The use of point-of-care ultrasound in Tshwane public and private sector emergency units.

BACKGROUND: The use of point-of-care ultrasound (POCUS) is an essential skill in the practice of emergency medicine (EM), with benefit to patient care by improving diagnostic accuracy. Despite this, there exists little data evaluating the use of POCUS in South African emergency units (EUs.). METHODS: One hundred and seventeen doctors working in 12 public and private sector EUs in Tshwane were included. A questionnaire was used comprising of descriptive data regarding doctor demographics, levels of experience, and outcome data including POCUS frequency use, training level, indications for, and barriers to its use. RESULTS: Many participants were general practitioners working in EUs (58.1%) followed by EM specialists and EM registrars. Of these participants, 88% used POCUS. Seventy one percent received informal POCUS training only. The indications for POCUS use were similar for both public and private sector, with no significant differences in overall use. The only significant association to POCUS use was age ( 33.3 years) and number of years since qualification ( 6.9 years.) Lack of and/or access to training were the main reasons for not using POCUS (18.8%.) There were no significant differences in the barriers to the use of POCUS between the sectors. CONCLUSION: Point-of-care ultrasound is used similarly in both public and private sector EUs in Tshwane. Lack of and/or access to POCUS training are the main barrier to its use.Contribution: This study underlines the state of POCUS use in Tshwane and highlights the barriers to its use, thus allowing academic heads and hospital managers to address them.

The psychological impact of COVID-19 on frontline doctors in Tshwane public hospitals.

BACKGROUND:  The coronavirus disease 2019 (COVID-19) pandemic placed immense pressure on frontline doctors. Burnout is a psychological syndrome that develops in response to chronic work stress. It consists of emotional exhaustion (EE), depersonalisation (DP) and reduced personal accomplishment (PA). Burnout is associated with personal dysfunction and compromises the work profession and patient safety. International studies suggest burnout is exacerbated during a pandemic. METHODS:  We conducted a descriptive cross-sectional observational study. Respondents included frontline doctors working in emergency medicine, family medicine and internal medicine during COVID-19 in Tshwane public hospitals. The survey included two validated questionnaires, the Maslach Burnout Inventory and the Depression, Anxiety, Stress Scale-21. The aim was to determine the prevalence and severity of burnout, psychological and somatic symptoms in frontline doctors. RESULTS:  Of the 163 participants, we found clinical burnout to be present in 58.9% (n = 96) and extreme burnout in 19.6% (n = 32). Moderate to extremely severe levels of stress, anxiety and depression were present in 55.1% (n = 90), 43.6% (n = 71) and 22.1% (n = 36) of participants, respectively. We found significant correlations between burnout and psychological symptoms. Increased levels of burnout, anxiety, depression and stress were found to be meaningfully associated with adverse somatic symptoms. CONCLUSION:  Our study demonstrated an insufferably high prevalence of burnout and psychosomatic symptoms in frontline doctors during COVID-19. In the event of future pandemics, more measures should be taken to support frontline doctors.Contribution: Pandemic-associated burnout and its psychophysical consequences have not been studied in frontline doctors in South Africa.

A qualitative study of COVID-19 related reasons for delayed presentation of patients with chest pain during the COVID-19 pandemic.

INTRODUCTION: In previous pandemics such as the Ebola virus outbreak in West Africa, it has been observed that patients with non-pandemic related complaints, delay their presentation to hospital. Similarly, delayed presentation of patients with chest pain during the COVID-19 pandemic has been documented. This qualitative study identified the COVID-19 related reasons which lead to this delay. METHODS: A qualitative study based on 10 individual patient interviews. Half of these were conducted at a public hospital emergency centre (EC) and the other half at a private EC. RESULTS: A variety of psychosocial factors were identified as themes for delayed presentation. Interestingly, the fear of contracting COVID-19 at the hospital was not found to be an important theme in our study. Rather, confusion around hospital protocols during the pandemic was identified as a recurrent theme. DISCUSSION: This study found that confusion about COVID-19 hospital protocols was the major pandemic related delaying factor. A number of themes unrelated to COVID-19 were also identified.

Predicting mortality in trauma patients - A retrospective comparison of the performance of six scoring systems applied to polytrauma patients from the emergency centre of a South African central hospital.

