Successful emergency medical service training with virtual field trips using video during the COVID-19 pandemic: the Official Development Assistance Project in Uzbekistan / 한국의학교육

Purpose@#The coronavirus disease 2019 pandemic saw many restrictions on the provision of emergency medical service (EMS) training through actual field trips (AFTs), requiring a search for alternatives. This study aimed to assess trainees’ reactions to virtual field trips (VFTs) and determine the characteristics of instructional design for successful VFTs using edited videos and expert interviews. @*Methods@#This study evaluated Uzbekistan trainees’ reactions to the VFT of EMS training using questionnaires in three categories: satisfaction, relevance, and engagement. Factors of satisfaction and dissatisfaction were identified through open-ended questions. @*Results@#A total of 286 trainees responded to the survey during 15 educational sessions conducted from 2020 to 2022. The trainees’ responses to the VFT were positive. Overall mean scores were 4.65±0.49, 4.63±0.50, and 4.63±0.50 out of 5 points for satisfaction, relevance, and engagement, respectively. The trainees reported that the most interesting and helpful videos concerned the introduction of an EMS training curriculum and the observation of training facilities, such as the simulation centers of educational institutes. The leading causes of satisfaction were (1) authenticity of the VFTs, (2) easy-to-understand content, and (3) relevance to the job. The trainees suggested that Uzbek or Russian voice-overs would be better than subtitles in the video clip for focusing on VFT. @*Conclusion@#In situations where AFTs are not available, VFTs using edited videos and expert interviews are a good alternative to EMS education. Based on these results, it is possible that AFTs could be replaced by VFTs using qualified videos with designed instructions as a distance learning method under specific conditions.

Awareness and attitude on international emergency medicine: a resident survey

OBJECTIVE: International emergency medicine (IEM) is a rapidly growing field in emergency medicine (EM). However, there are few studies of the interest and attitude of EM residents on this subject in Korea. The aim of this study was to assess the awareness of IEM and determine feasibility of adoption as an EM residency program. METHODS: A structured on/off-line survey was distributed to all current first to third grade EM residents in Korea (year 2016–2017). Ninety-two hospitals with residency programs and 463 residents were identified as potential survey candidates. The survey consisted of 20 questionnaires including binary yes/no and multiple choice questions. RESULTS: The response rate was 37.1% (172/463). The proportion of residents who have interest in IEM was 62.8% (108/172); 76.2% (131/172) respondents answered that they wanted to participate in IEM/global health activities during their residency. Approximately two thirds (68.6%, 118/172) reported that they plan to participate in any IEM activity even after graduation. More than half (56.4%, 97/172) agreed that the inclusion of IEM/global health training in their residency might be necessary and it may help them to guide their future careers after their training (68.6%, 118/172). A total of 144 respondents (83.7%) indicated lack of time during their residency mostly, absence of an IEM program (47.1%, 81/172), and lack of information on IEM (31.4%, 54/172). CONCLUSION: IEM is of interest to Korean EM residents. On the other hand, formal education and training offered to residents is limited in Korea. Korean Society of Emergency Medicine should start discussions on how to adopt a global IEM agenda, and reflect on a resident training program.

Radiographic basal ganglia abnormalities secondary to nonketotic hyperglycemia with unusual clinical features

A 77-year-old woman was admitted to a local clinic for altered consciousness and presented with a suspected basal ganglion hemorrhage detected on brain computed tomography. The patient was stuporous, but her vital signs were stable. Her initial blood glucose was 607 mg/dL, and a hyperdense lesion was found in the right basal ganglion on brain computed tomography. T1-weighted magnetic resonance imaging revealed high signal intensity in the right basal ganglion. Electroencephalography showed no seizure activity. The patient was treated with a fluid infusion, and serum glucose level was controlled with insulin. The patient gradually recovered consciousness and was alert within 24 hours as serum glucose level normalized. The basal ganglion lesion caused by hyperglycemia was not accompanied by involuntary limb movement. This is the first report of a patient presenting with decreased consciousness and typical neural radiographic changes associated with nonketotic hyperglycemia but without movement abnormalities.

