We undertook a retrospective case review of medical records in two regional hospitals in Cape Town. All adult patients intubated in the EC during the 6 months 1 July to 31 December 2008 were included. A single researcher assessed the case notes to assess documentation of specific procedural criteria: indication for intubation, drugs & doses, endotracheal tube size, laryngoscopy, insertion depth, securing method, position confirmation, ventilator settings and complications. General medical documentation including demographics and legibility of physician name were also assessed. Results are presented using basic descriptive statistics of the 32 criteria analysed.

Introduction: Injury and violence is a neglected global health problem, despite being largely predictable and therefor preventable. This study aimed to indirectly describe and compare the availability of resources to manage major trauma between high income, and low- to middle-income countries, as self-reported by delegates at the 2016 International Conference on Emergency Medicine held in Cape Town, South Africa. Materials and methods: A survey was distributed to delegates at the International Conference on Emergency Medicine 2016, Cape Town to achieve the study aim. The survey instrument was based on the 2016 NICE guidelines for the management of patients with major trauma. It captured responses from participants working in both pre- and in hospital settings. Responses were grouped according to income group (either high income, or low- to middle-income) based on the responding delegate’s nationality (using the World Bank definition for income group). A Fisher’s Exact test was conducted to compare delegate responses Results: The survey was distributed and opened by 980 delegates, of whom 392 (40%) responded. A total of 206 (53%) respondents were from high-income countries and 186 (47%) were from low- to middle-income countries. Responders of this self-reported survey described a significant discrepancy between the resources and services available to high income countries s and low- to middle-income countries to adequately care for major trauma patients both pre- and in-hospital. Shortages ranged from consumables to analgesia, imaging to specialist services, pre-hospital to in-hospital. Discussion: Resource restriction is a major concern in the care for major trauma patients in low- to middle-income countries. Current accepted reference standards does not take the resource restrictions that apply to the vast majority of the world’s injured patients into account. More research is required to describe the problem of resource restrictions in low to middle-income countries, and then working out how to overcome it.

Includes abstract. / Includes bibliographical references. / To determine whether the current South African Emergency Medicine Curriculum is appropriate for the burden of disease seen by registrars in Cape Town Emergency Centres, a cross- sectional retrospective audit of 1283 clinical presentations from three secondary level ECs in Cape Town was done. The type of clinical presentations, investigations done and procedures per- formed were analysed. Basic descriptives are presented. The curriculum did not cover all the clinical conditions, procedures and investigations encountered by EM registrars in Cape Town. There were also multiple categories in the curriculum that were not encountered in EM practice at all. The investigations section correlated particularly poorly with the skills needed for the burden of disease seen in ECs in Cape Town. The curriculum should be redrafted guided by a practice analysis of EM.

Background: The South African 2006 Advanced Life Support and Emergency Care Practitioner protocols do not currently reflect the latest, best evidence-based practices for emergency care, specifically regarding induction agents in head injury patients. Recent evidence has challenged some preconceptions regarding the use and safety of Ketamine in head injuries. In response to this, the Health Professions Council of South Africa Professional Board for Emergency Care (HPCSA PBEC) has requested a review of the emergency care protocols. Objectives: To determine the evidence of effectiveness and safety of intravenous/intraosseous (IV/IO) Ketamine as an induction agent for adult patients with traumatic brain injury, the authors aimed to determine the all-cause mortality at 30 days, adverse events/effects, morbidity and rate of successful intubation associated with ketamine administration, as compared to standard induction agents. Research Question: What is the evidence of effectiveness and safety of IV/IO Ketamine in adult patients with head injury, for pre-hospital induction in advanced airway management, compared to standard therapy? Methods: The review followed a tiered approach, where three different tiers of searches were performed for articles relevant to the research question. Two authors independently and in induplicate performed title, abstract and full-text review for each potentially included article, as well as critical appraisal of 3 CPGs found in the tier 1 searches. Tier 1 searched for Clinical Practice Guidelines (CPGs), tier 2 for Systematic Reviews (SRs) and tier 3 for Randomised Controlled Trials (RCTs) relating to the research question. No grey literature searches were performed, but reference lists of included articles were searched for relevant articles. Main Results: The authors could not find any studies to include (CPGs, SRs or RCTs) in this review which would answer the research question. However, several articles were found which describe ketamine use in the Intensive Care Unit (ICU) and surgical patients with regards to intracranial pressure, cerebral perfusion pressure and general haemodynamic effects. Another article (RCT) was found which used ketamine as an induction agent compared to etomidate to facilitate intubation in critically ill patients. These articles provide some helpful insights as to ketamine's effectiveness and safety for induction to facilitate intubation in traumatic brain injury patients in the pre-hospital setting. Conclusions: The authors could not make any recommendations regarding the research question, and the safety and effectiveness of ketamine for induction to facilitate intubation in adult traumatic brain injury remains unclear. A lack of empirical evidence at RCT level has led to substantial knowledge gaps regarding our understanding of Ketamine and its effects in traumatic brain injury patients.

