Planning recommendations for international emergency medicine and out-of-hospital care system development.

OBJECTIVES: To present suggestions on planning for development of emergency medicine (EM) and out-of-hospital care in countries that are in an early phase of this process, and to provide basic background information for planners not already familiar with EM. METHODS: The techniques and programs used by the authors and others in assisting in EM development in other countries to date are described. CONCLUSIONS: Some aspects of EM system development have applicability to most countries, but other aspects must be decided by planners based on country-specific factors. Because of the very recent initiation of many EM system development efforts in other countries, to the authors' knowledge there have not yet been extensive evaluative reports of the efficacy of these efforts. Further studies are needed on the relative effectiveness and cost-benefit of different EM development efforts.

International emergency medical services: assessment of developing prehospital systems abroad.

Many developing countries are experiencing a greater need for prehospital systems because of urbanization and changing population demographics, leading to greater death rates from trauma and cardiac illnesses. While emergency medical services (EMS) systems may take a variety of forms, they usually contain some system components similar to those found in the United States. In evaluating EMS abroad, it may be useful to compare the developing system type to one of five models of EMS delivery: hospital-based, municipal, private, volunteer, and complex. Using community-based services and available health providers can enable a developing system to function within a primary health network without overtaxing scarce resources. Developing such an approach can lead to creative and effective solutions for prehospital care in developing countries.

Proposed fellowship training program in international emergency medicine.

Interest in international emergency medicine (EM) has grown steadily over the last ten years. This growth has been fueled by increased demand for emergency services abroad and the proliferation of emergency physicians (EPs) working in international relief and development. As a response, several academic EM programs have developed international EM fellowships for the purpose of providing formal training to EPs interested in international health. Although there have been preliminary articles describing fellowship curricula, to the authors' knowledge no recommendations have been proposed by national consensus that suggest emphasis or required components of a fellowship program. Therefore, a group of EPs interested in fellowship training convened for the purpose of developing goals and objectives for a postgraduate training program in international EM. To that end, this article proposes guidelines for a fellowship training program for international EM.

Emergency medical services in China.

The objective of this article is to identify and describe Chinese emergency medical services (EMS) components. Chinese EMS system development began in the 1980s with "importing" of EMS principles from other systems. China is now attempting to unify these principles. Chinese EMS systems are absent in most rural areas. Urban ambulance dispatch or "rescue" centers provide both transport and inpatient care. Ambulances are staffed with either a physician or a driver. There is not extensive overlap between hospital emergency physicians and ambulance physicians and no out-of-hospital providers at the paramedic or emergency medical technician level exist. Access to EMS is accomplished by dialing 1-2-0. Emergency calls go directly to the rescue center and a physician is dispatched. No on-line radio communication between hospitals and ambulances typically takes place. China has assimilated both traditional and unique EMS components and is undergoing development. It remains unclear whether a systematized EMS structure will emerge.

United States physician assistance in development of emergency medicine in Hangzhou, China.

Emergency medicine is growing rapidly as a specialty and is beginning to be recognized as an essential component of medicine in China. Traditional Chinese medicine and modern technology exist together. A description of the US authors' experience as consultants at a new emergency department and in establishing an emergency medicine residency program in Hangzhou, China is provided. A total of 7 months were spent in the observation, identification, and development of a basic framework of emergency care at a new hospital. The practice of emergency medicine in China was researched by direct observation at several Chinese cities and by literature review. China is taking the parts of the Western system it can use and implementing its own methods in the overall practice of emergency medicine.

Ketamine safety profile in the developing world: survey of practitioners.

