Academic Emergency MedicineEarly View LETTER TO THE EDITOR Spinal care again Mark Hauswald MS, MD, Corresponding Author Mark Hauswald MS, MD [email protected] orcid.org/0000-0002-3572-0302 Emergency Medicine, University of New Mexico, Albuquerque, New Mexico, USA Correspondence Mark Hauswald, Emergency Medicine, University of New Mexico, Albuquerque, NM 87131, USA. Email: [email protected]Search for more papers by this author Mark Hauswald MS, MD, Corresponding Author Mark Hauswald MS, MD [email protected] orcid.org/0000-0002-3572-0302 Emergency Medicine, University of New Mexico, Albuquerque, New Mexico, USA Correspondence Mark Hauswald, Emergency Medicine, University of New Mexico, Albuquerque, NM 87131, USA. Email: [email protected]Search for more papers by this author First published: 26 February 2024 https://doi.org/10.1111/acem.14871 Supervising editor: Jeffrey A. Kline Read the full textAboutPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL Share a linkShare onEmailFacebookTwitterLinkedInRedditWechat No abstract is available for this article. REFERENCES 1Bond C, Suchisimita D, Milne WK. Hot off the press: prehospital cervical spine immobilization. Acad Emerg Med. 2023; 30(12): 1279-1282. doi:10.1111/acem.14809 10.1111/acem.14809 PubMedGoogle Scholar 2Neil McDonald N, Dean Kriellaars D, Pryce RT. Patterns of change in prehospital spinal motion restriction: a retrospective database review. Acad Emerg Med. 2023; 30(7): 698-708. doi:10.1111/acem.14678 10.1111/acem.14678 PubMedWeb of Science®Google Scholar 3Hauswald M. A re-conceptualisation of acute spinal care. Emerg Med J. 2013; 30(9): 720-723. 10.1136/emermed-2012-201847 PubMedWeb of Science®Google Scholar Early ViewOnline Version of Record before inclusion in an issue ReferencesRelatedInformation

In their commentary “Not Yet Time to Abandon Cervical Collars in Blunt Trauma”1 Baron and Scalea argue that since there are no randomized trials of cervical motion restriction we should “immobilize” and place cervical collars on (all?) blunt trauma patients until they arrive in the hospital. These recommendations are no longer the “standard of care.” Prehospital providers have been safely clearing low-risk trauma patients for decades.2, 3 It apparently does not require a medical degree to apply five-step algorithms. It is certainly prudent to continue to deliver spine specific care to high-risk patients until they can be fully evaluated and treated but many of the traditional methods—cervical collars, slippery “backboards,” mechanical immobilization of uncooperative or seizing patients, standing backboards, and forceful head stabilization during airway management are irrational and obsolete ways of doing this.4 The goal of spinal care is to minimize energy deposition (work) at the injury site—this is simply Newtonian physics. Restricting movement may or may not accomplish this. Although collars and forceful immobilization do restrict movement they do so by redistributing force and hence energy to other parts of the body. This is clearly not desirable if the redistribution is to the actual injury site. Collars also act as a lever and as such increase the force on the lower spine and thorax. Baron and Scalea argue that there is no direct evidence for harm from immobilization, but there is no direct evidence for benefit either and there is epidemiologic evidence that it is harmful.5 Classic immobilization methods clearly apply a distractive force on the spine, make airway management more difficult, preclude access to the anterior neck, and apply force to the upper thorax. Prolonged immobilization on a hard surface hurts and will eventually cause tissue necrosis. These are real, not theoretical, problems and effect all blunt trauma patients not just the few with treatable spinal injuries. Prehospital trauma care needs to maximize long-term outcomes by minimizing deterioration due to inadequate or inappropriate care. The spine can be protected through selective spinal care, careful transport, airway management, sedation when necessary, and the use of lateral restraints, which absorb rather than redistribute energy.4

Background Obstetrical hemorrhage continues to be the leading cause of maternal death; additional means of treatment are needed to reach women who are currently not being saved. We developed the "Ball and Binder", an inexpensive and innovative pneumatic abdominal-pelvic compression device made with a cloth binder and soccer ball. Objective To measure the change in distal aortic blood flow before and after placement of the device. Method A comparative study was done on nine healthy volunteers measuring the flow in the distal aorta before and after placement of a pneumatic abdominal binder. Result Distal aortic flow decreased by over half when the device was inflated. Conclusion An inexpensive pneumatic external abdominal compression "Ball and Binder" device was able to decrease flow to the pelvis by over half. This provides an additional tool for rapid treatment of postpartum hemorrhage unresponsive to routine initial measures.