Introduction: Nausea and vomiting are a common complaint with a wide variety of aetiologies. Patients frequently present to emergency care providers seeking treatment for nausea and vomiting. Metoclopramide and prochlorperazine are well established drugs that have long been used in the treatment of nausea and vomiting. This scoping review aims to map out the available literature on metoclopramide and prochlorperazine in treating nausea and vomiting in the emergency setting, and more specifically for prehospital use. Methods: A broad literature search was conducted using the following search terms “nausea”, “vomiting”, “emergency care setting”, “prehospital”, “motion sickness”, “emergency medical services”, “metoclopramide”, “prochlorperazine”, was done on online databases such as Pubmed, Medline, Embase Cochrane databases, CINAHL, Web of Science, TRIP and EBSCO host. Results: A total of 11 articles were found published between 1989 and 2014. Ten studies were found from emergency centres and just one from the prehospital setting. Six studies originated in America, three in Australia, one in the United Kingdom, and one in New Zealand. The total number of patients in the 11 included studies were 1319 subjects, where 511 received metoclopramide, 448 received a placebo, and 98 patients received prochlorperazine. One study found prochlorperazine to be the better antiemetic at treating nausea and vomiting, one study found metoclopramide to be better, and three studies found that the prophylactic use of metoclopramide cannot be justified. Conclusion: There is no consensus on the superiority of metoclopramide or prochlorperazine to treat uncomplicated nausea and vomiting in the emergency care setting. There is a paucity of research available and further studies needs to be done, particularly in the prehospital arena.

Includes bibliographical references / Introduction: When high quality cardiopulmonary resuscitation (CPR) is performed, survival rates can approach 50% following witnessed out-of-hospital cardiac arrest. However, survival rates are more commonly much worse in both the in-hospital and out-of-hospital context and range from 0% to 18%. There is a paucity of evidence surrounding the competency at which basic life support (BLS) CPR is provided among Emergency Medical Services (EMS) personnel in South Africa, and quality assurance mechanisms are generally scarce or do not exist. Methods: A descriptive analytical study design was used to assess theoretical knowledge and psychomotor skills of BLS CPR provision by EMS personnel in a province in South Africa. An assessment questionnaire from a 'BLS for healthcare providers' course was used to determine theoretical knowledge. Cardiac arrest simulations were video recorded to assess psychomotor skills. BLS instructors independently scored the latter. Results: Overall competency of BLS CPR among the participants (n=115) was poor. The median knowledge assessment was 50% and the median skills 22%. Only 25% of the items tested showed that the participants applied the relevant knowledge to the equivalent skill and the nature and strength of theory influencing skills was small. However, certain demographic and circumstantial variables such as sector of employment, guidelines they were trained according to, age, and location where trained had a significant effect (p<0.05) on knowledge and skills. Discussion: This study suggests that theoretical knowledge has a small but notable role to play in psychomotor skills performance of BLS CPR. Demographic and circumstantial variables that were shown to affect knowledge and skill may be used to improve training and therefore competency. The results of this study highlight the need for continuous, and perhaps tailored BLS CPR instruction to bring the diverse set of EMS personnel currently practicing in South Africa up to international competency standards.

