UMEM Educational Pearls - International EM

On a day when the 355^th mass shooting this year in the USA occurred in San Bernardino, California, it seems appropriate to discuss gun violence.

A recently accepted publication in the American Journal of Medicine compared morality data from the USA to other high-income countries, and found the following:

The US homicide rates were 7.0 times higher than the aggregated rates of all other high-income countries.

• This is driven primarily by a gun homicide rate that is 25.2 higher
• For 15-24 year olds, the gun homicide rate is 49.0 higher

The overall US suicide rate is average

• However, in the USA the firearm-related suicide rates were 8.0 times higher

Unintentional firearm deaths were 6.2 times higher in the US.

The overall firearm death rate in the US from all causes was 10.0 times higher.

Bottom line: As stated in the article: “The US has an enormous firearm problem compared to other high-income countries with much higher rates of homicide and firearm-related suicide.”

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There are two main models of Emergency Medical Services (EMS) Systems

Franco-German

• Doctor is brought to the patient
  • Care often provided by emergency physicians
• Based upon the “stay and stabilize” philosophy
  • Fewer transports to the hospital
  • Direct transport to inpatient wards
• Utilizes more extensive advanced technology
• Widely implemented in Europe
• EMS as part of public health organization

Anglo-American

• Patient is brought to the doctor
  • Care provided by emergency medical technicians/paramedics
• Based upon the “scoop and run” philosophy
  • More patients transported to the hospital
  • Brought to the emergency department
• More likely to be found in countries with emergency medicine as a developed specialty
• Widely implemented in English speaking countries globally
  • However, also found in other countries such as in the Arabian Gulf
• EMS as part of public safety organization

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Sickle Cell Disease (SCD) is a hemoglobinopathy that is considered a relatively rare disease in the United States, affecting about 90,000-100,000 individuals.

Globally, SCD affects millions, primarily in West and Central Africa.

Acute presentations of SCD include:

• Acute Pain (Sickle Cell or Vaso-occlusive) Crisis
  • Most common presentation in emergency departments
• Severe Anemia
  • Splenic sequestration crisis
  • Aplastic crisis
  • Hemolytic crisis
• Infections
  • Particularly from encapsulated organisms because of a damaged spleen (functional asplenia)
• Acute Chest Syndrome
  • From damaged lung tissues leading to hypoxia
  • A leading cause of death for patients SCD
• Stroke
• Priapism
• Other organ dysfunction including kidney failure and eye problems (retinopathy)

The bottom line: 

• Sickle Cell Disease is a serious, painful and potentially life threatening disease that can cause major damage to multiple organ systems.

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The World Health Organization (WHO) has just released a report on the current status of road traffic safety globally.

• 1.25 million people die each year from road traffic crashes
• 90% of road traffic deaths occur in low- and middle- income countries
  • Only 54% of the world vehicles are in these countries
• Countries in Africa have the highest death rates per capita
• Vulneable groups include:
  • Motorcyclists (23% of global deaths)
  • Pedestrians (22% of global deaths)
  • Cyclists (4% of global deaths)

From a postive perspective, road traffic deaths are stabilzing even though the number of motor vehicles are rapidly increasing.

The bottom line- injuries are preventable.  Continued policy efforts, laws with enforncement, can save lives. Specific life saving legislation includes:

• seat belt laws that apply to all occupants
• maximum speed, such as urban speed limits of 50 Km/h (31 mph)
• child restraint, based upon age, height or weight
• helmet laws that apply to all drivers, passengers and road types
• drink-driving laws with specific blood alcohol concentrations (e.g.: 0.05 g/dl or less)

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Overall, suicide is the 15^th leading global cause of death.  However, it is the 2^nd leading cause among 15-29 year olds

• Over 800,000 people die each year from suicide
• 75% of these deaths occur in low- and middle-income countries
• Most common methods of suicide globally are:
  • Pesticide ingestion (around 30%)
  • Hanging
  • Firearms

Suicides are preventable.  Interventions to decrease suicides include:

• Reduce access to means of suicide
• Alcohol policies that reduce the harmful use of alcohol
• Early identification and treatment of patients at risk
  • Mental health disorders
  • Substance use disorders
  • Chronic pain syndromes
  • Acute emotional distress
  • Prior suicide attempts
• Appropriate follow-up care for individuals who have attempted suicide

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If you are interested in learning about the current status of emergency medicine in a specific country, it can be difficult to find up-to-date information. One excellent resource for country specific details is the American College of Emergency Physicians’ (ACEP) International Ambassador Program.

