Mediterranean Journal of Emergency Medicine & Acute Care

7

Authors: Mazen J. El Sayed, Eveline A. Hitti, Mohamad Ali Cheaito, Tim Davis, Amin A. Kazzi

The first article in this series (Part I) discussed the abundant exposure of our emergency department (ED) to mass casualty incidents (MCIs), particularly over the past 14 years. This experience led us to define practical strategies that emergency departments can use to develop their own MCI response plans. In the first part, our main focus was to highlight the abrupt nature of MCIs and the subsequent need to use disaster drills. Additionally, we discussed the importance of having a tiered response and activation as well as other lessons learned from our experience to maximize the preparedness of the emergency department to receive mass casualty.In this article, we discuss the optimal way to triage patients. In addition, we will tackle the best methods for documentation and communication, which are vital yet overlooked during mass casualty incidents. We will also elaborate on what we learned from dealing with outbursts of anger and violence in the ED during MCIs and how to ensure the safety of the ED staff.

4-7

Authors: Karima Sajadi-Ernazarova, Edward A Ramoska, Mark A Saks

Introduction: Scores on “high-stakes” multiple choice exams such as the United States Medical Licensing Examination® (USMLE) are important screening and applicant ranking criteria used by residencies.Objective: We tested the hypothesis that USMLE scores do not predict overall clinical performance of emergency medicine (EM) residents. Methods: All graduates from our University-based EM residency between the years 2008 and 2015 were included. Residents who had incomplete USMLE records were terminated, transferred out of the program, or did not graduate within this timeframe were excluded from the analysis. Clinical performance was defined as a gestalt of the residency program’s leadership and was classified into three sets: top, average, and lowest clinical performer. Dissimilarities of the initial blind rankings were adjudicated during a consensus conference. Results: During the eight years of the study period, there were a total of 115 graduating residents: 73 men (63%) and 42 women. Nearly all of them (109; 95%) had allopathic medical degrees; the remainder had osteopathic degrees. There was not a statistically significant correlation between our ranking of clinical performance and the Step 2 Clinical Knowledge score. There was a non-significant correlation between clinical performance and the Step 1 score. Conclusion: Neither USMLE Step 1 nor Step 2 Clinical Knowledge were good predictors of the actual clinical performance of residents during their training. We feel that their scores are overemphasized in the resident selec­tion process.

7

Authors: Eveline A. Hitti, Mohamad Ali Cheaito, Mazen J. El Sayed, Arthur L. Kellermann, Amin A. Kazzi

Over the last century, mass casualty incidents (MCIs) affected many nations and their emergency departments. The unscheduled arrival of large number of injured victims over a short period of time often causes major chaos and crowding. When a rapid surge in operational needs overwhelms available Emergency Department (ED) resources and personnel, the chaos and overwhelming mismatch between needs and resources can quickly spread to the rest of the hospital.1, 2 Nonetheless, as the front door of the hospital, the ED plays a pivotal role in determining the quality and effectiveness of an institution’s MCI response. This requires effective planning, which translates into preparedness. Unfortunately, many EDs are overburdened even on regular days. Damaged infrastructure further compounds the challenge.

4-12

Authors: Eveline Hitti, Hani Tamim, Rinad Bakhti, Dina Zebian, Afif Mufarrij

Introduction: Medication errors are common, with studies reporting at least one error per patient encounter. At hospital discharge, medication errors vary from 15%-38%. However, studies assessing the effect of an internally developed electronic (E)-prescription system at discharge from an emergency department (ED) are comparatively minimal. Additionally, commercially available electronic solutions are cost-prohibitive in many resource-limited settings. We assessed the impact of introducing an internally developed, low-cost E-prescription system, with a list of commonly prescribed medications, on prescription error rates at discharge from the ED, compared to handwritten prescriptions. Methods: We conducted a pre- and post-intervention study comparing error rates in a randomly selected sample of discharge prescriptions (handwritten versus electronic) five months pre and four months post the introduction of the E-prescription. The internally developed, E-prescription system included a list of 166 commonly prescribed medications with the generic name, strength, dose, frequency and duration. We included a total of 2,883 prescriptions in this study: 1,475 in the pre-intervention phase were handwritten (HW) and 1,408 in the post-intervention phase were electronic. We calculated rates of 14 different errors and compared them between the pre- and post-intervention period. Results: Overall, E-prescriptions included fewer prescription errors as compared to HW- prescriptions. Specifically, E-prescriptions reduced missing dose (11.3% to 4.3%, p <0.0001), missing frequency (3.5% to 2.2%, p=0.04), missing strength errors (32.4% to 10.2%, p <0.0001) and legibility (0.7% to 0.2%, p=0.005). E-prescriptions, however, were associated with a significant increase in duplication errors, specifically with home medication (1.7% to 3%, p=0.02). Conclusion: A basic, internally developed E-prescription system, featuring commonly used medications, effectively reduced medication errors in a low-resource setting where the costs of sophisticated commercial electronic solutions are prohibitive.

22-28

Authors: Maruli Tua Sianipar, Bambang Budi Siswanto

Psoriasis is a disease characterized by chronic inflammation with a global prevalence of 1-2%. It has a strong genetic component with a systemic immunological response mainly driven by T helper (Th) 1 and 17 lymphocytes. The relationship between HF and psoriasis is not well-described. In this paper we describe 2 cases of concomitant psoriasis and heart failure. Furthermore, we revisit the pathogenesis of those entities and discuss the available evidence on their association, and the proper evaluation of psoriasis in the management of heart failure in patients present with both diseases.

32-36

Authors: Saleh Fares

As I began writing this article, I was stunned realizing that September 2019 marks the anniversary of a ten-year journey for the specialty of emergency medicine (EM) in the United Arab Emirates (UAE). I had returned home to the UAE after 17 years’ acquiring and refining knowledge and skills as well as building experience and expertise abroad. This included medical school studies in Ireland,1 an Emergency Medicine (EM) Residency training in Montreal, Quebec2, a Prehospital Care fellowship in Toronto, Ontario,3 a Disaster Medicine fellowship in Boston, Massachusetts4, and finally a public health graduate degree in Baltimore, Maryland5. Throughout that time spent in nations where EM was well-developed, I was persistently asking myself, “What can I learn from here to allow me to develop EM back home?”. This challenging journey was certainly exciting and beneficial and exposed me to so many different “systems”, to their strengths and weaknesses, to the different approaches used to address problems, needs and day-to-day operations, and reinforced my belief that there is room and a need for flexibility, variability and diversity in the EM models one could build.