Development and delivery of a higher diploma in emergency medicine and critical care for clinical officers in Kenya

The provision of emergency medicine and critical care in a cost-efficient manner has the potential to address many preventable deaths in low- and middle-income countries. Here, utilising Kern's framework for curriculum development, we describe the origins, development and implementation of the Emergency Medicine and Critical Care Clinical Officer training program; Kenya's first training programme for clinical officers in emergency medicine and critical care. Graduates are scattered across the country in diverse settings, ranging from national referral hospitals in the capital, Nairobi, to rural hospitals in northern Kenya. In these locations, they provide clinical care, leadership, and teaching. Similar programmes could be replicated in other locations to help plug the gap in critical care provision in Sub-Saharan Africa.

Challenges and opportunities to improve efficiency and quality of prehospital emergency care using an mHealth platform: Qualitative study in Rwanda

Introduction: Prompt, high-quality pre-hospital emergency medical services (EMS) can significantly reduce morbidity and mortality. The goal of this study was to identify factors that compromise efficiency and quality of pre-hospital emergency care in Rwanda, and explore the opportunities for a mobile health (mHealth) tool to address these challenges. Methods: In-depth interviews were conducted with 21 individuals representing four stakeholder groups: EMS dispatch staff, ambulance staff, hospital staff, and policymakers. A semi-structured interview guide explored participants' perspectives on all aspects of the pre-hospital emergency care continuum, from receiving a call at dispatch to hospital handover. Participants were asked how the current system could be improved, and the potential utility of an mHealth tool to address existing challenges. Interviews were audio-recorded, and transcripts were thematically analyzed using NVivo. Results: Stakeholders identified factors that compromise the efficiency and quality of care across the prehospital emergency care continuum: triage at dispatch, dispatching the ambulance, locating the emergency, coordinating patient care at scene, preparing the receiving hospital, and patient handover to the hospital. They identified four areas where an mHealth tool could improve care: efficient location of the emergency, streamline communication for decision making, documentation with real-time communication, and routine data for quality improvement. While stakeholders identified advantages of an mHealth tool, they also mentioned challenges that would need to be addressed, namely: limited internet bandwidth, capacity to maintain and update software, and risks of data security breaches that could lead to stolen or lost data. Conclusion: Despite the success of Rwanda's EMS system, this study highlights factors across the care continuum that could compromise quality and efficiency of prehospital emergency care. Mobile health tools hold great promise to address these challenges, but contextual issues need to be considered to ensure sustainability of use.

A prospective descriptive study on emergency medicines used most frequently from the emergency medicine packs at Universitas Academic Hospital and the associated financial loss of expired emergency medicines

Resuscitation trolleys with equipment and medicines for emergencies are required in all clinical areas in hospitals. Emergency medicines kept separately are more likely to expire than non-emergency medicines, as these are generally used less frequently. An updated list of essential emergency medicines was implemented in 2016 at an academic hospital in central South Africa. The aim of this study was to determine the frequency of both the use and the expiry, with associated financial losses, of the emergency medicines on this list. Methods: A prospective, descriptive study was conducted over a six-month period in 2019. Forms accompanying the emergency packs were returned to the pharmacy whenever packs expired or were opened. These forms were collected and the type and quantity of medicines either used or expired were recorded. Results: In total, 168 of the returned forms were included. The most frequently used emergency medicines were adrenaline, sodium bicarbonate and Ringer's lactate. Adrenaline use was recorded on 52.8% and 25% of the forms from the adult/paediatric and neonatal emergency packs, respectively. Medicines that were never used included: betamethasone, Darrow's half-strength solution and most of the neonatal pack medications. Neonatal emergency medicine packs were rarely used and the neonatal fluid packs were never used. The total cost of the expired medicines was R7 960.29 (US$569.41 at the time of the study). Adrenaline was the medication that expired most frequently but the greatest financial losses occurred from expired sodium bicarbonate. Conclusion: The total financial losses were low but can be reduced further. The contents of the emergency packs should be reviewed to possibly reduce the amount of items used infrequently. Also, the removal of those items not recommended in emergency care guidelines could be considered. Ensuring the policy was followed of returning unused medicines close to expiry and redistributing these to high-use areas would further reduce wastage

