic Dissection were negative. With time, the patient deteriorated with severe metabolic acidosis requiring rapid sequence intubation. Blood investigations showed multi-organ failure, high serum osmolarity, and high osmolar gap. Later, he was admitted to the intensive care unit and underwent hemodialysis. His laboratory test results improved, and he was extubated. Eventually, he revealed having taken homemade alcohol. Recommendations: High Anion Gap is a hallmark of toxic alcohol poisoning. A potential toxic alcohol ingestion surrogate marker is an elevated osmol gap. Abnormal presentation and a patient hiding key information can delay the diagnosis. The key to successful early diagnosis is good history taking, patient collaboration, complete examination, and interpretation of laboratory results. Isopropyl alcohol is associated with nausea, vomiting, and abdominal pain since it is a gastrointestinal irritant. Magnetic Resonance Imaging of the brain can play a role in diagnosing toxic alcohol ingestion especially methanol, due to its characteristics findings like hemorrhagic putamen necrosis (Figure 1), however, clinical suspicion should not delay a patient's treatment. Conclusion: Abnormal presentations are quite common, and one should always keep a wide differential diagnosis in mind. Uncommon causes of severe metabolic acidosis could be easily missed. The main success factor in the management of toxic alcohol ingestion is to recognize it, do the calculations, and provide treatment.