Utility of the Rapid Emergency Medicine Score (REMS) for Predicting Hospital Mortality in Severely Injured Patients

PURPOSE: We evaluated the power of the Rapid Emergency Medicine Score (REMS) for predicting hospital mortality in trauma patients. Then, we compared the REMS with two other scoring systems, the Emergency Trauma Score (EMTRAS) and the Injury Severity Score (ISS) for predicting prognosis. METHODS: We examined data from a prospectively collected registry in a single trauma center from January 2010 to November 2011. Patients enrolled in the registry were trauma patients who were predicted to have an ISS>15 or who required urgent multiple surgical consultations as soon as possible. Pediatric patients (<18-years-old) who were referred after initial care or death on arrival, and those with injuries due to burns, asphyxia, or drowning were excluded. The study population was divided into two subgroups according to hospital mortality, and the differences in clinical characteristics and calculated scores were examined. The odds ratio (OR) of REMS for predicting In-hospital mortality was calculated and the prognostic power of the three scoring systems for predicting hospital mortality by drawing receiver operating characteristic (ROC) curves was compared. RESULTS: A total of 103 patients were included in the analysis. Of these, 44 died during hospitalization. All three prognostic scores were significantly higher in the hospital mortality subgroup. The OR of the REMS for predicting hospital mortality was 1.35 (p<0.001). The areas under the ROC curves of the REMS, EMTRAS, and ISS were 0.815 (95% confidence interval [CI], 0.727-0.884), 0.872 (95% CI, 0.793-0.930), and 0.693 (95% CI, 0.595-0.780), respectively. The area under the ROC curve of the REMS was not different from that of the EMTRAS or ISS. CONCLUSION: The REMS showed good prognostic power for predicting hospital mortality in severely injured patients. Consecutive prospective studies are warranted to determine the utility of this scoring system for trauma patients.

A Study on Heuristic Transportation Routes of Patients with Acute Dysbarism for the Best Prognosis

PURPOSE: Acute dysbarism is a potentially lethal injury associated with environmental medicine. Therefore, prompt treatment, including transportation of victims, is important for the best prognosis. The aim of this study was to examine transportation routes of patients with acute dysbarism for the best prognosis in Korea. METHODS: Geography of South Korea was analyzed using the geographic information system (GIS). The study examined two scenarios using transportation analysis, which relies on a GIS base and pressure variation during air and ground transportation. Given the practical assumptions, we propose some heuristic transportation routes based on the simulation of altitude, transportation time, and availability of related factors. RESULTS: Currently, transportation by ground to the treatment facilities always passes high altitude areas above 152 feet. Also, available helicopters for air transportation could not approach the treatment facilities due to the limitation of flying distance and insufficiency of medical staff and treatment equipment. Altitude variation and delayed time were identified during the period of transportation by ground from Ganneung or Incheon to Tongyoung. Heuristic algorism through the above facts recommends air transport along coasts as the best method for transportation from Ganneung or Incheon to Tongyoung. CONCLUSION: In Korea, transportation by ground was not expected to result in the best prognosis for patients with acute dysbarism. Transportation by air should be considered first as the method of transportation. Also, for the best treatment of patients with acute dysbarism, additional treatment facilities need to be established in the west coast region.

Hematological Parameters Predicting Complications of Caustic Ingestion: A Retrospective Study

