Emergency Care Providers Research Articles

Evaluation of Violence and its Management Experienced by Emergency Medical Service Workers in Lithuania’s Biggest Cities

The purpose was to investigate violence experienced in work environment by emergency medical service workers of Lithuania’s biggest cities and methods of violence management.Methods – Questionnaire survey.Relevance of the research. Violence and aggression in the workplace affect many fields and workers of different levels. However, healthcare sector has the highest risk of experiencing violence. In recent years, it was found that healthcare specialists were under substantial risk of experiencing violence from patients or their companions and it raises concern about the medical personnel. Although workers may experience violence and aggression in every healthcare field, it is more likely for the specialists providing emergency medical aid. Therefore, it is of great importance to put efforts into protecting emergency care providers and patients from incidents of aggression or violence in order to deliver quality care for the patients. The objective of this study was to explore violence in the workplace experienced by Lithuania’s biggest cities emergency medical service workers and ways it can be managed.Research results and conclusions. After the analysis of the survey results it was found that emergency medical service workers of Lithuania’s biggest cities most frequently experience violence in form of verbal aggression (on average 57 times a year), provocative aggressive behaviours (22 times a year) and threats (20 times a year). The rarest form of violence experienced was sexual harassment.After analysing the responses, it was noted that emergency medical service providers of Lithuania’s biggest cities experienced violence from patients in more than half of all cases and in about one third of cases of violence it was received from relatives. It should also be noted that a small part (one-tenth of all cases) of violence was received from colleagues at work.In situations of violence, emergency medical service workers try to hide their fear and do not retreat, they remain close to the exit door and try to reduce excessive triggers and noises that could escalate frustration.Keywords: violence, ambulance, aggression.

Emergency Medicine Training Programs in Low- and Middle-Income Countries: A Systematic Review.

Background:Despite the growing interest in the development of emergency care systems and emergency medicine (EM) as a specialty globally, there still exists a significant gap between the need for and the provision of emergency care by specialty trained providers. Many efforts to date to expand the practice of EM have focused on programs developed through partnerships between higher- and lower-resource settings.Objective:To systematically review the literature to evaluate the composition of EM training programs in low- and middle-income countries (LMICs) developed through partnerships.Methods:An electronic search was conducted using four databases for manuscripts on EM training programs – defined as structured education and/or training in the methods, procedures, and techniques of acute or emergency care – developed through partnerships. The search produced 7702 results. Using a priori inclusion and exclusion criteria, 94 manuscripts were included. After scoring these manuscripts, a more in-depth examination of 26 of the high-scoring manuscripts was conducted.Findings:Fifteen highlight programs with a focus on specific EM content (i.e. ultrasound) and 11 cover EM programs with broader scopes. All outline programs with diverse curricula and varied educational and evaluative methods spanning from short courses to full residency programs, and they target learners from medical students and nurses to mid-level providers and physicians. Challenges of EM program development through partnerships include local adaptation of international materials; addressing the local culture(s) of learning, assessment, and practice; evaluation of impact; sustainability; and funding.Conclusions:Overall, this review describes a diverse group of programs that have been or are currently being implemented through partnerships. Additionally, it highlights several areas for program development, including addressing other topic areas within EM beyond trauma and ultrasound and evaluating outcomes beyond the level of the learner. These steps to develop effective programs will further the advancement of EM as a specialty and enhance the development of effective emergency care systems globally.

Pediatric Trauma Readiness: A Trauma-Specific Assessment to Complement the National Pediatric Readiness Project.