What presents to a rural district emergency department: a case mix

Background: There is little information available on the range of conditions presenting to generalist run rural district hospital emergency departments (EDs) which are the first point of acute care for many South Africans. Aim: This study aims to assess the range of acute presentations as well as the types of procedures required by patients in a rural district hospital context. Setting: Zithulele is a 147-bed district hospital in rural Eastern Cape. Methods: This is a cross-sectional study assessing all patients presenting to the Zithulele hospital emergency department from 01 October 2015 to 31 December 2015. Data collected included the triage acuity using the South African Triage Scale system, patient demographics, diagnosis, outcome and procedures performed. Diagnoses were coded retrospectively according to the international statistical classification of diseases and related health problems version 10 (ICD 10). Results: Of the 4 002 patients presenting to the ED during the study period, 2% were triaged as emergencies and 45% as non-urgent. The most common diagnostic categories were injuries, infections and respiratory illnesses respectively. Diagnoses from all broad categories of the ICD-10 were represented. 67% of patients required no procedure. Diagnostic procedures (n = 877) were more prevalent than therapeutic procedures (n = 377). Only 2.4% of patients were transferred to a referral centre acutely. Conclusion: Patients with conditions from all categories of the ICD-10 present for management at rural district hospitals. Healthcare professionals working in this setting need to independently diagnose and manage a wide range of ED presentations and execute an assortment of procedures

Drug dosing errors in simulated paediatric emergencies ­ Comprehensive dosing guides outperform length-based tapes with precalculated drug doses

Background: The accuracy of drug dosing calculations during medical emergencies in children has not been evaluated extensively. The objectives of this study were to evaluate the accuracy of drug dose calculations using the Broselow tape, the PAWPER XL tape plus its companion drug-dosing guide, a custom-designed mobile phone app and no drug-dosing aid (control group). Methods: This was a prospective study in which 32 emergency medicine volunteers participated in eight simulations of common paediatric emergency conditions, using children models. The participants used the three methods to estimate the children's weight and calculate drug doses. The accuracy of and time taken for the drug dose determinations were then evaluated for each of the methods. Results: The overall accuracy of drug dose determinations was extremely and potentially dangerously low in the control group in which no dosing guide was used as well as in the Broselow tape group (<20% of doses were correct). The accuracy was significantly higher with the PAWPER XL tape group and the mobile app group (47% and 31% respectively). The times taken to obtain the required information did not differ in a clinically meaningful magnitude. Conclusions: Both an accurate weight estimation and a dosing guide with comprehensive information were necessary to produce an accurate prescription. The information on the Broselow tape was not sufficient for this purpose. The current guidelines recommending the use of tapes with limited information should be revised. The results from the comprehensive dosing guides were substantially better, but still had a lower proportion of accurate prescriptions than desirable. The role of training in every aspect of the emergency paediatric weight estimation and drug dosing procedure cannot be underestimated and should be routine in any environment where emergency care may be needed

Paediatric Emergency Department preparedness in Nigeria: a prospective cross-sectional study

Introduction: Paediatric emergency medicine (PEM) is poorly developed in low and middle-income countries. The magnitude of challenges facing Paediatric Emergency Departments (PEDs) in Nigeria has not been well described. This study aimed to assess paediatric emergency care preparedness across PEDs in Nigeria. Methods: This was a prospective cross-sectional study that utilized a self-administered questionnaire and a check list to assess three key domains (managerial, medication and equipment) in tertiary care PED facilities that were recruited across Nigeria. Preparedness scores and other institutional attributes were compared between zones and regions. Results: Thirty-four tertiary-level PEDs across Nigeria were included. The mean number of patient visits over the 30-day period prior to data collection was 253.2 ( ± 261.2). The mean (SD) managerial, medication and equipment performance scores of the included PEDs were 42.9% ( ± 14.3%), 50.7% ( ± 22.3%) and 43.9% ( ± 11.8%) respectively. The mean (SD) total performance score was 46.9% ( ± 15.3%). Only 13 PEDs had a total performance score of > 50%. There was a statistically significant higher mean equipment score (p = 0.029) in the Southern region (47.6 ± 3.1) compared to the Northern region (38.9 ± 2.3) of the country. Conclusions: This study reports a global but remediable deficiency in emergency care preparedness amongst PEDs in tertiary care facilities in Nigeria. This study highlights the need for training of PED managers in basic and advanced life support and for the improvement in medication and equipment procurement across Nigeria

Evolution des patients opérés en médecine humanitaire dans une zone de conflit au Mali : Une série de 63 cas