Objective To evaluate obstetric hemorrhage outcomes and present data specific to adoption of pneumatic circumferential abdominopelvic compression devices. Methods Two resource-limited locations added low-cost pneumatic compression devices to their standard protocols for obstetric hemorrhage between 2010 and 2019. Providers in rural Nepal and Papua New Guinea used devices that incorporated a bicycle tube or soccer ball ("Ball and Binder") to provide abdominopelvic pressure after all available routine treatments had failed. Data were collected during the entire period as part of ongoing obstetric quality improvement. Data presented include obstetric event, etiology of bleeding, need for surgery, transfusion, transport, length of transports, maternal survival, and complications. Results Circumferential abdominopelvic compression was used 106 times. The devices were used primarily after vaginal birth with atony, but also for obstetrical lacerations, miscarriages, and post-abortion bleeding. In all cases the bleeding stopped "promptly." All women survived, none required hysterectomy, and no complications were reported resulting from device use. Only 15 (14%) patients were transported to a referral hospital. Conclusion In this quality improvement project, obstetric hemorrhage was controlled when circumferential pressure was applied after usual care had failed.

INTRODUCTION: This quality improvement project evaluated obstetric hemorrhage patient outcomes following adoption of low cost simple pneumatic circumferential abdominopelvic compression devices. METHODS: Two resource-limited locations added low cost inflatable compression devices to their standard protocols for obstetric hemorrhage. Providers in small medical facilities in rural Nepal and Papua New Guinea used devices that incorporated either a bicycle tube or soccer ball to provide abdominopelvic pressure after all available routine treatments had failed. Data collected included obstetric event, etiology of bleeding, need for surgery, transfusion, transport, length of transports, maternal survival and complications. RESULTS: The device was used a total of 106 times: the soccer ball “Ball and Binder” device was used thirty-eight times; the prototype bicycle tube device was used sixty-eight times. Devices were used primarily after vaginal birth with atony, but also for obstetrical lacerations, miscarriages and post-abortion bleeding. In all cases the bleeding stopped promptly after inflation of the device. All 106 women survived, none required hysterectomy or abdominal surgery, and no complications were reported from device use. Only fifteen patients were transported to a referral hospital, primarily for blood transfusion. CONCLUSION: Obstetric hemorrhage was controlled after an abdominopelvic circumferential pressure device was applied after usual care had failed. This device provided an additional method for treatment in resource-limited settings with limitations in surgical, transfusion and transport capability.

Abdominal tourniquets are used to treat critical, otherwise uncontrollable bleeding from the pelvis, pelvic organs and lower extremity junctional sites (those too close to the pelvis to allow for peripheral tourniquet placement). They are used primarily for traumatic injuries but have also been suggested for obstetrical hemorrhage. Commercial devices are relatively expensive and unavailable in low resource countries. The objective of this study was to develop and test a low cost abdominal tourniquet that could be made on-site using locally available supplies. An abdominal tourniquet was made by placing an uninflated standard size 5 soccer ball on the subject's abdomen, wrapping it tightly with a 12-inch wide sturdy cloth binder and securing the binder with sewn-on hook and loop (eg, Velcro) strips. A comparative trial using this device was done in 12 healthy volunteers. The ball was gradually inflated using a hand pump. The internal ball pressure was measured during inflation while distal aortic blood flow was monitored just below the superior mesenteric (SMA) takeoff using a GE VolusonTM ultrasound. When blood flow stopped the ball pressure was recorded. The subject was then asked how painful the procedure was, using a 10-point scale where 1 equaled no pain and 10 equaled the most pain tolerable. The ball was then deflated. The study was approved by the University of New Mexico Institutional Review Board. The mean pressure to completely stop distal aortic flow was 150 mmHg (95% CI 130 - 170mmHg). The mean pain score was 4.5 (95% CI 3.4-5.6). This abdominal tourniquet was able to completely stop blood flow to the pelvis and lower extremities. It was only moderately painful.