The National Pediatric Readiness Project of the Emergency Medical Services for Children surveyed emergency departments in the United States in 2013 for readiness to provide emergency care to children. However, that survey did not query for many elements considered essential to Advanced Trauma Life Support (ATLS). Our pediatric trauma center and state department of health collaborated to develop a survey reflecting ATLS principles regarding pediatric-specific trauma stabilization, clinical/administrative resources, and interfacility transfer to complement the 2017 PedsReady survey. We distributed the survey to all emergency department medical directors in our state in 2017. Medical directors of all 11 emergency departments responded. Only 2 reported having physician or nurse pediatric trauma coordinators. Two reported comfort with all emergency procedures at all ages (eg, airway, traumatic pneumothorax treatment, etc), whereas 9 had variable thresholds of comfort by age and procedure. Reported utilization of pediatric trauma-specific protocols varied the following: hyperosmolar therapy (1), neurological assessment (3), chest injury (4), massive transfusion (1), triage (5), trauma transfer agreements (10), imaging-limitation protocols (4), internal (1) and inter-facility (4) quality assurance/quality improvement process (1), and real-time image transfer (11). This survey identified gaps in the readiness of emergency departments to treat injured children in our state that were not detected by the 2013 PedsReady surveys. Future surveys of emergency department pediatric readiness should consider more detailed, trauma-specific readiness questions. This will allow for assignment of more accurate goals and benchmarking standards for national pediatric trauma readiness.

Clinical Guidelines and Advocacy for the Reduction of Pediatric Button Battery Injuries

Button batteries (BBs) are a severe potential hazard present in household settings, and BB injuries in children continue to be a significant source of morbidity and mortality. When lodged in the body, BBs can cause serious injury within as little as 2 hours. Without a known history of BB ingestion, the diagnosis can be challenging because symptoms may be nonspecific and mimic common viral illnesses seen in children. Based on recent research on esophageal BBs, novel mitigation strategies can be used in the urgent care and emergency department settings, or during transport between facilities <12 hours from ingestion. These include the preremoval use of honey or sucralfate to help decrease the rate of esophageal tissue injury. All emergency care providers should be aware of these interventions for esophageal BB and help to expedite these children to the operating room for removal.

Physical Health Status of Emergency Care Providers in South Africa

Background: Emergency care providers (ECPs) have a physically, mentally, and emotionally demanding profession. Therefore, they are predisposed to cardiovascular and other non-communicable disease risk factors. Objectives: The objective of the study was to determine the physical health status of ECPs in the North West province of South Africa through a selected anthropometric and other health parameter test battery. Methods: Ninety-one ECPs (64 males, 27 females) took part in the study voluntarily for health screening tests including body mass index (BMI), lean body mass (LBM), resting heart rate (RHR), blood pressure (BP), skinfold measurement, waist circumference (WC), waist-to-hip ratio (WHR), fasting blood glucose (FBG), and total cholesterol (TC). The collected data were subjected to statistical analysis using the Statistical Package for Social Sciences (SPSS) version 25 (IBM). Results: The participants demonstrated a mean BMI of 28.2 ± 5.5 kg/m2, body fat of 26 ± 7.6 %, and LBM of 58.6 ± 10 kg. Significant differences were seen in height (170.5 ± 6.2 vs. 160.7 ± 5.3 cm), BF% (22.5 ± 5.3 vs. 34.2 ± 6.2 %), and LBM (62.3 ± 8 vs. 49.2 ± 8.2 kg) between males and females (P ≤ 0.05). Mean systolic BP was 122 ± 15 mmHg, and diastolic BP was 81 ± 10 mmHg. Mean WC was 90.8 ± 11.4 cm. Other health parameters included mean FBG of 5.1 ± 2.4 mmol/L and mean TC of 4.9 ± 0.7 mmol/L. Significant differences were seen in WHR (0.88 ± 0.04 vs. 0.79 ± 0.06) between males and females (P ≤ 0.05). Conclusions: A significant number of ECPs presented with cardiovascular and other NCD risk factors such as hypertension, obesity, high WC, elevated FBG, and abnormal levels of TC. This can be attributed to the nature of their occupation such as working irregular shifts leading to sleep deprivation, being exposed to psychological trauma, poor nutrition during shifts, and/or lack of exercise. Stress management is an important part of these workers’ rehabilitation program. A well-formulated employee wellness program is required to set remedial measures in place.