Introduction : La pratique de l'anesthésie en médecine humanitaire est contraignante. Elle l'est davantage dans un pays à ressources limitées et à faible revenu en période de conflit. Objectif : Décrire le devenir des patients opérés en médecine humanitaire dans une zone de conflit à Niono au Mali. Méthodologie : Il s'agissait d'une étude prospective et descriptive sur une période 30 jours. La saisie et l'analyse ont été faites par Windows 8, Epi info 3.5.3.fr et le khi² pour le test statistique. Résultats : Au total, 63 patients étaient colligés pendant la période d'étude. La moyenne d'âge était de 33,3 ± 18, 5 ans et une prédominance du sexe féminin. Les urgences représentaient 65,1% des cas. L'indication opératoire était gynécologique ou obstétricale dans 63, 5% des cas, suivie de la chirurgie viscérale (20,6%), de l'urologie (11,1%) et la traumatologie dans 4,8% des cas. Les patients étaient ASA I dans 69,8% et de la classe Altemeier II dans 81%. Une antibioprophylaxie était instaurée dans 88,9% des cas. Une anesthésie générale a été faite dans 76,2% suivie de la rachianesthésie dans 11,1%. Un évènement per opératoire était observé dans 66,7% des cas. La survenue d'une complication infectieuse était notée dans 11, 1% des cas. Il s'agissait d'une suppuration pariétale dans 57,1%, un sepsis sévère, une fistule vésico-pariétale et un choc septique dans 14,3% chacun. La durée médiane d'hospitalisation était de 4, 19 jours. L'évolution était favorable dans 98,4%. Conclusion : Dans nos pays, le conflit armé influence la bonne organisation du système de santé avec une augmentation de la morbidité-mortalité

Needs assessment for a formal emergency medicine residency program in southern Madagascar

Introduction:World Health Organization data for Madagascar reveal that the nation's under age five mortality rate is 56/1000, and that its maternal mortality rate is 440/100,000. Malaria, leprosy, plague, and tuberculosis remain significant communicable disease threats. Malnutrition rates are improving but continue to impact negatively on the general health of the Malagasy population, especially in the southern region with its 1.9 million inhabitants. There are no emergency medicine (EM) training programs to serve the southern half of Madagascar, which has a large urban population in Fianarantsoa. This study aimed to assess the need for and potential feasibility of an emergency medicine training program in southern Madagascar. Methods:We met with the institutional leadership on site at the university hospital in Fianarantsoa. A needs assessment was performed on multiple domains. Domain 1: existing hospital infrastructure and its physical plant and emergency centre (EC) space allotment. Domain 2: existing clinical and technological resources. Domain 3: educational resources and the existing curriculum for EM. Domain 4: medical student educational program and availability of prospective residency candidates. Domain 5: pre-hospital care and emergency medical services.Results: The size of the EC is adequate for the current census. Clinical resources are typical of many developing countries, with significant need for technological advancement and support, which we delineate in the body of our paper. There is an existing curriculum in Antananarivo and in Majanga, as well as one available through the African Federation for Emergency Medicine. The medical school in the area is relatively new, with graduating classes numbering approximately 30. There is no organised pre-hospital care system, no 9-1-1 equivalent, and no pre-hospital treatment from within metropolitan Fianarantsoa. Conclusions:While the needs assessment indicates substantial need for emergency medicine development in southern Madagascar, the yield (particularly for the metropolitan Fianarantsoa area) would serve the population well

Rapid, remote education for point-of-care ultrasound among non-physician emergency care providers in a resource limited setting