Background: Short-term experiences in global health (STEGH) are increasingly common in medical education, as they can provide learners with opportunities for service, learning, and sharing perspectives. Academic institutions need high-quality preparatory curricula and mentorship to prepare learners for potential challenges in ethics, cultural sensitivity, and personal safety; however, availability and quality of these are variable. Objective: The objective of this study is to create and evaluate an open-access, interactive massive open online course (MOOC) that prepares learners to safely and effectively participate in STEGH, permits flexible and asynchronous learning, is free of charge, and provides a certificate upon successful completion. Methods: Global health experts from 8 countries, 42 institutions, and 7 specialties collaborated to create The Practitioner's Guide to Global Health (PGGH): the first course of this kind on the edX platform. Demographic data, pre- and posttests, and course evaluations were collected and analyzed. Results: Within its first year, PGGH enrolled 5935 learners from 163 countries. In a limited sample of 109 learners, mean posttest scores were significantly improved (p < 0.01). In the course's second year, 213 sampled learners had significant improvement (p < 0.001). Conclusion: We created and evaluated the first interactive, asynchronous, free-of-charge global health preparation MOOC. The course has had significant interest from US-based and international learners, and posttest scores have shown significant improvement.

This issue of Academic Emergency Medicine includes an article by Haydar et al.1 that describes a project designed to reduce ED crowding by admitting patients without having the inpatient physicians actually see them first. This is not a new idea of course and is one that has not been without controversy. There are clearly advantages in direct admissions: it can benefit the admitted patient by providing a more comfortable place to be treated, it certainly benefits the patients in the lobby who are waiting to be seen, and it allows the inpatient service more flexibility. In a community hospital it may even allow consultants to finish seeing patients in clinic or even get bit more precious sleep. But there are benefits in requiring that the admitting physician actually see the patient in the ED too: it minimizes miscommunication, ensures continuity of care, and eliminates the risk from a hiatus in the patient's evaluation and treatment. These factors probably also reduce the emergency physician's malpractice risk. Importantly, a face-to-face meeting between colleagues can (and should) be an opportunity for social interaction and mutual learning. The project managers in this case were obviously cognizant of some of these issues and took care to mitigate them. As such I suspect that the benefits of this system greatly outweighed the harms. But I am not certain that this is true, and the project raises several complex issues. This was a quality improvement (QI) project. A group of managers, presumably experts in system dynamics, identified a problem and developed a solution. They proposed this solution to the involved workers, in this case emergency physicians, who rejected it. To carry out their plan they instituted a series of more and more coercive actions. When simple education failed they tried “counseling” by the physician's administrative superiors; when this proved inadequate, financial incentives were instituted and group sanctions imposed. Technically this was a command-based process. Decision-making was centralized and feedback from the affected parties was minimized. We do not really know if the physicians initially rejected the process for good or bad reasons, if relationships between the ED and admitting services improved or deteriorated, or if benefit exceeded harm to patients. Some of this information was undoubtedly collected and presumably acted upon, but it was apparently done in an informal way. Staff involved in the process did “carefully monitor for any occurrence of potential harm” and since they were intimately involved in day-to-day operations this probably would have picked up any serious problems, provided that the problems were recognized by the providers and reported. Only a few patients who the emergency provider thought merited admission were seen in the ED by the inpatient providers and discharged; this is important to know from the standpoint of overall hospital resource utilization. Other issues may not have been optimally analyzed. Did the gap in care cause any problems? How quickly did the inpatient staff actually see the patients? How many patients were quickly discharged, downgraded, or upgraded once admitted? Were there delays in obtaining or reviewing important tests? Were there delays in giving essential medications or treatments? Were patients happier? Did patients have better outcomes? Were providers eventually pleased with the change? Did the apparent increase in ED provider work load per patient have any unforeseen consequences? Was total hospital throughput time increased or decreased? How did the individual protocol decisions (like ordering follow-up troponin tests on inpatients) work out? These are important questions and although I suspect the results were generally reasonable, clear answers to these questions would be reassuring for the affected hospital as well as other facilities contemplating a similar change. Command decision-making is managerially efficient, and this is often desirable and occasionally even necessary, but it is well accepted that information flow is the Achilles heel of command processes. You only see what you look for, and decision-makers