This program has Emergency Medicine Ambassadors (U.S. emergency physicians), Liaisons (in-country emergency physicians) and Representatives (U.S. emergency physicians in training) for many countries around the world.  Additionally, there are country specific reports that give annually updated information about emergency medicine in each country.

Included on the website are links to send emails to the Ambassadors, Liaisons and Representatives in order to request more detailed information. 

To learn more, see: http://www.acep.org/IntlAmbassador/

Which infectious disease listed as Class A agents occur naturally, though sporadically within the U.S?

• Anthrax- primarily in the West and Southwest (including Texas)
• Plague- western United States
• Tularemia- in all states except Hawaii, but most common south central US
• Botulism- throughout the U.S. Most common type reported is infant botulism
• Dengue- primarily Puerto Rico. Within the continental US, a small outbreak was reported from south Texas.

Small pox no longer occurs naturally and other viral hemorrhagic fevers occur in tropical settings.

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Injuries are a leading cause of morbidity and mortality globally

• Approximately 5.8 million deaths annually
• 90% occur in lower and middle income countries

Injuries are the leading cause of preventable death in travelers

• Cause 18%–24% of deaths among U.S. travelers
• From 2011-2013, an estimated 2,466 US citizens traveling in foreign countries died from non-natural causes, such as injuries and violence
  • Excluded the wars in Iraq and Afghanistan
• Main causes for non-natural deaths among Americans are:
  • Motor vehicle crashes (n= 621, 25%)- the single largest cause
  • Homicide (n=555, 23%),
  • Suicide (n=392, 16%),
  • Drowning (n=309, 13%)

Bottom Line: Stay safe while travelling.  The same safety habits used in the US, such as wearing your seatbelt or not drinking and driving, are important patterns while traveling.

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Introduction: As discussed in previous Pearls, Middle East respiratory syndrome coronavirus (MERS-CoV) is a recently emerged respiratory viral infection that is caused by a single stranded, positive-sense RNA novel coronavirus.

Updates:

As of August 12^th, 2015, WHO has received reports of:

• 1413 laboratory confirmed cases
• 502 deaths

The current reported case fatality rate is approximately 36%

Recent outbreaks have included

• Wide spread dissemination in Korea, which impacted multiple hospitals and near-by countries
• A very recent outbreak at King Abdulaziz Medical City in Riyadh, Saudi Arabia which has closed an emergency ward for two weeks. Of the approximately 46 people currently reported infected, at least 15 were medical personnel.

Bottom Line:

MERS-CoV is significantly contagious respiratory virus with high lethality.  It is spread primarily as an airborne virus, though the CDC currently recommends both standard contact and airborne precautions. There is currently no vaccine and only supportive treatment is advised.

Don’t be a vector or have your emergency department be a nidus of infection! Take appropriate precautions, including:

• Minimize chances of exposure when patients arrive
  • Have them wear a face mask if they have respiratory symptoms
  • During triage and throughout the visit, have patients adhere to respiratory hygiene and cough etiquette, hand hygiene
• Adhere to standard contact and airborne precautions
• Use caution when performing aerosol-generating procedures

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Introduction

Obtaining quality information about emergency care in low- and middle-income countries (LMIC) is challenging.  Data is sparse and often of low quality and the number of peer reviewed publications is limited.

In order to address this, Obermeyer et. al. just published in the WHO Bulletin a systematic review of emergency care in 59 low- and middle-income countries.  In this article, the authors systematically reviewed 195 reports related to 192 facilities. The search included English or French articles from 1990 found within PubMed, CINAHL and World Health Organization (WHO) databases.

Burden of Emergency Care

Most articles were from emeregncy departments (EDs) in academically-affiliated hospitals in urban areas. Median mortality in the EDs was 1.8% (interquartile range, IQR: 0.2–5.1%), though in sub-Saharan Africa it was 3.4% (IQR: 0.5–6.3%).  The median number of patients seen per year was 30,000 (IQR: 10 296–60 000). The facilities were staffed primarily by physicians-in-training or by physicians whose level of training was unspecified.  There were very few providers specialized in emergency care.