Finnish and Swedish prehospital emergency care providers’ knowledge and attitudes towards pressure ulcer prevention

BackgroundDespite the knowledge that transportation by emergency medical services may increase the risk of pressure ulcers (PU), there is still lack of knowledge about the possibility of prehospital emergency care providers to be a part of preventing and reducing the risk of PUs. MethodsA survey was carried out during 2017 in Finland and Sweden. Validated questionnaires were used. ResultsA total of 179 (72.7%) Finnish and 188 (28.8%) Swedish prehospital emergency care providers participated in the study. The overall rate of correct answers and the mean total knowledge score was 58.8% (SD 21.8), 20/34, in the Finnish group and 70.5% (SD 15.7), 24/34, in the Swedish group (p < 0.000). The percent of the total and the mean attitude score was in the Finnish group 71.3% (SD 0.48), 37.1/52, and in the Swedish group 69.4% (SD 0.77), 36.1/52 (p < 0.813). Half of the Finnish and most of the Swedish participants felt they needed more education about PUs (Fin 50.2% & Swe: 76.0%). ConclusionsPrehospital emergency care providers don’t see themselves as responsible for PU prevention. Therefore, there is a need for increasing the level of knowledge on PU prevention and classification among prehospital emergency care providers. They could play a key role in developing methods to improve PU prevention and identifying patients in risk of developing PUs.

Analysis of Providing Emergency Care to Patients with Myocardial Infarction without ST Segment Elevation

A high mortality rate due to acute myocardial infarction (AMI) stimulates the analysis of the quality of emergency medical care at the prehospital stage. Firstly, an analysis of the reasons for the treatment of patients with AMI to general practitioners is necessary. Secondly, the quality of the provision of medical services by general practitioners is one of the criteria for the effectiveness of the implementation of patient management protocols, which requires a systematic analysis and relevant studies.The objective: to analyze the provision of emergency medical care to patients with acute myocardial infarction without ST segment elevation (NSTEMI) when they seek medical care.Materials and methods. The referral routes for hospitalization of patients with acute coronary syndrome and clinical manifestations were analyzed among 280 patients with STEMI and 91 patients with NSTEMI. The assessment of treatment tactics in patients with NSTEMI was carried out in the following paragraphs of the emergency medical care protocol: determination of blood saturation, ensuring reliable venous access, administration of nitroglycerin in aerosol (1–2 doses or 0,4–0,8 mg), use of acetylsalicylic acid (ASA ) after chewing 160–325 mg, the use of clopidogrel 300 mg orally; the appointment of β-blocker; narcotic analgesic; anticoagulant. Statistical data processing was carried out using non-parametric criterion χ2.Results. Appeals to primary health care centers were significantly more frequent in patients with NSTEMI, due to the clinical course of the disease.Conclusion. At the stage of medical care by general practitioners, only the appointment of acetylsalicylic acid met the criteria for the implementation of the protocol for the provision of emergency medical care to patients with NSTEMI.

Assessing healthcare service quality using routinely collected data: Linking information systems in emergency care

Emergency departments need to continuously calculate quality indicators in order to perform structural improvements, improvements in the daily routine, and ad-hoc improvements in everyday life. However, many different actors across multiple disciplines collaborate to provide emergency care. Hence, patient-related data is stored in several information systems, which in turn makes the calculation of quality indicators more difficult. To address this issue, we aim to link and use routinely collected data of the different actors within the emergency care continuum. In order to assess the feasibility of linking and using routinely collected data for quality indicators and whether this approach adds value to the assessment of emergency care quality, we conducted a single case study in a German academic teaching hospital. We analyzed the available data of the existing information systems in the emergency continuum and linked and pre-processed the data. Based on this, we then calculated four quality indicators (Left Without Been Seen, Unplanned Reattendance, Diagnostic Efficiency, and Overload Closure). Lessons learned from the calculation and results of the discussions with staff members that had multiple years of work experience in the emergency department provide a better understanding of the quality of the emergency department, the related challenges during the calculation, and the added value of linking routinely collected data.