INTRODUCTION: Over 90% of trauma-related deaths worldwide, ensue in low- and middle-income countries. Multiple useful trauma scoring systems have been devised. Although validated in high-income countries, they cannot always be replicated in resource-limited countries. This study compares six trauma scores to identify the best-suited system to use for polytrauma patients in a hospital in Pretoria, South Africa. METHODS: This is an observational retrospective analysis of polytrauma admissions from 1 July 2016 to 31 December 2016. Data collected from patients' records from the EC of Steve Biko Academic Hospital, was analysed using Stata Release 14. Outcomes were recorded as 30-day survival, ICU- and overall hospital LOS. Scores pertaining to patient mortality, were compared in terms of sensitivity, specificity, and cut-off points based on ROC curve. Finally, for LOS Pearson correlation analysis was used. RESULTS: At the best calculated mortality prediction cut-points for the scores, the sensitivities and specificities were respectively 87% and 68% for TRISS, 81% and 61% for ISS, RTS yielded 81% and 60%, while for REMS it was 61% and 69%. The SI and RSI (cut-points used in agreement with the literature) produced sensitivities 58% and only 48%, and specificities of 73% and 83%, respectively.45(41,7%) patients required ICU admission. Though the ICU LOS best correlated with ISS(r = 0.2710), the ICU LOS correlation coefficient was weak for all trauma scores. None of the scores had a significant p value for hospital LOS. DISCUSSION: Among the scores compared, TRISS had the highest sensitivity and NPV for mortality prediction in this South African polytrauma population. ISS correlated best with ICU LOS. However, compared to developed countries, ROC analyses & predictability of these scores fare relatively worse, and no correlation was found with hospital LOS. Therefore, we conclude that further studies are needed to ascertain a more suitable system for resource-limited settings.

Case Report: Safe Tourniquet Removal in Black Mamba (Dendroaspis polylepis) Bites.

The black mamba is known for its notorious potent neurotoxic venom. For this reason, their bites are often erroneously treated in the field with the application of a tourniquet in the hope of delaying systemic spread of the venom. Observational studies have shown that inappropriate tourniquet application is a common, harmful practice. An arterial tourniquet is not a recommended first aid measure because of the risk of limb ischemia and gangrene. When inappropriately applied, the rapid removal of the tourniquet in the emergency department may precipitate a life-threatening venom and metabolic toxin rush, leading to respiratory arrest. We present two cases of black mamba bites in Gauteng, South Africa, where gradual tourniquet removal was used to avoid a venom rush and rapid respiratory paralysis. Venom and metabolic toxin rush with potentially fatal respiratory muscle paralysis may be averted by gradual, cautious removal of field-applied tourniquets with concomitant antivenom administration.

A case report of detecting subclinical coagulopathy in a patient with boomslang (Dipholidus typus) bite.

The boomslang (Dipholidus typus) has a predominantly haemotoxic venom. Because of the consumptive nature of the coagulopathy, signs and symptoms are usually delayed by up to 72 h after the bite. Traditional laboratory coagulation assays have a long turnaround time, by which time the patient's bleeding and clotting profile has changed. A 25-year-old male patient was bitten by a boomslang. Despite two normal laboratory coagulation assay results, a point-of-care rotational thromboelastometry showed low fibrinogen levels, leading to the administration of monovalent antivenom. This report highlights the value of point-of-care thromboelastometry in the care of patients with subclinical boomslang envenomation.

Ethylene glycol poisoning: A diagnostic challenge in a patient with persistent seizures and a severe metabolic acidosis.

INTRODUCTION: Due to the nationwide lockdown to mitigate the spread of COVID-19 and subsequent alcohol ban in South Africa, several cases of toxic alcohol ingestion presented to our emergency unit. Many of these patients admitted to making home brews of alcohol while others simply use industrial toxic alcohols. The diagnosis of these poisonings is challenging as direct assays are not available in our setting. CASE REPORT: We present a case of presumed ethylene glycol poisoning that presented with persistent seizures and a high anion gap metabolic acidosis (HAGMA). DISCUSSION: A high index of suspicion for toxic alcohol poisoning should be maintained in patients presenting with an altered mental status, seizures and a HAGMA. Indirect markers such as clinical features and laboratory results can lead to the diagnosis when direct assays are unavailable.

