Includes abstract. Includes bibliographical references.

published_or_final_version / Community Medicine / Master / Master of Public Health

Mestrado em Medicina de Emergência / Master Degree Course in Medicine of Emergency / Milhões de pessoas assistem a eventos com multidões ( mass gathering ), sendo estes definidos como os que ocorrem com mais do que 1.000 espectadores, por ano em todo o mundo. As características de um sistema de emergência médica criado para o efeito, bem planeado, são: a) reconhecer e responder rápida e adequadamente ao espectador que necessita de cuidados médicos de emergência; b) ministrar, ao espectador com lesões/ patologia minor tratamento adequado, de forma expedita e eficiente; c) garantir transporte rápido à unidade de saúde apropriada; d) preservar as capacidades habituais do sistema de emergência médica local. Analisa-se a experiência com o Campeonato Europeu de Futebol (EUROTM) 2004 e pretende-se, para os Eventos com Multidões em geral: a) propor uma forma sistematizada de planear; b) definir recursos humanos e logísticos da equipa de emergência médica e c) sugerir ainda uma nova classificação dos Eventos com Multidões .

Mestrado em Medicina de Emergência / Master Degree Course in Medicine of Emergency

BACKGROUND: Delirium is a disorder that is characterized by an acute change in cognitive functioning including inattention, and disordered thinking. Delirium disproportionately affects the population over the age of 65, and is associated with increased costs, worse outcomes and longer lengths of stay. Although delirium is estimated to affect approximately 10% of elderly patients in the emergency department (ED) and 42% of elderly inpatients, it often goes unrecognized by the clinical staff. There is evidence that delirium can be prevented through non-pharmacologic prevention strategies, however it is less clear which patients should be targeted for these measures. OBJECTIVES: The objective of this study is to identify risk factors for development of hospital-acquired delirium during the most proximal aspect of a patient’s hospital course, namely the ED. Secondary objectives of this study are to analyze resource utilization and outcomes associated with the development of hospital-acquired delirium. METHODS: This study is a secondary analysis of a prospective observational study conducted over 3 years at a single urban university hospital. Patients over the age of 65, who could complete a structured cognitive assessment interview, were screened for delirium by a trained research assistant. Patients that were judged to be not delirious in the ED, and who were then admitted to an inpatient unit were included in the final cohort. A validated chart review method was used to determine if patients developed delirium during the course of their hospitalization. Potential predictors of hospital-acquired delirium, including demographics, laboratory values, comorbidities and outcomes, were also abstracted from the medical chart. We performed a univariate analysis of these predictors and included those covariates with a p values ≤0.2 in multivariate analysis. We allowed 1 predictor per 10 outcomes in the final model to avoid over-fitting and evaluated the discriminatory ability and calibration of the model using the c-statistic and Hosmer-Lemeshow goodness-of-fit test. RESULTS: Of the 520 patients included in our cohort, 77 developed delirium over the course of their inpatient visit. Multivariate analysis identified 7 risk factors to predict delirium in elderly emergency department patients admitted to the hospital. Patients were more likely to develop delirium during their stay if they were age 80 or older, had a history of dementia, had a history of stroke or transient ischemic attack, were hypoxic or hyponatremic in the ED, or had an ED admitting diagnosis of acute stroke/transient ischemic attack or fall. The model had a c-statistic of 0.73 and a non-significant p-value of 0.7 in the Hosmer-Lemeshow goodness-of-fit test. CONCLUSION: The predictive model that we created may help identify a population to target for delirium prevention strategies in elderly emergency department patients, thereby reducing delirium incidence in hospitalized patients, and the associated morbidity, mortality, and healthcare utilization.