Bottom Line

Based upon available data, there are high patient loads and mortality in LMIC- particularly in sub-Saharan Africa.  This report highlights the importance of emergency care and the opportunity for systematic improvement to reduce mortality in these countries.

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Every wonder what are the major global killers? Per the World Health Organization, the following were the top 20 causes. 

Not unexpected, diseases primarily of the elderly, such ischemic heart disease, stroke and chronic obstructive pulmonary disease are on the top of the list.  However, there are others, such as road traffic injuries and HIV/AIDS that could impact anyone.

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Tuberculosis (TB) remains a deadly scourge killing approximately 1.5 million each year (see Pearl from 7/2/2105). Recognition by astute clinicians in the emergency department is key, as there is no readily available rapid test.

Current testing options:

1) Tuberculin skin test (also known as the Mantoux tuberculin skin test).  A small amount of fluid (tuberculin purified protein derivative) is placed intradermally, usually in the left forearm. A positive test means the person was infected with TB.  (Alternatively, if they grew up outside the US, they could have been vaccinated with Bacillus Calmette–Guérin or BCG.) A positive test is determined by the size of the reaction, but this can vary depending on the patient’s immune status.

2) Two interferon-gamma release assays or IGRA blood tests are approved for TB.  While not readily available in all institutions, this is the preferred method for someone vaccinated with BCG.

Diagnosis of TB disease is based upon:

• Medical history
• Physical exam
• A positive TB test
• Chest radiograph
• Other appropriate laboratory test (such as acid fast bacilli on sputum smear followed by culture)

Treatment:

TB treatment depends on the susceptibility of the organism and the immune status of the patient.  For a susceptible organism in a non-HIV patient, the first-line anti-TB agents regimens include

• isoniazid (INH),
• rifampin (RIF),
• ethambutol (EMB), and
• pyrazinamide (PZA).

Typical treatment has an initial phase of 2 months, followed by a choice of several options for the continuation phase of either 4 or 7 months. Further information can be found at the CDC website on tuberculosis

Bottom Line

As stated previously, in the emergency department, maintain a strong clinical awareness for tuberculosis for someone with night sweats, cough, chest pain, and intermittent fever lasting for 3 weeks or longer.  In particular, consider this diagnosis for someone from a low- or middle-income country or if he or she is HIV positive.

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As noted in a previous pearl (see 1/7/2015), tuberculosis (TB), caused by Mycobacterium tuberculosis, is the second greatest infectious killer after HIV/AIDS globally. While the incidence and death rate from TB is decreasing, it is still a widespread problem.

• 9 million people fell ill with TB in 2013
• 1.5 million deaths
• Most deaths (95%) occur in low- and middle-income countries
• Among the top 5 causes of death in women aged 15 to 44

Mycobacterium tuberculosis primarily attacks the lungs.  However, it can attack any part of the body such as the kidney, spine, and brain. TB is primarily spread person to person through the air, for example when a person with TB coughs, sneezes, speaks, or sings.

Once a person is infected with TB, the likelihood of developing disease is greater if the person:

• Is HIV infected;
• Has recently acquired TB infection (past 2 years);
• Has other health problems, like diabetes, that impair the immune response;
• Is a substance abuser (alcohol or illegal drugs);
• Was not adequately treated in the past for TB.

Classic symptoms for pulmonary TB include:

• A prolonged (> 3 weeks) bad cough
  • coughing up blood or sputum
• Pain in the chest
• weakness/ fatigue
• weight loss
• anorexia
• chills
• fever
• sweating at night

Other TB symptoms can also include:

• Prolonged headaches and mental status changes (TB meningitis),
• Prolonged back pain/stiffness leading to lower extremity paralysis, or single joint arthritis (skeletal TB)
• Flank pain, frequent urination, scrotal mass or epididymo-orchitis, pelvic inflammatory disease (genitourinary TB)

Bottom line

In the emergency department, maintain a strong clinical awareness for tuberculosis for someone with night sweats, cough, chest pain, and intermittent fever lasting for 3 weeks or longer.  In particular, consider this diagnosis for someone from a low- or middle-income country or if he or she is HIV positive.

Next time: Testing and treatment for TB.