Is it home delivery or health facility? Community perceptions on place of childbirth in rural Northwest Tanzania using a qualitative approach

BackgroundIn low and middle-income countries, pregnancy and delivery complications may deprive women and their newborns of life or the realization of their full potential. Provision of quality obstetric emergency and childbirth care can reduce maternal and newborn deaths. Underutilization of maternal and childbirth services remains a public health concern in Tanzania. The aim of this study was to explore elements of the local social, cultural, economic, and health systems that influenced the use of health facilities for delivery in a rural setting in Northwest Tanzania.MethodsA qualitative approach was used to explore community perceptions of issues related to low utilization of health facilities for childbirth. Between September and December 2017, 11 focus group discussions were conducted with women (n = 33), men (n = 5) and community health workers (CHWs; n = 28); key informant interviews were conducted with traditional birth attendants (TBAs; n = 2). Coding, identification, indexing, charting, and mapping of these interviews was done using NVIVO 12 after manual familiarization of the data. Data saturation was used to determine when no further interviews or discussions were required.ResultsFour themes emerge; self-perceived obstetric risk, socio-cultural issues, economic concerns and health facility related factors. Health facility delivery was perceived to be crucial for complicated labor. However, the idea that childbirth was a “normal” process and lack of social and cultural acceptability of facility services, made home delivery appealing to many women and their families. In addition, out of pocket payments for suboptimal quality of health care was reported to hinder facility delivery.ConclusionHome delivery persists in rural settings due to economic and social issues, and the cultural meanings attached to childbirth. Accessibility to and affordability of respectful and culturally acceptable childbirth services remain challenging in this setting. Addressing barriers on both the demand and supply side could result in improved maternal and child outcomes during labor and delivery.

Prehospital acute traumatic pain assessment and management practices in the Western Cape, South Africa: a retrospective review

BackgroundTrauma is a common aetiology of acute pain in the emergency setting, and traumatic injuries have been recognised as a global public health crisis leading to numerous deaths and disabilities. This study aimed to identify the prevalence of acute pain among high acuity trauma patients presenting to a public sector emergency medical service and to describe prehospital acute traumatic pain assessment and management practices amongst emergency care providers in the Western Cape Province, South Africa.MethodsA retrospective review of electronic patient care reports of trauma patients treated by the South African Western Cape Emergency Medical Services between January 1 and December 31, 2017 was conducted. Stratified random sampling was utilised to select 2401 trauma patients out of 24,575 that met the inclusion criteria.ResultsOf the 2401 patients reviewed, 435 (18.1%) had a pain score recorded, of which 423 (97.2%) were experiencing pain. An additional 8.1% (n = 194) of patients had pain or tenderness mentioned in the working diagnosis but no pain score noted. Eighty-one (18.6%) patients experienced mild pain, 175 (40.2%) moderate pain and 167 (38.2%) severe pain. No association was found between a pain score recorded and age group (≤ 14 versus > 14 years) (p = 0.649) or gender (p = 0.139). Only 7.6% of patients with moderate-to-severe pain and 2.8% of all trauma patients received any form of analgesic medication. No association was found between the administration of analgesia and age group (≤ 14 versus > 14 years) (p = 0.151) or gender (p = 0.054). Patients were more likely to receive analgesia if they had a pain score recorded (p < 0.001), were managed by advanced life support practitioners (p < 0.001) or had severe pain (p = 0.001).ConclusionAcute trauma pain assessment and management practices in this prehospital cohort are less well established than reported elsewhere and whether this reflects emergency care training, institutional culture, scopes of practice or analgesic resources, requires further research. Emergency medical services need to monitor and promote quality pain care, enhance pain education and ensure that all levels of emergency care providers have access to analgesic medication approved for prehospital use. Clear and rational guidelines would enable better pain management by all cadres of providers, for all levels of pain.

Ethical issues in access to and delivery of emergency department care in an era of changing reimbursement and novel payment models.