Although there is extensive literature regarding out-of-hospital use of capnography, the willingness and knowledge of South African paramedics where capnography is available for routine use is poorly understood. From informal reviews, it would appear that even when capnography is available the practitioners decided to not use the tool. Aim: To determine the knowledge of prehospital providers with respect to the use of capnography to guide decision making in the treatment of patients. Methods: A cross-sectional research-generated survey of 80 out-of-hospital advanced life support paramedic providers in South Africa working in the private industry where capnography is available. Participants will be recruited with the assistance of the company's research committee using an email platform, and consent process. The questionnaire will establish the knowledge, ability and willingness of advanced life support paramedics to identify and use capnography as part of their clinical decision making process. Descriptive statistics will be used to interpret and report the data. The study should be concluded within 6 months of receiving ethical approval from Human Research Ethics Committee of the University of Cape Town. Discussion: The findings of the study will describe a cohort of out-of-hospital practitioners' knowledge and willingness to use capnography in an environment where it is routinely available. Recommendations will be made regarding the need for further policy development and change management for the implementation of best practice.

Introduction Acute Myocardial Infarction (AMI) is a time sensitive emergency. In resource limited settings such as South Africa, prompt identification and management of these patients in the pre-hospital setting may minimise the negative consequences of an overburdened emergency medical and hospital service. Expedited care thus, in part, relies on the dispatch of appropriate pre-hospital medical providers by emergency medical dispatchers. Identification of these patients in the call centre is challenging due to a highly diverse South African society, with multiple languages, cultures, and levels of education. The aim of this study was therefore, to describe the terms used by members of the South African public when calling for an ambulance for patients suffering an AMI. Methodology In this qualitative study, we performed content analysis to identify keywords and phrases that callers used to describe patients who were experiencing an AMI. Using the patient report form number of randomly selected paramedic- diagnosed AMI cases, original voice recordings between the caller and call centre operators at the time of the emergency were extracted and transcribed verbatim. Descriptors of AMI were identified, coded and categorised using content analysis, and quantified. Results Of the 50 randomly selected calls analysed, 5 were not conducted in English. The descriptors (meaning units) used by callers were and found to fall into three categories; Pain: Thorax, No pain: Thorax and Ill- health. The code that occurred most often was no pain, heart related (n=16; 23.2%), followed by the code describing pain in the chest (n=15; 21.7%). Conclusion South African callers use a consistent set of descriptors when requesting an ambulance for a patient experiencing an AMI. The most common of these are non- pain descriptors related to the heart (“heart attack”). These descriptors may ultimately be used in developing validated algorithms to assist dispatch decisions. In this way, we hope to expedite the correct level of care to these time- critical patients and prevent the dispatching of resource limited advanced life support paramedics to inappropriate cases.

Background and aim Inefficient storage and sourcing of routinely required consumables located on procedure trolleys results in time wasted when preparing for common procedures in Emergency Centres, contributing to poor efficiency and quality of care. We designed a novel purpose-orientated procedure trolley, and evaluated its impact on time spent on procedure preparation and efficiency. Methods In an urban emergency centre, eight participants were measured each day over 24 days, once using the contemporary setup and once using the modified procedure setup. During each simulation, efficiency markers were assessed (time spent on procedure preparation, steps taken, stops made, and amount of time participants had to open a drawer to locate required items). Results The mean time required to collect the required items for IV cannulation and blood sampling from the purpose-orientated trolley was 22.7 seconds(s) (SD = 3.66) compared to 49.2 s (SD = 15.45) using the contemporary trolley. There was a significant difference in mean collection time between the two trolleys (p < 0.0005). There was a significant difference (p-value < 0.0005) in all the other categories: steps taken, stops made, and drawer opening. Conclusion In our setting, stocking procedure trolleys in a purpose-orientated manner has the potential to improve efficiency by reducing time spent on procedure preparation.

Includes abstract. / Includes bibliographical references (leaves 35-37). / The aim of this study is to assess whether ECG interpretation improves with advancing years of Emergency Medicine training in South Africa, and to compare the results with similar international studies. A prospective cross-sectional study of Emergency Medicine registrars and recently qualified emergency physicians was conducted between August 2008 and February 2009 during training sessions at various universities through South Africa. Subjects completed a survey about level of training and experience, previous ECG training and their impression of the current training program and how it could be improved. They were then asked to interpret 10 clinically important ECGs. The trainees in their first and second years of emergency medicine training were compared to their more senior counterparts (third to fifth years).