Introduction: Low and middle-income countries account for over 90% of worldwide morbidity and mortality associated with injuries. While insufficient resources preclude appropriate care, suboptimal clinical skills, are a universal setback. Major curricula gaps have been identified as underlying this situation. In Africa, most training efforts are targeted at postgraduate level, relegating undergraduate Emergency Medicine (EM) education to a less formal undertaking. This study set out to delineate a list of locally appropriate undergraduate EM procedural core competencies for the University of Zimbabwe College of Health Sciences (UZCHS), through a consensus building process. Methods: A three-stage modified online Delphi survey was used to gain consensus among expert medical trainers at UZCHS, between July and August 2017. Opinion was sought on a five-point Likert scale, regarding agreement with items for inclusion on the procedural core competency list. The original survey list of 105 competencies was generated from literature. The second round included suggestions from panelists. The study was ethically cleared by the University of Cape Town, UZCHS and the Medical Research council of Zimbabwe. Results: 19 expert medical teachers, representing seven clinical departments responded to the survey, with 15 completing all rounds. 79% had more than 5 years’ experience in teaching and assessment of emergency procedures. Of these, 50% had at least 10 years’ experience. The experts reached consensus (75% selecting agree or strongly agree) on 64 competencies (61%), on the first round. The second round yielded consensus on a further 33 items. Only one additional item reached consensus in the final round. A final list of 98 core procedural competencies was generated by three Delphi rounds. Qualitative comments are summarised per emerging themes. Conclusions: A locally appropriate list of undergraduate procedural core competencies, was established. This process can serve as guidance for curriculum projects in Zimbabwe and similar settings.

Background To date, health facilities in Sub-Saharan Africa have not had an objective measurement tool for evaluating comprehensive emergency service provision. One major obstacle is the lack of consensus on a standardised evaluation framework, applicable across a variety of resource settings. The African Federation for Emergency Medicine (AFEM) developed an assessment tool specifically for these settings - the Emergency Care Assessment Tool (ECAT) - that assesses provision of key medical interventions. These interventions are referred to as signal functions for the six sentinel conditions that occur prior to death: respiratory failure, shock, altered mental status, severe pain/trauma, and dangerous fever. A signal function represents the culmination of knowledge of interventions, supplies, and infrastructure capable for the management of an emergent condition. Previous studies aimed at the refinement and context modification of the ECAT have already been performed in multiple African countries. We undertook a validation study to help determine the applicability of the tool in assessment of emergency services throughout the continent. Aims and Objectives The aim of this study was to determine the content, construct, and face validity of the AFEM Emergency Care Assessment Tool in Cameroon. To achieve this, the study had the following objectives: (1) Employ the ECAT in district, regional, and central hospitals in Cameroon. (2) Use direct observation to determine whether the signal functions can be performed in these facilities. Methods This was an observational study at a convenience sample of five hospitals in Cameroon: three district, one regional, and one central. The goal of this study was to validate the instrument, not the facility, and so the sample size was related to the number of signal functions witnessed rather than the number of facilities visited. The tool was administered with the Head of Emergency at each facility. This completed ECAT was then compared with direct observations of the signal functions, a process which was conducted by the partner local emergency care specialists accompanied by the ECAT researcher. Results In general, the higher the level of facility, the greater the emergency care capacity and the greater the number of signal functions that could be performed correctly and consistently. Discrepancies in funding, supplies, resource allocation, and care delivery ability were apparent through ECAT results, expounding on barriers to care delivery, and direct observation. McNemar tests on the ECAT results versus direct observation at each facility yielded statistically significant support for tool validation at the national level emergency unit as well as two of the district level emergency units. Concordance between reported and observed signal functions could not be achieved at the regional facility and one of the district facilities. Conclusions The ECAT has good potential for facility level assessment of emergency care provision, and collects meaningful information that can guide effective improvements in the delivery of emergency care.

Author Assist is an initiative of the African Journal of Emergency Medicine (AfJEM) that pairs an experienced researcher with an author recently rejected for publication to assist with revision of the rejected article. This study explores the factors of the assistance process within partnerships that have achieved successful publication after resubmission and blind peer-review. It aims to improve Author Assist's ability to facilitate successful publication by identifying potential areas of focus that impact individual researcher development. A grounded theory, qualitative approach first looks at the assistance process for seven individuals via semi-structured interview. Structured surveys with a wider sample size of authors then provide feedback on specific components of the process and inform recommendations for improvements to the programme. Interviews are analysed by deductive placement of themes into inductively-developed categories. Participant stories within the African acute care context tend to be consistent with available literature describing current global challenges in overcoming barriers to scientific research and publication. Recounts of the Author Assist process are overwhelmingly positive, and frame the programme as a worthwhile, albeit time consuming, initiative that makes a substantial difference in the professional development of individuals, their ability to take on mentorship roles themselves, and their future success in scientific publication. Inductive build-up from interviews of effective components of the process, and suggestions for progression of the programme are confirmed by responses from other past participants. Common themes arising from author feedback include perceived pressure by assistants to complete work on time amidst other career demands; the effectiveness of the partnerships in addressing issues of language, structure, and submission requirements; and the desire for the programme to encompass the full research process. Assistant themes tend to mirror those of the authors. In addition, assistants suggest a more involved manuscript assessment by the journal, prior to commissioning a partnership. Also suggested is a redesign of the assistant database to categorise by type of assistance offered, rather than by topic expertise. The findings from this study confirm Author Assist's unique niche within emergency care development, and its effectiveness in supporting individual research careers. A number of reasonable and low cost improvements to the programme have been put forward for AfJEM to improve ability to facilitate successful publication.

Background: Prehospital emergency care providers in South Africa are regularly called to assist with the management of mental healthcare users. The Mental Health Care Act no 17 of 2002 regulates mental healthcare in South Africa but makes no reference to the roles and responsibilities of prehospital emergency care providers in the provision of mental healthcare, rather giving the South African Police Services authority over the wellbeing of a mental healthcare user outside the hospital setting. Aims: To investigate what prehospital emergency care providers understand their responsibilities are towards a mental healthcare user and the community during the management of a behavioural emergency. Setting: Prehospital emergency care providers from the three main levels of care, currently operational within the boundaries of Pretoria. Methods: A grounded theory qualitative study design was chosen using semi-structured focus groups for each level of prehospital emergency care; Basic Life Support, Intermediate Life Support and Advanced Life Support. Data from each focus group was collected through audio recordings, transcribed and analysed using a framework approach. Results: A total of 19 prehospital emergency care providers from all three main levels of care participated in the focus group discussions (4 BLS, 6 ILS and 9 ALS). Four main themes were identified: Perceptions of behavioural emergencies, responsibilities, understanding of legislation and barriers experienced. Conclusion: Participants placed high value on their moral and medical responsibilities towards a mental healthcare user and would like to have the backing of legislation to fulfil their role. There is a desire for better education, skill development and awareness of mental healthcare in the prehospital emergency care setting.

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.