Also see prior pearls on TB: Multidrug Resistant Tuberculosis (MDR TB) (1/21/2015), Tuberculosis (1/7/2015); XDR Tuberculosis (8/14/2013); PPD positive? Good news... (2/6/2013)

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While most infections from parasites are associated with poor communities in low-income countries, there are still some important parasitic infections found in the United States.

The U.S. Centers for Disease Control and Prevention (CDC) has identified 5 parasitic diseases as priorities for public health action based upon:

• Number of infected individuals
• Severity of illness
• Ability to prevent and treat the diseases

These are

• Chagas Disease
  • More than 300,000 people in the U.S. are infected with Trypanosoma cruzi, the parasite that causes Chagas disease
• Cysticercosis
  • At least 1,000 people are hospitalized annually with neurocysticercosis
• Toxocariasis
  • 70 individuals, mostly children are blinded annually from toxocariasis
• Toxoplasmosis
  • More than 60 million individuals carry Toxoplasma gondii, but it usually doesn’t cause symptoms in immunologically competent individuals. 
  • However, it is the 2^nd leading cause of death from foodborne illness and it can cause severe problems during pregnancy and in immunocompromised individuals.
• Trichomoniasis
  • 3% of women in the U.S. are infected with this sexually transmitted parasite
  • 1.1 million people newly infected annually

Bottom line:

Remember to keep your differential broad and maintain awareness of these generally unusual but important infections.

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Introduction:

As noted in the previous pearl (May 20, 2015), globally diarrheal diseases are the second leading cause of death for children under five- killing approximately 760,000 annually.  What can be done to prevent and treat diarrhea, especially among young children?

Prevention of diarrheal illness:

• Improve access to safe drinking water
• Improve access to sanitary facilities (i.e.- toilets)
  • Keep drinking water and sewage separate!
• Good personal hygiene
  • Hand washing with soap
• Good food hygiene
• Breastfeeding during the first 6 months of life
• Improved health education for individuals and communities
  • Especially about the spread of infectious diseases
• Increased rotavirus vaccination

Treatment of diarrheal illness:

• Oral rehydration salts (ORS)
  • Made from clean water, salt and sugar
  • Cheap (a few cents per treatment)
  • Absorbed in the small intestine
  • Replaces water and electrolytes lost in the diarrheal stools
• Zinc supplements
  • Reduces duration and volume of stools
• Intravenous rehydration for severe dehydration or shock
• Nutrient-rich food (including breast milk) as tolerated during an episode
  • Generally- good nutrition and a nutritious diet to keep children healthy
• Appropriate (and selective) use of antibiotics
  • Not appropriate for most cases of diarrhea in young children

Bottom Line

Diarrheal diseases kill hundreds of thousands of children in developing countries each year.  Appropriate prevention measures (clean water, improved sanitation) can markedly decrease the burden of disease.  Appropriate treatment (ORS) can save lives for pennies.

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Background:

While diarrhea in adults can be inconvenient and briefly debilitating, in children it can be fatal.  Globally, diarrheal diseases are the second leading cause of death for children under five.

• Approximately 760,000 children under five die each year from diarrhea
  • Kills 2,200 children daily- more than AIDS, malaria and measles combined
• Most of the diarrhea can be prevented
  • Safe drinking water
  • Adequate sanitation and hygiene
• Diarrhea is also a leading cause of malnutrition

Clinical types of Diarrhea (with common infectious causes):

• Acute watery diarrhea lasting hours or days (e.g. rotavirus, norovirus, Vibrio cholerae)
• Acute bloody diarrhea, a.k.a. dysentery (e.g. Entamoeba histolytica, Shigella, Salmonella, Campylobacter, E. coli)
• Persistent diarrhea lasting longer than 14 days (e.g. parasites, C. difficile)

Clinical assessment:

• Early dehydration- no signs or symptoms
• Moderate dehydration
  • Thirst
  • Irritability/tiredness/lightheadedness
  • Dry mucous membranes/decreased tears
  • Decreased urine output/dark (concentrated) urine
  • Sunken eyes
  • Decreased capillary refill (2-4 sec)*
  • Decreased skin turgor*
  • Increased respiratory rate*
• Severe dehydration
  • Decreased mental status
  • Shock (rapid heart rate, low blood pressure)
  • Minimal or no urine output
  • Very sunken eyes/no tears
  • Parched/cracked mucous membranes
  • Marked decreased capillary refill (> 4 sec)*
  • Skin tenting*
  • Markedly increased respiratory rate*

*Best indicators of hydration status

Next week: Prevention and Treatment

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Introduction:

There were approximately 56 million deaths worldwide in 2012. The causes of death vary significantly based upon the income level of the country.