Hospital emergency departments (EDs) and the emergency physicians, nurses, and other health professionals who provide emergency care in them, are a critical component of the United States (US) health care system in the 21st century. Although access to emergency care has become a de facto right in the United States, funding for emergency care is fragmented and complex, which causes confusion and conflict about who should bear the cost of care. This article examines the tension between universal access to emergency care in the United States and the fragmentary, tenuous, and contentious financial arrangements that make it possible, viewing the issue in context of the historical development, legal and moral foundations, current situation, and future challenges of ED care in the United States. It begins with a review of the origins and evolution of emergency care and of hospital EDs in the United States. It then examines arguments for a right to emergency medical care and for shared obligations of patients to seek and of professionals and society to provide that care. Finally, it reviews current strategies and future prospects for protecting access to emergency care for patients who require it.

Emergency department visits resulting from electric scooter use in a major southeast metropolitan area.

To determine the frequency, characteristics, and resource use related to the emergency department (ED) encounters resulting from electric scooter use in a major metropolitan area. This Institutional Review Board-approved study was conducted at a four-hospital healthcare system. Our clinical data warehouse was retrospectively searched from 5/3/2018 (the date electric scooters were introduced) through 8/15/2019 for various forms of the word "scooter" in triage notes. Demographic variables, arrival mode, length of stay, disposition, and resource utilization, including diagnostic radiology, were extracted. Over the 471-day study window, 293 unique patients presented with e-scooter injuries (0.62 mean ED visits/day). When broken down into 8-h periods, there was a significant increase (p = 0.048) from Friday after 5 PM through Sunday night. Thirty-two percent of patients arrived at the ED during (newly enacted at the time of study) nighttime e-scooter ban hours (9 PM-4 AM). There was a range of one to nine diagnostic radiology examinations per patient, with 100% (293) of patients receiving at least one diagnostic radiology examination. A total of 710 diagnostic radiology examinations were performed on the entire cohort (mean 2.4 per patient): 77.2% (548) were radiographs and 22.1% (157) were computed tomography (CT). ED visits resulting from electric scooter injuries are common and increasing. E-scooter injury patients disproportionately present on evenings and weekends, possibly exacerbating already busy periods in the ED. Healthcare resource needs and availability should be considered when developing policy about electric scooter use and distribution, particularly involving emergency care providers in close proximity to e-scooter distribution centers.

Characteristics of frequent adult emergency department users: A Korean tertiary hospital observational study.

Emergency department (ED) crowding is a public health burden that impedes the provision of high-quality emergency care and is related to poor outcomes. Frequent ED visits are known to contribute to ED crowding. This study aimed to identify frequent ED users' characteristics and risk factors related to frequent ED visits.A retrospective observational study was conducted using ED-based data derived from adult patients at a university hospital. The main exposure variable was frequent ED visits, which were defined as ≥4 visits within 12 months (January 1-December 31, 2018). Characteristics and risk factors for frequent ED users were evaluated using stepwise regression analysis.Within the study period, there were 36,932 ED visits involving 29,759 patients. Of these, 3031 (8.2%) visits were from 556 (1.9%) patients classified as frequent ED users. The independent risk factors for frequent ED visits were older patients (≥65 years); the winter season; daytime discharge from ED; patients with medical aid insurance; and patients designated as high acuity at their first visit. Patients with a malignant neoplasm, mental health disorder, alcohol-related liver disease, chronic kidney disease, or chronic obstructive pulmonary disease were associated with more frequent ED visits.Frequent ED users comprised a significant proportion of total ED visits. Frequent ED users were more likely than occasional ED users to be in poorer health, older, or have a chronic disease or a mental health disorder.