Introduction : Access to high-quality emergency care in low- and middle-income countries (LMIC) is lacking. Many countries utilise a strategy known as "task-shifting" where skills and responsibilities are distributed in novel ways among healthcare personnel. Point-of-care ultrasound (POCUS) has the potential to significantly improve emergency care in LMICs.Methods:POCUS was incorporated into a training program for a ten-person cohort of non-physician Emergency Care Providers (ECPs) in rural Uganda. We performed a prospective observational evaluation on the impact of a remote, rapid review of POCUS studies on the primary objective of ECP ultrasound quality and secondary objective of ultrasound utilisation. The study was divided into four phases over 11 months: an initial in-person training month, two middle month blocks where ECPs performed ultrasounds independently without remote electronic feedback, and the final months when ECPs performed ultrasounds independently with remote electronic feedback. Quality was assessed on a previously published eight-point ordinal scale by a U.S.-based expert sonographer and rapid standardised feedback was given to ECPs by local staff. Sensitivity and specificity of ultrasound exam findings for the Focused Assessment with Sonography for Trauma (FAST) was calculated.Results:Over the study duration, 1153 ultrasound studies were reviewed. Average imaging frequency per ECP dropped 61% after the initial in-person training month (p = 0.01) when ECPs performed ultrasound independently, but rebounded once electronic feedback was initiated (p = 0.001), with an improvement in quality from 3.82 (95% CI, 3.32­4.32) to 4.68 (95% CI, 4.35­5.01) on an eight-point scale. The sensitivity and specificity of FAST exam during the initial training period was 77.8 (95% CI, 59.2­83.0) and 98.5 (95% CI, 93.3­99.9), respectively. Sensitivity improved 88% compared to independent, non-feedback months whereas specificity was unchanged.Conclusions : Remotely delivered quality assurance feedback is an effective educational tool to enhance provider skill and foster continued and sustainable use of ultrasound in LMICs

The status of emergency medicine in Ethiopia, challenges and opportunities

Back ground: Emergency medicine(EM) is one of the most rapidly developing medical specialties in Africa. After just 8 years since its introduction in Ethiopia, there were 22 qualified emergency medicine specialists and 2 pediatric emergency specialists in the country. The aim of this study was to qualitatively assess the status of emergency medicine and the challenges and opportunities of working as an emergency physician in Ethiopia.Methodology: An interview and a videotaped focus group discussion involving 17 selected participants were done in December of 2016. The data was transcribed, translated and analyzed by identifying the most common themes that emerged.Result: All the participants agreed the field of emergency medicine is rapidly expanding in Ethiopia. Six themes were identified as challenges: The undeveloped state of the emergency medical system, the disorganization prevalent in emergency rooms, an undefined scope of practice, problems with acceptance of the specialty, poor continuity of care, and an unsatisfactory remuneration. Meanwhile, the increasing attention given by the government and the demand for pre-hospital and in hospital emergency care were identified as future opportunities for growth of the specialty. Conclusion: Emergency medicine in Ethiopia faces multiple challenges as it is a new field in a resource limited setting. The challenges range from problems with acceptance to difficulties of patient disposition. In order to overcome these challenges, government level support and advocacy work among health sectors, physicians, and medical associations is imperative

Essential medicines for emergency care in Africa

Essential medicines lists (EMLs) are efficient means to ensure access to safe and effective medications.The WHO has led this initiative, generating a biannual EML since 1977. Nearly all countries have implemented national EMLs based on the WHO EML. Although EMLs have given careful consideration to many public health priorities, they have yet to comprehensively address the importance of medicines for treating acute illness and injury.Methods:We undertook a multi-step consensus process to establish an EML for emergency care in Africa. After a review of existing literature and international EMLs, we generated a candidate list for emergency care. This list was reviewed by expert clinicians who ranked the medicines for overall inclusion and strength of recommendation. These medications and recommendations were then evaluated by an expert group. Medications that reached consensus in both the online survey and expert review were included in a draft emergency care EML, which underwent a final in-person consensus process.Results:The final emergency care EML included 213 medicines, 25 of which are not in the 2017 WHO EML but were deemed essential for clinical practice by regional emergency providers. The final EML has associated recommendations of desirable or essential, and is subdivided by facility level. Thirty-nine medicines were recommended for basic facilities, an additional 96 for intermediate facilities (e.g. district hospitals), and an additional 78 for advanced facilities (e.g. tertiary centres).Conclusion:The 25 novel medications not currently on the WHO EML should be considered by planners when making rational formularies for developing emergency care systems. It is our hope that these resource-stratified lists will allow for easier implementation, and will be a useful tool for practical expansion of emergency care delivery in Africa

African federation for emergency medicine's francophone working group ­ may 2018 report

Even though the African Federation for Emergency Medicine (AFEM) has been successfully developing emergency care in Africa for the past nine years, a considerable amount of potential AFEM members from the African-Francophone countries are not able to access AFEM resources. In response, an AFEM Francophone Working Group has been created to coordinate all existing and new initiatives to promote emergency care in African-Francophone countries