High-income Countries:

• 7 out of 10 deaths were among individuals 70 years or older
• Only 1 in 100 deaths were in children under 15 years
• Most deaths were due to chronic diseases, such as cardiovascular diseases, cancer, dementia, COPD or diabetes

Low-income Countries:

• Only 2 of every 10 deaths were among individuals 70 years or older

• Almost 4 of every 10 deaths were among children under 15 years
• People frequently die of infectious diseases, such as lower respiratory infections, HIV/AIDS, diarrheal diseases, malaria and tuberculosis.
• Complications of childbirth are also among the leading causes of death

Bottom Line:

Acute care services in the US and high-income countries need to acknowledge the growing number of individuals with chronic diseases and the rapidly growing elderly population. In low-income countries, acute care services still need to primarily address maternal/child infections and problems as well as infectious diseases.

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A Lancet Commission on Global Surgery has just published a 56 page article about the need to improve access to surgery and anesthesia care.  Its five key messages are:

• 5 billion people lack access to safe, affordable surgical and anaesthesia care when needed
• 143 million additional surgical procedures are needed each year to save lives and prevent disability
• 33 million individuals face catastrophic health expenditure due to payment for surgery and anaesthesia each year
• Investment in surgical and anaesthesia services is affordable, saves lives, and promotes economic growth
• Surgery is an indivisible, indispensable part of health care

The need for high quality acute care, both for urgencies and emergencies, is clearly an important component of providing “universal access to safe, affordable surgical and anaesthesia care”- the vision of the Commission.

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In 2011, approximately 630,00 children under 15 died from unintentional injuries. Injuries are the leading cause of childhood deaths in children over 9 years old.  Ninety-five percent of these childhood injuries occur in lower- and middle-income countries.

The 2008 World Report on Child Injury Prevention listed the following as the top five causes of pediatric injury deaths globally:

1)   Road Crashes- approximately 260,000/year

2)   Drowning- approximately 175,0000/year

3)   Burns- approximately 96,000/year

4)   Falls- approximately 47,000/year

5)   Poisoning (unintentional)- approximately 45,000/year

Many of these deaths occur around the home and could be prevented through proven prevention measures, which include:

·      Child appropriate seatbelts and helmets

·      Separate children from vehicular traffic

·      Limit hot tap water temperature

·      Placing medications and potentially harmful household products in child proof containers

·      Draining unnecessary water from baths and buckets

·      Redesigning nursery furniture, toys and playground equipment

·      Strengthening emergency medical services

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Background:

• Polio is a crippling and potentially fatal infectious disease
  • Can cause temporary or permanent acute flaccid paralysis
  • Fecal-oral or oral transmission
  • The majority of cases of polio infection are asymptomatic
  • The public/global health significance of polio has been discussed in previous UMEM Educational Pearls (See: 5/7/2014 and 12/18/2013).
• Caused by small, single-strand, positive-sense RNA virus of the genus Enterovirus

Enterovirus D68

• Recent widespread nationwide outbreak of this non-polio enterovirus
  • From mid-August 2014 to January 15, 2015, federal and state public health laboratories confirmed 1,153 people with infections
  • Usually seen in children
  • Usually causes mild to severe respiratory illness.
• Concurrent with the national outbreak of Enterovirus D68, there was a concurrent increase in children with acute flaccid myelitis

Is there a relationship between Enterovirus D68 and the outbreak of acute flaccid myelitis?

• Recent NIH funded research published in Lancet Infectious Disease analyzed the genomes of 48 patients with enterovirus infections
  • Phylogenetic analysis showed that all enterovirus D68 sequences associated with acute flaccid myelitis were part of the same clade B1 strain .
• These findings strengthen the possible relationship between enterovirus D68 and acute flaccid myelitis

Bottom Line

• Acute flaccid myelitis may rarely occur after Enterovirus D68 in susceptible hosts

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