Acute pain assessment and management in the prehospital setting, in the Western Cape, South Africa: a knowledge, attitudes and practices survey

BackgroundAcute pain is frequently encountered in the prehospital setting, and therefore, a fundamental aspect of quality emergency care. Research has shown a positive association between healthcare providers’ knowledge of, and attitudes towards pain and pain management practices. This study aimed to describe the knowledge, attitudes, and practices of emergency care providers regarding acute pain assessment and management in the prehospital setting, in the Western Cape, South Africa. The specific objectives were to, identify gaps in pain knowledge; assess attitudes regarding pain assessment and management; describe pain assessment and management behaviours and practices; and identify barriers to and enablers of pain care.MethodsA web-based descriptive cross-sectional survey was conducted among emergency care providers of all qualifications, using a face-validated Knowledge, Attitudes and Practices of Pain survey.ResultsResponses of 100 participants were included in the analysis. The survey response rate could not be calculated. The mean age of respondents was 34.74 (SD 8.13) years and the mean years’ experience 10.02 (SD 6.47). Most respondents were male (69%), employed in the public/government sector (93%) as operational practitioners (85%) with 54% of respondents having attended medical education on pain care in the last 2 years. The mean percentage for knowledge and attitudes regarding pain among emergency care providers was 58.01% (SD 15.66) with gaps identified in various aspects of pain and pain care. Practitioners with higher qualifications, more years’ experience and those who did not attend medical education on pain, achieved higher scores. Alcohol and drug use by patients were the most selected barrier to pain care while the availability of higher qualified practitioners was the most selected enabler. When asked to record pain scores, practitioners were less inclined to assign scores which were self-reported by the patients in the case scenarios. The participant dropout rate was 35%.ConclusionOur results suggest that there is suboptimal knowledge and attitudes regarding pain among emergency care providers in the Western Cape, South Africa. Gaps in pain knowledge, attitudes and practices were identified. Some barriers and enablers of pain care in the South African prehospital setting were identified but further research is indicated.

Innovative Left Ventricular Assist Device in High-fidelity Patient Simulator.

Left ventricular assist devices (LVADs) are implantable mechanical devices that pump blood from the apex of the left ventricle to the aorta in order to assist the forward flow of blood; they are most commonly used as a bridge to transplant for patients with heart failure. As of February 2019, a total of 25,145 patients with ventricular assist devices have been reported in the Interagency Registry for Mechanically Assisted Circulatory Support (Intermacs). As this number continues to grow, more and more of these patients will inevitably be seen in the acute care setting outside of their defined LVAD center. Currently, however, LVAD emergencies represent a high-acuity low-occurrence event with limited opportunities for exposure and mastery for most physicians. Therefore, a growing need exists for emergency care providers to familiarize themselves with these devices and the management of LVAD emergencies. We present a novel model for the simulation of LVAD emergencies created through simple modifications of a Laerdal 3G Manikin.

Evaluative Research of Technologies for Prehospital Communication and Coordination: a Systematic Review.

Various technologies have been designed and developed to support communication and coordination between the field and hospital during a medical emergency. The usability issues and human factors entailed in these new technologies are important to their application and effectiveness, suggesting the need to examine this information in a systematic review. The systematic review aims to synthesize the user-centered evaluative research of prehospital communication technologies. We conducted a systematic literature search in four databases (Medline, Cochrane, Embase, and Web of Science) for articles published between the years 2000 and 2019. We included articles that evaluated the technologies developed for supporting prehospital communication and collaboration, and were published in English. A total of 918 articles were retrieved and screened, with 17 articles included for in-depth analysis. Two authors conducted independent screens and reviews of the articles using a list of inclusion/exclusion criteria and defined factors. The types of technology of reviewed articles included ambulance-based telemedicine, wearable, handheld, and Internet of Things (IoT) devices. Even though these technologies have demonstrated high levels of user acceptance, the reviewed studies noted a variety of challenges faced by emergency care providers, which were grouped into three categories-technical, usability, and organizational challenges. Our review also highlighted the paucity of evaluative research of prehospital communication technologies and the lack of user engagement throughout system design process. Based on the results, we discuss the importance of adopting user-centered design approaches and accounting for three social-technical factors in designing technologies for time-critical medical settings, including cognitive and physical stressor, workflow, and context. This systematic review presents an overview of key evaluative research of prehospital communication technologies. The paucity of evaluative research in prehospital communication technology and challenges faced in adopting advanced technological solutions in emergency care highlight the need to adopt user-centered design and take into account socio-technical issues at the point of system design.