PURPOSE: In addition to chemical burn of the alimentary tract, caustic ingestion can cause severe complications including esophageal perforation, airway edema, esophageal stricture, and death. Hematological parameters have been reported to be useful inflammatory markers predicting prognoses in various clinical situations where oxidative stress is increased. We hypothesized that hematological parameters might be useful for prediction of complications after caustic ingestion. METHODS: We performed a retrospective analysis of patients admitted to our Emergency Department after caustic ingestion. The numbers of leukocytes, neutrophils, lymphocytes, and monocytes, and the neutrophil-lymphocyte ratio were compared between uncomplicated and complicated patient groups. Receiver operating characteristic curve analysis was performed for parameters that differed between the two groups. Subgroup analysis was performed according to the substance ingested, thus acid or alkali. RESULTS: Thirty-seven patients were included in our study and eight had complications. Leukocyte, neutrophil counts, and the neutrophil-lymphocyte ratio of the complicated group were higher than those of the uncomplicated group. The areas under the receiver operating characteristic curves of leukocyte counts, neutrophil counts, and the neutrophil- lymphocyte ratio, were 0.819, 0.832, and 0.750, respectively. The cut-off values of these parameters for prediction of complications were 12 060/uL, 9607/uL, and 2.72, respectively. In subgroup analysis, the leukocyte and neutrophil counts, and the neutrophil-lymphocyte ratio of complicated patients who had ingested alkali were higher than those of the uncomplicated group. CONCLUSION: Leukocyte counts, neutrophil counts, and the neutrophil-lymphocyte ratio might serve as useful predictors of complications after ingestion of caustic substances.

Is Unenhanced Abdominal CT Scan Necessary for the Diagnosis of Acute Appendicitis in Children?

PURPOSE: This study was designed to evaluate the question of whether a computed tomography (CT) protocol without an unenhanced phase could be used for diagnosis of appendicitis in pediatric patients who visited the emergency department (ED) with acute non-traumatic right lower abdominal pain. METHODS: We retrospectively selected 100 samples from pediatric abdominal CT scans performed in the ED and read by pediatric radiologists. Thirty emergency physicians were separately asked to evaluate the samples twice. The first evaluation was performed without the unenhanced phase (protocol A). The second evaluation was performed with both the unenhanced phase and the contrast-enhanced phase (protocol B). The sensitivity and specificity of each protocol for diagnosis of suspected acute appendicitis were determined. Intraobserver and interobserver agreements were measured using kappa statistics. RESULTS: The mean sensitivity and specificity of the two protocols were similar. The sensitivities of protocol A and protocol B were 97.13% (95% Confidence interval=96.13-98.14) and 97.60% (96.67-98.53), respectively. The specificities of protocol A and protocol B were 95.47% (94.34-96.59) and 94.67% (93.33-96.00), respectively. The mean kappa value for intraobserver agreement between results from the two protocols was 0.91 (0.88-0.93). The kappa value for interobserver agreement was 0.90 (0.89-0.91) for protocol A and 0.87 (0.86-0.88) for protocol B. CONCLUSION: It is feasible to perform a CT scan without an unenhanced phase for evaluation of suspected appendicitis in children with abdominal pain visiting the ED.

A Comparison of Passive Release Technique and Minimal Occlusive Volume Technique for Endotracheal Tube Cuff Inflation

PURPOSE: Inflation of an endotracheal tube cuff with adequate pressure is an important procedure. Passive release technique (PRT) is a useful and convenient method for inflating the cuff. To date, no study comparing this method with minimal occlusive volume technique (MOVT), one of the most commonly used methods for inflating the cuff, has been reported. We conducted this study for comparison of effectiveness, difficulty, and preference between the two methods. METHODS: We conducted a prospective, crossover, randomized study in which participants used each technique, one at a time. Participants inflated the cuff of an endotracheal tube inserted into a manikin after receiving brief education on use of the two methods. After inflating the cuff using each method, pressure and volume of the inflated cuff were measured using a portable manometer and syringes, respectively. Then, difficulty of each method was investigated using the visual analogue scale (VAS) and preference for each method was investigated. RESULTS: A total of 47 participants were enrolled in the study. The mean pressure between the two methods was not statistically different (p=0.27). However, adequate pressure was achieved in 37 (78.7%) and 16 (34.0%) of participants in PRT and MOVT, respectively (p<0.01). The mean volume was 6.0+/-0.4 ml in PRT and 5.7+/-0.6 ml in MOVT (p<0.01). The VAS score for diffculty was 17.7+/-15.8 in PRT and 76.0+/-15.8 in MOVT (p<0.01). Preference for PRT was 46(97.9%) and that for MOVT was 1 (2.1%). CONCLUSION: PRT is an easier, more preferred, and more effective method for cuff inflation than MOVT.