A cross-sectional survey of burnout amongst doctors in a cohort of public sector emergency centres in Gauteng, South Africa.

INTRODUCTION: Working in emergency care is commonly regarded as highly stressful. This is also true in the African setting characterised by high patient loads and limited resources. As in other similarly demanding occupations, burnout can be anticipated. The aim of this study was to examine the level of burnout amongst doctors in a cohort of public sector emergency centres in Gauteng, South Africa. METHODS: An observational, cross-sectional design was employed, using the Maslach Burnout Inventory-Human Services Survey (which has been tested and validated in similar settings elsewhere). The study included a cohort of doctors working in the emergency centres of public sector hospitals in Gauteng, South Africa. RESULTS: One hundred participants completed the questionnaire out of a possible 124 doctors working at the five centres. Ninety-three met the inclusion criteria and was further analysed. Seven respondents were specialist emergency physicians (7.5%), 36 were emergency medicine registrars (38.7%) and 50 were medical officers (53.8%). Fifty one respondents were female (55.0%). Analysis of burnout component scores showed a mean emotional exhaustion score of 31.69 (standard deviation, SD = 10.32), with 62 respondents (66.7%) in the high-risk group - from 86 (92.5%) at moderate to high risk. The mean de-personalisation score was 13.39 (SD = 6.21), with 50 respondents (53.8%) in the high-risk group - from 75 (80.7%) at moderate to high risk of burnout. The mean personal accomplishment score was 34.87 (SD = 6.54), with 21 respondents (22.6%) in the high-risk group - from 65 (69.9%) at moderate to high risk of burnout. DISCUSSION: The results indicate that a large proportion of the doctors who work in these emergency centres are at moderate to high risk of burnout. Based on our findings we recommend that interventions be introduced at the work place to reduce burnout in doctors and improve their mental well-being. This will ensure better service delivery to patients with emergencies. Further research into the causes of occupational burnout should be explored.

A cross-sectional survey of burnout amongst doctors in a cohort of public sector emergency centres in Gauteng, South Africa

Introduction:Working in emergency care is commonly regarded as highly stressful. This is also true in the African setting characterised by high patient loads and limited resources. As in other similarly demanding occupations, burnout can be anticipated. The aim of this study was to examine the level of burnout amongst doctors in a cohort of public sector emergency centres in Gauteng, South Africa.Methods:An observational, cross-sectional design was employed, using the Maslach Burnout Inventory-Human Services Survey (which has been tested and validated in similar settings elsewhere). The study included a cohort of doctors working in the emergency centres of public sector hospitals in Gauteng, South Africa.Results:One hundred participants completed the questionnaire out of a possible 124 doctors working at the five centres. Ninety-three met the inclusion criteria and was further analysed. Seven respondents were specialist emergency physicians (7.5%), 36 were emergency medicine registrars (38.7%) and 50 were medical officers (53.8%). Fifty one respondents were female (55.0%). Analysis of burnout component scores showed a mean emotional exhaustion score of 31.69 (standard deviation, SD = 10.32), with 62 respondents (66.7%) in the high-risk group ­ from 86 (92.5%) at moderate to high risk. The mean de-personalisation score was 13.39 (SD = 6.21), with 50 respondents (53.8%) in the high-risk group ­ from 75 (80.7%) at moderate to high risk of burnout. The mean personal accomplishment score was 34.87 (SD = 6.54), with 21 respondents (22.6%) in the high-risk group ­ from 65 (69.9%) at moderate to high risk of burnout.Discussion:The results indicate that a large proportion of the doctors who work in these emergency centres are at moderate to high risk of burnout. Based on our findings we recommend that interventions be introduced at the work place to reduce burnout in doctors and improve their mental well-being. This will ensure better service delivery to patients with emergencies. Further research into the causes of occupational burnout should be explored

Design and validation of a clinical scale for prehospital stroke recognition, severity grading and prediction of large vessel occlusion: the shortened NIH Stroke Scale for emergency medical services.