Introduction: The difficulties in the management of the blunt chest wall trauma patient in the Emergency Department due to the development of late complications are well recognised in the literature. The first aim of this study was to investigate the risk factors for the development of complications following blunt chest wall trauma. Using these risk factors, the second aim was to develop and validate a prognostic model that can be used to assist in the management of this patient group. Methods: The risk factors for the development of late complications following blunt chest wall trauma were investigated using a number of methodologies. These included a systematic review and meta-analysis, a questionnaire study and a retrospective observational study. Following identification of the risk factors, a prognostic model was developed using multivariable logistic regression. This model was then externally validated in a prospective multi-centre study. Results: The systematic review, questionnaire study, retrospective study and development study results highlighted that the risk factors for the development of complications following blunt chest wall trauma were an increasing patient age, the existence of chronic lung disease, an increasing number of rib fractures, the use of pre-injury anti-coagulants and a decreasing oxygen saturation level on presentation to the Emergency Department. These risk factors were included in the final model. Results of the validation study indicated an overall model accuracy of 87%, a sensitivity of 75% and a specificity of 97%. A concordance index of 0.96 highlighted an excellent discriminatory ability of the model. Conclusions: The prognostic model developed in this study demonstrated good predictive capabilities in the derivation sample and excellent discrimination in the validation sample. The model demonstrates clinical usefulness as it includes risk factors not normally considered in the management of blunt chest wall trauma patients in the clinical setting.

A dissertation submitted in fulfilment of the requirements for the degree of Master in Technology: Emergency Medical Care in the Department of Emergency Medical Care and Rescue, Durban University of Technology / Strong earthquakes are frequent catastrophic disasters occurring worldwide and often lead to structural collapse of buildings. Urban Search and Rescue (USAR) is the specialised process of locating, extricating and providing immediate medical treatment to victims trapped in collapsed structures. This research project aimed to identify the key preparedness efforts necessary by an earthquake affected country to ensure best coordinated use of international USAR assistance. / M

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The growing worldwide use of clinician-performed ultrasound (CPU) marks a dramatic change in bedside medicine and patient care. With steadily improving portability, accessibility and technology, ultrasound use continues to grow amongst many medical specialties. Likewise, the application of CPU in emergency medicine is increasing. Emergency Medicine (EM) is a medical specialty “based on the knowledge and skills required for the prevention, diagnosis and management of acute and urgent aspects of illness and injury…” (International Federation for Emergency Medicine, 1991). Increasingly, emergency physicians are using emergency department ultrasound (ED U/S) to enhance their assessment of critically-ill patients (American College of Emergency Physicians, 2008). The purpose of this study was to evaluate and describe those aspects of ultrasound simulation (during HFS) that contribute to the development of critical care ED U/S skills. Secondly, it was of interest to assess how a novel ultrasound simulator (edus2) compared to video playback on a laptop in terms of the above-mentioned aspects. The population of interest included both EM trainees and faculty. This investigation was a randomized, prospective, crossover study with two intervention treatments for all participants. In Phase I, EM trainees and faculty from London, UK, were invited to participate in one of four day-long critical-care HFS sessions during which they participated in four critical-care scenarios. Faculty were involved in assisting with session debriefing and feedback. All participants completed two cases with each intervention. In Phase II, faculty in Saskatoon, SK, Canada, were invited to review video recordings of the sessions from Phase I and evaluate the educational merits of the two ED U/S simulation interventions. iii This study produced both quantitative and qualitative data. As this study looked at two interventions and how they could contribute to the development of ED U/S skills, pre- and postintervention changes were analysed for statistically significant differences between them. T-test analyses were used for comparisons. Effect sizes (Cohen’s d) were calculated where statistically significant findings were observed. Qualitative data was assessed through emergent thematic analysis and triangulation. The findings of the study support the integration of ED U/S simulation into HFS. Integration was found to be of value to both trainees and faculty by allowing trainees to demonstrate knowledge of indications as well as correct image interpretation and general integration of ED U/S into critical care (p<0.05). Trainees described an increased motivation to develop their ED U/S skills as well as greater desire to use ED U/S in everyday practice. Furthermore, the edus2 was identified as being the preferred training intervention. The edus2 met functional fidelity through its real time and hands-on applicability. Faculty preferred the edus2 as it allowed for better assessment of trainee skills that then influenced session debriefing and formative feedback. Faculty in Phase II found the edus2 intervention sufficient in offering basic insights into trainee ED U/S skills and mastery (p<0.05). Implications of the study include support for the use of ultrasound simulation during HFS for the development of critical care ED U/S skills amongst EM trainees. Further study on the effects of such hybrid simulation on clinical performance is warranted.