Is the Phone Mightier than the Virus? Cell Phone Access and Epidemic Containment Efforts

This paper examines the impact of mobile phone access on the containment of an epidemic. Combining proprietary data on cellphone towers and disease cases during the 2014 Ebola epidemic in Liberia, we estimate a high-resolution radio-wave propagation model to predict signal strength. Comparing villages at the margin of the signal strength threshold required for coverage, we uncover a 10.8 percentage point reduction in the likelihood of a case in villages with coverage. Results from a novel survey collected following the epidemic suggest that this is mostly explained by cellphone access facilitating emergency care provision rather than improving access to information.

Current Strategies for Pain Management in Pediatric Trauma and Risk for Opioid Use Disorder

Amidst the opioid crisis, acute pain management in pediatric trauma is complicated by the fact that children respond differently to pain than adults. This is largely due to incomplete development of neural networks and immature mechanisms in verbalizing distress. Much of the literature emphasizes that adequate and timely analgesic relief in pediatric patients is necessary to avoid complications of chronic pain. This article analyzes current strategies in nonpharmacologic and pharmacologic alternatives to opioid management in the setting of pediatric trauma. We also acknowledge that, albeit having a lower incidence than in the adult population, opioid use disorders (OUD) are a serious consequence of narcotic prescriptions in adolescent patients, and emergency and primary care providers must remain vigilant of the signs and symptoms of OUD.

An 11-Month-Old With Vomiting, Altered Mental Status, and Hypoventilation

Vomiting is a common pediatric complaint seen frequently in both pediatric and general emergency departments. Obstructive causes of vomiting are rare outside of the newborn period compared to more benign causes such as viral gastroenteritis. Timely recognition of these rarer causes of obstruction is essential for optimal care. This case highlights a severe presentation of chronic isolated vomiting caused by obstruction. It serves as a strong reminder to emergency care providers that obstruction can occur outside of the newborn period and, if unrecognized, can result in significant morbidity.

Impact of endemic HIV on emergency care service delivery in South Africa.

South Africa (SA) has the highest burden of HIV in the world. This study sought to evaluate the impact of high HIV prevalence on the burden of disease in an emergency department (ED). To determine the burden of comorbidities in HIV-positive emergency care patients, their demographic profiles and severity of illness were compared with the general ED population in order to make recommendations for resource allocation and training in EDs in SA. A prospective cross-sectional observational study was conducted from June 2017 to July 2018 in three EDs in Eastern Cape Province. All eligible patients (aged ≥18 years, fully conscious and clinically stable) presenting to the ED during the 6-week study period were approached and asked to give consent for a point-of-care HIV test and collection of demographic information. Simple descriptive statistics were used to analyse data. Log binomial and Poisson models were fitted to estimate prevalence ratios (PRs). Over the total study period, 8 000 patients presented to the ED for care across all sites and 3 537 patients were enrolled. The HIV status of 2 901 individuals (82.0%) was determined. Of those who were screened, 811 (28.0%) were identified as HIV-positive. Medical complaints were more common in HIV-positive patients (n=586, 72.3%) than in trauma patients (n=225, 27.7%). In comparison, HIV-negative patients reported fewer medical complaints (n=1 137, 54.4%) and more trauma (n=953, 45.6%) (p&lt;0.001). HIV-positive patients were more likely to have a life-threatening emergency (n=192, 23.7%) (p=0.004), to be critically ill by triage score (p&lt;0.001) and to be admitted to the hospital (p&lt;0.001) than those who were HIV-negative. Despite high acuity overall, people living with HIV/AIDS were significantly less likely to be deemed critically ill according to vital signs (adjusted PR 0.94; p=0.046). While EDs in SA provide care to high volumes of patients with trauma-related injuries, in areas where HIV prevalence is highest, patients are more likely to present with acute medical emergencies. Providers of emergency care in SA need to be well versed in the management of HIV and associated complications.