Urgences et médecine de catastrophe

La concentration humaine et urbaine, le développement des technologies , les menaces de destruction et de contamination sont à l'origine d'une prise de conscience de la nécessité d'une assistance civile. L'aide médicale urgente, qui s'affirme et s'oriente vers une médecine de réseau, en partenariat avec toutes les structures concourant à l'urgence, participe à la rationalisation de la politique sociale. Les acteurs de l'aide médicale urgente contribuent ainsi à sauvegarder, tout en l'améliorant, un secteur sanitaire et social qui est désormais l'un des fondements de la démocratie et l'une de ses assises face aux défis du futur

Telemedicine and e-health in Algeria facing challenges in medical practice

The Algerian health system operates in a demographic, economic, environmental, and societal specific context to meet the challenges of epidemiological transition. Development of information and communication technologies in this atmosphere allow telemedicine and e-health emergence in the vast country of Algeria. Thus, the country may face these challenges by including them in a national telemedicine plan and making a major focus of global action for the prevention and control of prevalent diseases. The interest to adopt this tool in daily practice stems from an improvement in the quality of communication between practitioners and in the doctor­patient relationship with a possibility of quick access to care and more efficient care pathways. Thus, national goals in fight plans against diseases will be achieved. Telemedicine and e-health projects that methodologically well-defined, respecting regulations and using all means and all available resources, including WHO mobile health, are to be designed and implemented in all areas, especially in the national plan against not-communicated diseases, maternal and child health, old aging health, and mental health. This approach will integrate telemedicine in the health care system whose inevitable implementation can be done on solid foundations and will be actively supported by SATeS

Undergraduate emergency medicine in an african medical school : experiences from Botswana

Introduction: In August 2011; the first cohort of students at the University of Botswana School of Medicine (UBSOM) began their third year of undergraduate medical training. As part of their 2011-2012 curriculum they each completed a 10 week rotation in Emergency Medicine (EM); involving problem based learning (PBL) sessions; maintenance of log books; case presentations; and clinical time at the Emergency Centre (EC) of the main tertiary referral hospital in Gaborone; Princess Marina Hospital. Methods :Since EM rotations are often undertaken in the final year of medical training; students were given an anonymous voluntary survey to study the effect of an EM experience in their first clinical year of training. A 5-point Likert scale was used to evaluate learning opportunities and the overall EM experience. Students described which procedures they had observed or performed in their rotation. The survey concluded with open-ended questions seeking additional feedback. Results : These were very encouraging for both early exposure to EM and the PBL approach. More than 90 of students agreed or strongly agreed that they felt more confident in clinical settings; improved their clinical decision making process; and found the PBL model to be effective over the rotation. 22 different procedures were observed in the EC with 100 observing venesection and plaster applications. 14 different procedures were performed with 83 students performing venesection and over 65 performing chest compressions and venous cannulation. Discussion : It is hoped that this study will provide valuable practical information about undergraduate EM learning in a PBL based Medical School within Sub Saharan Africa that can be replicated across other medical education institutions throughout the region

Acute care in Tanzania: epidemiology of acute care in a small community medical centre

Introduction :Without uniform recognition of Emergency Medicine as a specialty in developing sub-Saharan African countries; data are limited on the epidemiology of emergency care needs. The purposes of this study were to quantify the burden of disease presenting as medical or surgical emergencies and describe the patient population at a small community medical centre in the Republic of Tanzania. Methods : An observational study was conducted from March to June 2011 at the University of Arusha (UOA) Medical Centre in Arusha; Tanzania. All consenting patients presenting with acute illness or injury were eligible for inclusion in the study. A standardized form was used to record demographic information; chief complaint; diagnosis/diagnoses; procedure(s); treatment(s); and disposition. Results : Data were collected on 719 patients; with a mean age of 21.8 years (range neonate to 83 years). Fever (19.5); respiratory (17.5); and gastrointestinal complaints (15.0) were the top three chief complaints; 94.9 of chief complaints were atraumatic. The top three diagnoses included respiratory infection (22.1); malaria (21.4); and skin or soft tissue infection (7.9). Forty-three percent of patients required no procedures or tests; and 42 required only one procedure or test. Of treatments administered; 67.6 were analgesics; 51.3 were cough medications; and 47.6 were antipyretics. Ninety-seven percent of patients were discharged home after their visits. Discussion: Respiratory infections; malaria; and skin or soft tissue infections are leading reasons for seeking medical care at a small community medical centre in Arusha; Tanzania; highlighting the burden of infectious diseases in this type of facility. Males may be more likely to present with trauma; burns; and laceration injuries than females. Many patients required one or no procedures to determine their diagnosis; most treatments administered were inexpensive; and most patients were discharged home; suggesting that providing acute care in this setting could be accomplished with limited resources

