Three top studies identified by the International Emergency Medicine Literature Review
In recent years, the growth of emergency medicine around the globe has been exponential, with nearly 70 countries now granting some form of formal recognition to the field. At the same time, interest in Global Emergency Medicine (GEM) as a unique subspecialty of emergency medicine has also grown rapidly over the past decade. International sections, interest groups, and committees now exist within many emergency medicine organizations across North America and Europe, and in some cases have become the largest special interest sections within these organizations. One of the barriers, however, to the development of the nascent field of GEM has been the lack of an easily accessible literature base that can be used to guide its development. Both research articles and communiqués of value to various stakeholders in GEM are spread throughout the general medical literature, the emergency medicine literature, the public health literature, the health policy/health systems literature, and the humanitarian/disaster literature. Many publications with GEM relevance exist only in the gray literature in the form of assessments or reports by international agencies, national or local governments, foundations, donor agencies, financial institutions, or non-governmental organizations. Furthermore, GEM research may be published in a variety of different languages, further limiting its accessibility to a global audience of emergency medicine practitioners.
Recognizing the need for a clear and accessible literature base to guide the growing field of GEM, the International Emergency Medicine Literature Review Group was formed in 2005. Publishing annually in the journal Academic Emergency Medicine, this review gathers together a number of articles from disparate sources, presenting the ones chosen as having specific relevance or value to the field of global emergency medicine. The goals of the review are to illustrate best practices, stimulate additional research, and promote further professionalization of the field of global emergency medicine.
Before we can review the global emergency medicine literature, however, we must first define the boundaries of the field. For the purpose of our review, we have created a framework that divides GEM research into one of three categories: development of emergency medical care systems in both developed and developing nations, delivery of emergency care in resource limited settings, and provision of humanitarian and disaster relief.
Emergency medicine development encompasses clinical, educational and systems components at both the national and local levels. Included within this rubric would be efforts as diverse as developing a national disaster relief plan, creating a city-wide EMS system, and training rural health practitioners to provide basic emergency services. Emergency care in resource limited settings deals with adapting old methods and developing new methods for providing acute medical care and trauma care in rural areas and low-income countries, where advanced technology and specialist physicians may not be available. The field of humanitarian relief also encompasses several different domains, and is rapidly becoming more organized through critical analyses of operations executed. Both humanitarian relief agencies and donor governments are looking closely at ways to improve humanitarian response, including the conduct of rapid needs assessments, the deployment of personnel and supplies, and ongoing monitoring and evaluation.
Each year, we perform a Medline search of the published literature using a set of structured terms that we have honed over time, as well as a search of the grey literature using a variety of databases and algorithms. Our multilingual team of reviewers then screens the thousands of citations captured by our search to find the few hundred studies that clearly fall within the realm of GEM, as defined above. Our reviewers then read and score each manuscript, using a set of questions that evaluates the clarity, methodology, ethics, importance, and likely impact of each study in order to find the top GEM articles published each year. Finally, our reviewers provide a summary and critique of each article, for the benefit of our readers.
In addition to reviewing the highest quality and most important research studies of the year, the review also identifies and tracks emerging trends in GEM research. Our 2008 review, for instance, noted an explosion of articles related to pandemic response, as well as articles detailing the importance of international collaboration in the development of emergency care systems around the globe. In our 2009 review, we found many more articles focusing on issues related to disaster response, including the evaluation of various triage systems, methods of rationing care in humanitarian emergencies, and the ethics of both humanitarians responding to disasters and conducting research to study the humanitarian response to disasters.
Our 2010 review, in turn, found a shift towards articles falling within the realm of emergency care in resource limited settings, especially those related to maternal and child health. Indeed, we saw several excellent studies identifying better methods for diagnosing and treating acute respiratory infections, diarrhea, and malaria in children in the developing world, as well as a number of randomized controlled trials aimed at preventing complications of obstetric emergencies such as post-partum hemorrhage or pre-term labor. The 2010 review also noted a number of new studies specifically analyzing trauma care in the developing world, including road traffic accidents and domestic violence, looking at the systems-level barriers and solutions to improving care for patients with traumatic injuries. Overall, our annual reviews have also noted a consistent improvement over the past several years in the methodological quality of global emergency medicine research. Clearly, global emergency medicine research is finally coming into its own as a rigorous scientific field.
In this installment, we highlight a few of the top research articles identified by our 2010 International Emergency Medicine Literature Review. In future issues we will continue to provide additional snapshots of cutting edge global emergency medicine research from around the globe. For a more in-depth discussion of the methodology and results for our annual review, as well as for summaries and critiques of the top 27 GEM articles of 2010, please see our full review at www.aemj.org.
Three must-read studies from the global em community
GERMANY– Understanding the causes and effects of road traffic crashes in developing countries
Schmucker U, Seifert J, Stengel D, Matthes G, Ottersbach C, Ekkernkamp A. Road traffic crashes in developing countries. Unfallchirurg. 2010; 113(5): 373-7.
