Volume 6, Issue 1: What is emergency medicine?

​With less than a month to go to the International Conference on Emergency Medicine (to be held on African soil for the first time) I thought it is appropriate to reflect on what exactly it means to provide emergency care as a profession. I’m quite sure many of you have seen the bemused look on family and friends’ faces when you tell them that emergency care is actually a career choice, your career choice, and not just a stepping stone to something bigger and better. “Why not become a specialist?” they ask, “you have so much to offer”. Well I agree, I do have much to offer.

For some strange reason patients want specialist care when they get to a hospital but find it strange that emergency centres have the need to employ specialists. Patients want a paediatrician when their child has had a febrile seizure, an orthopaedic surgeon when grandma has broken her wrist and a cardiologist when they are having chest pain. So, I explain to my family and friends: I am all of that rolled into one. I can do what any of these specialists can do in the emergency centre, at the front door of the hospital, without the need for the hospital to employ a dedicated emergency centre paediatrician, orthopaedic surgeon, cardiologist or any other specialist for that matter. The difference is that I specialise in the emergency aspects of each of those specialties. This allows me to slip comfortably from terminating a seizure, to manipulating a fracture, to reading an ECG. If necessary I pass the patient on to the relevant inpatient specialist who can be rest assured that specialist emergency care have already been provided. In order to do all of that I need to surround myself with likeminded nurses and pre-hospital staff, trained in emergency care, so that any patient that enters into our care can get the specialist care they long for. That tends to do the trick for family and friends; but we all know that doing emergency care is more than just that. Acting as specialist gatekeepers we drive efficiency, keep costs down and limit admissions to only the absolute necessary. Acting as specialist decision makers we make daily calls on who stays and who goes, who needs investigations and who can do without, who gets advanced care and who gets active palliation. So really we should be called specialist-emergency-generalist-gatekeeper-decision-makers. Of course that is too long a term to practically make use of in real life, so instead we use emergency physician. And that is what I am.

Issue line-up
The clinical practice of emergency medicine in Mahajanga, Madagascar
It is really nice to see emergency care develop in Africa, and that includes the islands around Africa. This paper provides the first report of the practice of emergency care in Madagascar. There are no surprises in the disease profile as trauma fills the top spot and infectious diseases the third. However, this paper is about more than simply reporting a descriptive sample of emergencies presented to an urban emergency centre. It also shows a certain level of maturity that is likely to help bring formalised emergency care to the Malagasy people. The authors rightfully reflect on the burdens and challenges of achieving the latter.

Free open access medical education resource knowledge and utilisation amongst emergency medicine trainees: a survey in four countries
It may be free, but if you don’t know about it you still won’t have access to it. This interesting survey compares two high income settings against two low-to-middle-income settings regarding penetration of free, open access, educational, social media tools. It seems that low-to-middle-income settings struggled with awareness, in particular Papua New Guinea. Botswana wasn’t too bad; likely due to the influence of international faculty in their training team. However, the spectrum of what Batswana were accessing was much smaller than what was accessed by their high income setting counterparts. So despite being aware of free, open access, educational, social media tools, it wasn’t optimally used. Given the increase of mobile phones in these settings and the fact that these are free resources, it may be worth promoting awareness in low-to-middle-income settings from an education point of view.

Agar ultrasound phantoms for low-cost training without refrigeration
One of the problems in Africa is that it is really, really hot a lot of the time. Given that services such as electricity are not all that dependable, finding a way to practice ultrasound on phantoms that will not go off is pretty innovative. These agar phantoms stood up well against its gelatine counterparts and in some respects outdone it. The ingredients required and method are provided in the paper. Expect to see an agar phantom at an ultrasound practice session or workshop near you.

Endotracheal tube cuff pressures and tube position in critically injured patients on arrival at a referral centre: avoidable harm?
When it comes to intubation, it seems that we’re mostly confident on how deep the tube should go, but less so on how tight to inflate it. In this setting the out of hospital group was more often the culprit than the in-hospital group. That said the in-hospital group only got the pressure right 27% of the time. It is important for practitioners that intubate to realise that getting the tube down is only half the work. Incorrect placement and high cuff pressures lead to avoidable downstream complications. The paper re-emphasises that each intubation should be checked with an X-ray for position and a cuff manometer for pressure.

Availability of resources for emergency care at a second-level hospital in Ghana: a mixed methods assessment
Some things were good and some things were bad. Sadly the former could not balance out the latter. Low cost items such as basic airway supplies, chest tubes and facemasks were lacking, as was a ventilator and defibrillator. At least part of the problem appeared to be lack of staff awareness. Staff acknowledged the shortcomings and made some sensible suggestions, such as: increasing capacity in the emergency centre and regular training. Increasing staff competency and holding the powers that be to account for patient care through regular audit, as was done in this study, is a good way for African emergency centres to improve patient safety, experience and care.

Electronic medical records in low to middle income countries: the case of Khayelitsha Hospital, South Africa
There is no doubt that electronic medical records are the way forward. However, the dual system implemented at this district level hospital was not able to accurately trace the trauma load. The case becomes a good example for other facilities wishing to adopt electronic medical records too.

​http://dx.doi.org/10.1016/j.afjem.2016.02.001