The state of emergency care in the Republic of the Sudan

Sudan is one of the largest African countries; covering an area of 1.9million km2-approximately one fifth of the geographic area of the United States. The population is 30million people; the majority of whom (68) live in rural areas; as compared with the sub-Saharan African average of approximately 62. Sudan is considered a lower-middle income country-with 47 of the population living below the poverty line and a gross domestic product (GDP) of US $62billion in 2010. In addition to excessive burden of communicable diseases such as malaria; tuberculosis; and schistosomiasis; Sudan is particularly susceptible to both natural and manmade disasters. Drought and flood are quite common due to Sudan's proximity to and dependency on the Nile; and throughout history Sudan has also been plagued with internal conflicts and outbreaks of violence; which bring about a burden of traumatic disease and demand high quality emergency care. The purpose of this paper is to describe the state of emergency care and Emergency Medicine education; and their context within the Sudanese health care system. As is the case in most African countries; emergency care is delivered by junior staff: new graduates from medical schools and unsupervised medical officers who handle all types of case presentations. In 2001; increased mortality and morbidity among unsorted patients prompted the Ministry of Health to introduce a new triage-based emergency care system. In late 2005; twenty-one Emergency physicians delivered these new Emergency Services. In 2011; following a curriculum workshop in November 2010; the Emergency Medicine residency program was started in Khartoum. Currently there are 27 rotating registrars; the first class of whom is expected to graduate in 2015

Development of emergency medicine in Rwanda

"Rwanda; known as the ""Land of a Thousand Hills;"" is a small; East African country that was the site of the devastating 1994 genocide. In the past 18years; this post-conflict country has made tremendous progress in rebuilding itself and its health infrastructure. The country has recovered or surpassed many of its pre-1994 health levels; including reduction in HIV/AIDS prevalence; under-five mortality and road traffic accidents. Nevertheless; Rwanda continues to face a high burden of disease. The leading causes of mortality in Rwanda include complications of HIV/AIDS and related opportunistic infections; severe malaria; pulmonary infections; and trauma; and are best managed with emergency and acute care services. However; health care personal resources remain significantly lacking; and there is currently no emergency medicine-trained workforce. The Rwandan government; partnering with international organizations; has launched a campaign to improve human resources for health; and as a part of that effort the creation of training programs in emergency medicine is now underway. The Rwandan Human Resources for Health program can serve as a guide to the development of similar programs within other African countries. The emergency medicine component of this program includes two tracks: a 2-year postgraduate diploma course; followed by a 3-year Masters of Medicine in Emergency Medicine. The program is slated to graduate its first cohort of trained Emergency Physicians in 2017."

Place de la medecine d'urgence dans le systeme sanitaire Ivoirien : cas du SAMU

Entite tripartite regroupant le SMUR; le CENTRE d'HeMODIALYSE et le CENTRE des GRANDS BRuLES; le SAMU a ete cree par decret presidentiel le 14 Avril 1976. Notre travail est une etude retrospective a visee descriptive qui a porte sur cinq annees d'activites du 1er Janvier 1999 au 31 Decembre 2003 et qui a releve 75 219 interventions hormis les actes de laboratoire et de production d'acetate. Ces activites sont realisees a 50;23 pour cent par le centre d'hemodialyse (37 784 dialyses) a 30;85 pour cent par le centre des grands brules (23 210 actes) et a 18;92 pour cent par le SMUR. Toute cette activite de soins est soutenue par l'action du laboratoire produisant 186 500 Litres de dialysat pour le centre d'hemodialyse et realisant 22 309 examens de laboratoire pour les insuffisants renaux; les grands brules et le grand public. Au niveau du SMUR; les activites ont ete dominees par les transports medicalises (67pour cent) emanant pour la plus part des particuliers (72pour cent) et provenant essentiellement des communes de Cocody (35pour cent) et Yopougon (22pour cent).Les motifs d'appels ont ete domines par la traumatologie (19;84pour cent) et la neurologie (15;30 pour cent). Les problemes entravant le fonctionnement de la structure ont ete releves et des recommandations proposees en vue d'un developpement repondant aux normes de qualite