Retrospective Analysis on the Clinical Differences of Children and Adolescents Treated for Acute Pediatric Poisoning in an Emergency Department?

PURPOSE: This study reports the clinical features of children and adolescents treated for acute poisoning at a regional emergency department (ED). METHODS: We retrospectively analyzed children and adolescents (under 19 years) treated for poisoning in an emergency department (ED) from 2003 to 2012. Children range from 0 to 10 years and adolescents range from 11 to 18 years. Demographic data, poisonous material data, treatment, and outcome from poisoning were collected. RESULTS: There were 742 cases of pediatric poisoning during the study period. The distribution of patient ages was bimodal, with two peaks during 1~2 years and 17~18 years of age. The proportion of adolescents with acute poisoning increased from 22.7% (years 2003~2007) to 38% (years 2008~2013). Among children less than 11 years of age, various poisonous agents and therapeutic drugs comprised 43.9% of the total toxic substance subtypes. However, four types of toxic substances dominated among adolescents: acetaminophen, carbon monoxide, corrosives, and psychiatric drugs. Overall, 54.6% of acute intoxicated patients were asymptomatic (17.7% in adolescents). In addition, 25.8% of patients who wer children were not medically treated compared to 2.8% of adolescent patients. Gastric lavage, charcoal usage, and antidote therapy were performed more often in adolescents and enhanced elimination was only performed in adolescents. The discharge rate from the emergency department was 86.8% for children and 69.1% for adolescents. Also, 4.8% of adolescents were admitted into an intensive care unit but no patients died. CONCLUSION: The incidence of adolescent poisoning increased during the period examined. There were many clinical differences in acute poisoning between children and adolescents. Therefore, strategies to cope with acute poisoning according to age group are required.

Changes in Preventable Death Rates and Traumatic Care Systems in Korea

PURPOSE: This study was performed in order to determine the changes over time in preventable and potentially preventable traumatic death rates, and to assess the factors that affected the deaths of trauma patients which occurred in Korean pre-hospital and hospital settings. METHODS: All trauma deaths occurring either in the emergency department (ED) or after admission at twenty Korean hospitals between August 2009 and July 2010 were retrospectively analyzed. The deaths were initially reviewed by a team of multidisciplinary specialists and classified into non-preventable, potentially preventable, and preventable deaths. Only preventable and potentially preventable deaths were the subject of our analysis. Structured data extraction included patient demographics, vital signs, injury severity, probability of survival, preventability of mortality, reported errors in the evaluation and management of the patient, and classification of error types (system, judgment, knowledge). RESULTS: During the study period, 446 trauma victims died in the ED or within 7 days after admission. The mean age was 52 years, 74.1% were men and the mean time from injury to death was 35.6 hours. The most common cause of death was head injury (44.7%) followed by hemorrhage (30.8%) and multi-organ failure (8.0%). The rates of preventable/potentially preventable deaths were 35.2% overall and 29.8% when limited to patients surviving to admission. Of all death classifications, 31.2% were potentially preventable and 4.0% were preventable. Errors leading to preventable death occurred in the emergency department (51.2%), pre-hospital setting (30.3%) and during inter-hospital transfer (60.8%). Most errors were related to clinical management (48.4%) and structural problems in the emergency medical system (36.5%). CONCLUSION: The preventable death rates for Korean trauma victims were higher than those found in other developed countries, possibly due to poorly established emergency medical systems for trauma victims in pre-hospital and hospital settings. A system wide approach based on the emergency medical system and well-developed in-hospital trauma teams should be adopted in order to improve the quality of care of trauma victims in Korea.