This article, published in the German medical journal Unfallchirurg, provides a systematic review of the causes and effects of road traffic accidents (RTA) in low and middle-income countries (LMIC). Globally, more than 1.25 million people die every year in RTAs and more than 50 million people sustain traffic-related injuries, with over 90% of this morbidity and mortality occurring in LMIC. The authors point out that the available statistics on RTA likely underestimate their impact, as many LMICs have very limited abilities in adequately documenting and investigating RTA, and there are few scientific publications from LMICs that deal with the medical impact of road traffic accidents. Nevertheless, the authors identify major trends in RTA in LMICs based on the available data. The majority of lethal injuries in LMIC involve pedestrians, in contrast to high-income countries (HIC). The use of motorcycles, cars or other means of transportation (e.g., rickshaws) varies greatly between HICs and LMICs and even among LMICs. The majority of fatal RTA is not associated with driving under the influence of ethanol; however, only 25% of LMICs have implemented drunk driving limits and less than 50% of LMICs document ethanol levels in injured drivers. In addition, use of seat belts is not mandatory in half of all LMICs. The authors also point out that early emergency care is limited in most LMICs. 40% have neither a uniform emergency call number nor an organized EMS system. Ambulance personnel often lack even basic BLS skills, such as splinting (50%), while only 6% underwent formal ATLS training. In addition, EMS services are only rarely available in remote areas, while traffic conditions in urban areas interfere with adequate response times.
Although the authors offer information about general trends in the epidemiology of RTA, they acknowledge that the data is limited, and the general trends identified should be interpreted cautiously when dealing with RTA in a particular region or country, as local circumstances may influence the relevance of some of the findings. Nevertheless, this article will likely stimulate further research to better understand the epidemiology of RTA in specific countries and contexts, which may ultimately lead to more precise preventive measures. Preventive measures become increasingly important in view of the growing urbanization in many LMICs and the associated surge in road traffic density. The article also underlines the importance of multidisciplinary approaches to minimizing the morbidity and mortality of RTA, including a combination of better education, engineering, and regulation, while also optimizing access and quality of early emergency medical care.
Reviewed by Adam C. Levine, MD, MPH and Torben Kim Becker, MD on behalf of the Global Emergency Medicine Literature Review Group
UNITED KINGDOM– British military experience with pediatric trauma in Afghanistan
Walker N, Russell RJ, Hodgetts TJ. British military experience of pre-hospital paediatric trauma in Afghanistan. J R Army Med Corps. 2010; 156(3): 150-3.
This retrospective analysis describes the pediatric experiences of the British military’s helicopter borne pre-hospital Medical Emergency Response Team (MERT) while on deployment in Afghanistan. A MERT team consisted of 1 physician, 1 nurse, and 2 paramedics. During a 20-month period spanning 2006 and 2007, the MERT team transported 78 pediatric patients, reflecting a far greater proportion of pediatric trauma than the team would normally manage in a non-conflict setting. In most cases, the injury mechanisms and triage categories were significantly more severe than what the MERT team would typically see when not deployed abroad. The distribution of triage categories, with 88% of triaged patients categorized as T1 or T2, reflects high-energy transfer mechanisms of injury. Local medical services were significantly limited in their ability and availability, requiring long transport times for injured patients.
Trauma is the leading cause of death in children greater than 1 year of age. Morbidity and mortality in this age group can be minimized if pre-hospital health care providers of pediatric patients get the training they need to care for very sick children. However, familiarity with treating severely injured children can only be gained and maintained by appropriate training and continued medical practice. Children’s size, unique physiology, and anatomy produce different injury patterns when exposed to the same mechanisms of trauma. It is pertinent that all military pre-hospital emergency health care providers gain training and exposure to the care of the seriously injured pediatric patient. In order to best train providers how to triage, treat, and transport these patients, courses such as PALS (Pediatric Advanced Life Support) and PHPLS (Pre-Hospital Pediatric Life Support) should be implemented for military personnel providing pre-hospital trauma care in conflict settings.
Reviewed by Adam C. Levine, MD, MPH and Gabrielle A. Jacquet, MD on behalf of the Global Emergency Medicine Literature Review Group
ISRAEL– Reducing secondary traumatization following war and terror
Berger R, Gelkopf M. An intervention for reducing secondary traumatization and improving professional self-efficacy in well baby clinic nurses following war and terror: A random control group trial. International Journal of Nursing Studies, 2010.
Infants and children exposed to war and terror frequently develop devastating long term mental health complications such as post-traumatic stress disorder, anxiety and depression, as well as poor daily functioning. Health care providers that care for such patients are at risk of developing secondary traumatization, leading to compassion fatigue, poor professional sense of self-efficacy and burnout. This prospective, quasi-randomized control trial evaluated a 12-week intervention for pediatric nurses in war and terror-affected regions of Israel. The intervention consisted of weekly 6-hour sessions designed to provide nurses with knowledge pertaining to stress and trauma in infants and young children; tools for identifying children and parents at risk of developing stress-related problems; and to equip them with stress management techniques for both children and adults. The sessions also included team building, support groups and self-maintenance skills designed to allow nurses to better cope with secondary traumatization. Nurses enrolled in the intervention demonstrated significantly improved professional self-efficacy, compassion, satisfaction and burnout compared to nurses placed on the waiting list during the same time period. The authors conclude that training health personnel in civilian war zones to better understand and deal with trauma and secondary traumatization can yield better professional functioning.
The issue of secondary traumatization in war and terror-affected regions is of critical importance.
This study demonstrated a well designed, but time-intensive, intervention that demonstrated improved job satisfaction and decreased burnout among pediatric nurses. However, the sample size is small, and only two regions in a single country were examined, suggesting implementation and evaluation in other locales and among other types of health professionals, such as physicians and non-pediatric nurses, should be completed before considering universal utilization.
Reviewed by Adam Levine, MD, MPH and Herbie Duber, MD on behalf of the Global Emergency Medicine Literature Review Group