OBJECTIVE: To evaluate the safety profile of ketamine when used to facilitate surgical procedures in the less controlled setting of developing world, rural hospitals. METHODS: A survey addressing clinical experience with ketamine in the developing world was administered to a convenience sample of missionary physicians. Descriptive statistics are reported. RESULTS: Of the 172 surveyed physicians, 122 (71%) responded; 55 reported experience with ketamine. These physicians estimated a total of 12,844 administrations. The format of one procedural physician and a second trained anesthesiologist/anesthetist was unavailable in the practice of 59% of the responding physicians, and 34% routinely performed procedures while simultaneously supervising ketamine administration and monitoring its clinical effect. Pulse oximetry was used "often" or "always" by only 10% of the physicians. Cardiac monitoring and intermittent vital signs were used in only 19% and 45%, respectively. One unexplained pediatric death occurred during an unmonitored, unobserved ward recovery. An adult suffered cardiac arrest after a failed intubation attempt. Seventeen other complications possibly related to ketamine were apnea (n = 10), laryngospasm (n = 6), and aspiration (n = 1), all of which were transient and without sequelae. Physicians believed that recovery hallucinations and agitation were frequent in adults and unusual in children. CONCLUSIONS: Death and other serious complications were rare in this survey reporting > 12,000 estimated ketamine administrations in the developing world. Although the limitations of survey data are recognized, the margin of safety with ketamine appears to be high, even when administered by non-anesthesiologists in settings lacking basic mechanical monitoring. These findings have important implications for the use of ketamine outside the controlled operating room environment in developed countries.

Emergency medicine expeditions to the developing world: the Loma Linda University experience in Papua New Guinea.

Emergency physicians (EPs) are increasingly participating in international medicine in regions that are chronically medically underserved. In August 1994, a ten-member emergency medicine team from the Loma Linda University School of Medicine staffed a 70-bed bush hospital in the primitive highlands of Papua New Guinea, providing both outpatient and inpatient medical care. Typhoid fever, malaria, polio, and numerous other infectious diseases were encountered. Rampant local tribal warfare resulted in regular penetrating injuries from arrows, spears, and machetes. The expedition was judged highly successful, in that 1) substantial medical service was provided to tribespeople accustomed to minimal care, 2) education was provided to local health care providers, and 3) team participants became adept at managing medical conditions uncommon in industrialized societies, and gained valuable ethical and utilitarian perspectives regarding health care delivery in underserved areas. In this article the objectives, organization, and experiences of the team members are described. This information may encourage other EPs to participate in medical expeditions to the developing world, and to provide general principles to assist in their organization and implementation.

Can seizures be the sole manifestation of meningitis in febrile children?

OBJECTIVE: It is frequently taught that lumbar puncture is a mandatory procedure in many or all children who have fever and a seizure, because the convulsion may represent the sole manifestation of bacterial meningitis. We attempted to determine the incidence of this occult manifestation of meningitis. DESIGN: Retrospective case series. SETTING AND PATIENTS: 503 consecutive cases of meningitis in children aged 2 months to 15 years seen at two referral hospitals during a 20-year period. MAIN OUTCOME MEASURES: Signs and symptoms of meningitis in patients having associated seizures. RESULTS: Meningitis was associated with seizures in 115 cases (23%), and 105 of these children were either obtunded or comatose at their first visit with a physician after the seizure. The remaining 10 had relatively normal levels of consciousness and either were believed to have viral meningitis (2) or possessed straightforward indications for lumbar puncture: nuchal rigidity (6), prolonged focal seizure (1), or multiple seizures and a petechial rash (1). No cases of occult bacterial meningitis were found. CONCLUSION: In our review of 503 consecutive children with meningitis, none were noted to have bacterial meningitis manifesting solely as a simple seizure. We suspect that this previously described entity is either extremely rare or nonexistent. Commonly taught decision rules requiring lumbar puncture in children with fever and a seizure appear to be unnecessarily restrictive.

Objectives to direct the training of emergency medicine residents on off-service rotation in neurosurgery.

The off-service rotation in Neurosurgery is included in some programs training emergency medicine residents. It may also be offered as an elective. The experience on this rotation can lack opportunity and educational content if structured guidance is not available. We have addressed this problem by developing a written curricula containing subject content listing, objectives, and references for the Neurosurgery off-service rotation for emergency medicine residents. This is the 23rd in a series of objectives for off-service rotations for emergency medicine residents.