OBJECTIVE: To develop an NIH Stroke Scale (NIHSS)-compatible, all-in-one scale for rapid and comprehensive prehospital stroke assessment including stroke recognition, severity grading and progression monitoring as well as prediction of large vessel occlusion (LVO). METHODS: Emergency medical services (EMS) personnel and stroke physicians (n=326) rated each item of the NIHSS regarding suitability for prehospital use; best rated items were included. Stroke recognition was evaluated retrospectively in 689 consecutive patients with acute stroke or stroke mimics, prediction of LVO in 741 consecutive patients with ischaemic stroke with acute vessel imaging independent of admission NIHSS score. RESULTS: Nine of the NIHSS items were rated as 'suitable for prehospital use.' After excluding two items in order to increase specificity, the final scale (termed shortened NIHSS for EMS, sNIHSS-EMS) consists of 'level of consciousness', 'facial palsy', 'motor arm/leg', 'sensory', 'language' and 'dysarthria'. Sensitivity for stroke recognition of the sNIHSS-EMS is 91% (95% CI 86 to 94), specificity 52% (95% CI 47 to 56). Receiver operating curve analysis revealed an optimal cut-off point for LVO prediction of ≥6 (sensitivity 70% (95% CI 65 to 76), specificity 81% (95% CI 76 to 84), positive predictive value 70 (95% CI 65 to 75), area under the curve 0.81 (95% CI 0.78 to 0.84)). Test characteristics were non-inferior to non-comprehensive scales. CONCLUSIONS: The sNIHSS-EMS may overcome the sequential use of multiple emergency stroke scales by permitting parallel stroke recognition, severity grading and LVO prediction. Full NIHSS-item compatibility allows for evaluation of stroke progression starting at the prehospital phase.

Comparison of stroke recognition and stroke severity scores for stroke detection in a single cohort.

OBJECTIVE: First, to determine the sensitivity and specificity of six stroke recognition scores in a single cohort to improve interscore comparability. Second, to test four stroke severity scores repurposed to recognise stroke in parallel. METHODS: Of 9154 emergency runs, 689 consecutive cases of preclinically 'suspected central nervous system disorder' admitted to the emergency room (ER) of the Heidelberg University Hospital were included in the validation cohort. Using data abstracted from the neurological ER medical reports, retrospective assessment of stroke recognition scores became possible for the Cincinnati Prehospital Stroke Scale (CPSS), Face Arm Speech Test (FAST), Los Angeles Prehospital Stroke Screen (LAPSS), Melbourne Ambulance Stroke Screen (MASS), Medic Prehospital Assessment for Code Stroke (Med PACS) and Recognition of Stroke in the Emergency Room score (ROSIER), and that of stroke severity scores became possible for the Kurashiki Prehospital Stroke Scale (KPSS), Los Angeles Motor Scale (LAMS) and shortened National Institutes of Health Stroke Scale (sNIHSS)-8/sNIHSS-5. Test characteristics were calculated using the hospital discharge diagnosis as the reference standard. RESULTS: The CPSS and FAST had a sensitivity of 83% (95% CI 76 to 88) and 85% (78% to 90%) and a specificity of 69% (64% to 73%) and 68% (63% to 72%), respectively. The more complex LAPSS, MASS and Med PACS had a high specificity (92% to 98%) but low sensitivity (44% to 71%). In the ROSIER, sensitivity (80%, 73 to 85) and specificity (79%, 75 to 83) were similar. Test characteristics for KPSS, sNIHSS-8 and sNIHSS-5 were similar to the simple recognition scores (sensitivity 83% to 86%, specificity 60% to 69%). The LAMS offered only low sensitivity. CONCLUSIONS: The simple CPSS and FAST scores provide good sensitivity for stroke recognition. More complex scores do not result in better diagnostic performance. Stroke severity scores can be repurposed to recognise stroke at the same time because test characteristics are comparable with pure stroke recognition scores. Particular shortcomings of the individual scores are discussed.

Competition between heterogeneous and homogeneous nucleation near a flat wall.

We studied the competition between heterogeneous and homogeneous nucleation of an aqueous suspension of charged colloidal spheres close to the container walls. Samples of equilibrium crystalline structure were shear-melted and the metastable melt left to solidify after the cessation of shear. The crystallization kinetics was monitored using time-resolved scattering techniques: at low particle number densities n we applied an improved static light scattering method while at large particle concentrations ultra-small-angle x-ray scattering was applied for the first time. Our results show some unexpected behavior: the heterogeneous nucleation at the container walls is delayed in comparison to the homogeneous bulk nucleation and its rate density appears surprisingly slightly smaller, demonstrating the complexity of the observed crystallization process.