Usefulness of Low-Risk Criteria for Serious Bacterial Infections in Febrile Infants Younger than 90 Days of Age

PURPOSE: To examine the usefulness of simple and quick criteria for identifying febrile infants younger than 90 days with a low risk for serious bacterial infection (SBI). METHODS: We conducted a retrospective study of febrile infants younger than 90 days who visited an emergency department (ED) between July 2010 and June 2011. We reviewed their medical history, physical examination findings, levels of white blood cells (WBC) and C-reactive protein (CRP), blood culture, urinalysis, and an analysis of their cerebrospinal fluid (CSF). Patients who met all the following criteria were considered to have a low risk for SBI: (1) an unremarkable medical history, (2) a good appearance, (3) no focal physical signs of infection, (4) WBC 5,000~15,000 /mm3, (5) CRP <2.0 mg/dL, (6) a normal urinalysis, and (7) CSF WBC <25 /mm3 for neonate or <10 /mm3 for infants between 29 days and 90 days. SBI was defined as a positive culture of bacteria from blood, cerebrospinal fluid, or urine. RESULTS: Complete data were available for 493 infants. SBI was documented in 62(12.6%) infants, with 54(11.0%) having a urinary tract infection, 3(0.6%) with bacteremia, 1 (0.2%) with bacterial meningitis, and 4(0.8%) with co-infections. The sensitivity and negative predictive value for SBI from the combination of low-risk criteria was 98.4% and 99.6%, respectively. CONCLUSION: Although low-risk infants must be carefully observed, our criteria for low-risk might be a reliable and useful tool for excluding SBI for febrile young infants in ED.

A Case of Acute on Chronic Salicylate Poisoned Elderly Patient with Early Utilization of Continuous Venovenous Hemodiafiltration: A Case Report / 대한구급학회지

Salicylate poisonings are divided into acute and chronic syndromes. The most challenging aspect of the management of aspirin-poisoning may be recognition of subtle signs and symptoms of chronic, unintentional overdose. Chronic poisoning typically occurs in elderly as a result of unintentional overdosing on salicylates used to treat chronic conditions. Treatment is directed toward preventing intestinal absorption of the drugs and enhanced elimination. After the first-line treatments, aspirin overdose with its complications of hemodynamic, electrolyte and acid-base issues, is best managed by prompt hemodialysis. We report a case of a 87-year-old woman, who presented with acute on chronic salicylate poisoning. After early continuous venovenous hemodiafiltration, old woman made a good recovery from the salicylism but suffered paralytic ileus caused by aspirin enteroliths. Physician can decide a prompt hemodialysis for salicylate-poisoned patients, who worsen clinical courses despite of first-line therapies.

Usefulness of Multidetector Computed Tomography Angiography in Vertebral and Basilar Artery Dissection

PURPOSE: Vertebral and basilar artery dissection (VBAD) is difficult to diagnose by conventional computed tomography. However, Multi-detector computed tomography (MDCT) angiography is not only a less invasive diagnostic technique than conventional angiography but also provides high quality images. We assessed clinical manifestations and usefulness of MDCT angiography in VBAD. METHODS: We retrospectively reviewed clinical manifestations, magnetic resonance angiography (MRA) and MDCT angiographic findings of 29 patients who were diagnosed with VBAD by conventional angiography from January 2001 to December 2004. A radiologist reviewed MRA, MDCT axial source images, and three dimensional angiography. RESULTS: The mean patient age was 45.9+/-10.2 years. and 23 (79.3%) patients were less than 55 years old. Eight patients had precipitating factors such as trauma, hyperextension and sports activity. Nineteen patients out of 29 presented with neurological symptoms such as sensory change, dysarthria, ataxia and cerebellar dysfunction. The remaining 10 patients exhibited only nonspecific symptoms such as headache, neck pain and dizziness. Among 19 VBAD patients tested by MRA, 13 patients had positive radiological findings. and 16 of 17 patients evaluated MDCT angiography had positive radiological findings. Therefore, the sensitivities of MRA and MDCT angiography in diagnosing VBAD were 68.4% and 94.1%, respectively. CONCLUSION: VBAD is a cause of stroke at young age. The patients with VBAD may have precipitating factors and can present with nonspecific symptoms without any neurological deficit. MDCT angiography is suitable for use as a rapid diagnostic tool for VBAD.