are insulated from the direct effects of their decisions. This inevitably causes an overemphasis on the identified process problem (delays in admissions), which is easily measured and underemphasizes outcomes (particularly rare or unforeseen ones) that might be more important overall. The alternative process is dispersed decision-making. Spreading the decision-making process among many actors maximizes the information available to the system. But dispersed decision making has flaws too. It is inefficient, and since the managers are often right this can be a major problem. It requires a considerably different attitude about the individual agency of people lower on the chain of command. Managers tend be exasperated with physician “professionalism” and view physicians as overly focused on the specifics of the individual therapeutic encounter. Dispersed decision-making, in addition to often being inefficient, poses its own problems for information flow. Information that is available to the system may not be easily accessible to those actually making decisions. As emergency physicians we often do not even know what eventually happens to our patients. Ensuring adequate information flow from patient to provider (which is essential for making treatment decisions) and from provider to manager (which is essential to carry out treatment decisions) can be very difficult. Identified problems in dispersed decision-making within medicine has led to an increase emphasis on command-based processes over the past decades but although these have reduced some problems they have also resulted in some well-known inefficiencies. Some are minor. Mandatory training seems a bit out of hand. Do patients really benefit from having their physician take three essentially identical trainings on patient confidentiality for three different agencies every year? Providers occasionally feel like Bart Simpson writing “I will not throw spitballs in class” on the blackboard over and over. Annoying but not actually likely to change behavior. Other cases are not so benign. The widespread adoption of poorly designed EMR systems is an excellent example of how command requirements can result in increased risk, significant treatment delays, and economic inefficiency as is a billing system that requires that a family history be obtained from a 60-year-old with crushing chest pain. This project was defined as QI rather than research. This interpretation was supported by the institution's review board and frankly was probably correct. Research and QI tend to differ in their essential starting points and goals. Both require identification of a problem but research assumes much less knowledge about either the nature of the problem or the effects of the intervention. QI activities focus on solving the identified problem whereas researchers try to look at outcomes more globally. As such, research activities tend to be more thoughtfully developed, rigorous, and time-consuming, i.e., less efficient. Doing every QI project as thoroughly as a formal experiment would paralyze management and be fundamentally absurd. If a manager discovers that nurses are unable to safely keep up with current patient volume they should be free to hire additional nurses. Evaluating this change using informal means would be adequate. The line between research and QI is not clear, however. Both make an overt change in an attempt to improve things and then evaluate the effects of that change. Both can help or harm the individuals subject to the change. Some writers base the distinction on the intent to produce “generalizable” knowledge, i.e., to publish or otherwise disseminate the results. In industry this makes fairly good sense but it is problematic in medicine. Intent is difficult to measure and relying on actual publication is inappropriate for several hopefully obvious reasons (it would essentially define QI as badly done and/or secret research). Indeed federal regulations specifically reject this interpretation. At the same time every managerial decision cannot be subject to the myriad requirements of a formal research project. It may be best to embrace the ambiguity and accept that QI is research, at least from a functional if not from a legal standpoint. The plan-do-study-act method requires that preliminary outcomes are evaluated, that is, what the “study” part means, but the evaluation is often much less carefully done than if it were viewed as an experiment involving human subjects. There are at least three reasons why “study” is not viewed as research and these have to do partly with the different “cultural values” of managers and researchers (or at least of individuals who are currently acting in one of these roles). First, managers are more overtly confident than researchers. Good research requires a fundamental lack of certainty that one knows the answer or at least a willingness to admit that one could be wrong. Managers must be more convinced that they are right or at least that their solution is good enough to be acted upon. Second, managerial hierarchies reward swift and successful completion of tasks that are set by one's superiors. Pleasing one's superior is a good idea for researchers too, but researchers are more likely to get rewarded for discovering unanticipated outcomes than are their managerial colleagues. Third, even personalities change when one moves from one camp to the other. Carrying out good research requires a bit more introspection and getting others to do a task a bit more extroversion. If we accept that QI is research it will benefit from including a formal research-oriented approach. QI projects need to seriously consider the big picture and not hone in too quickly on solutions to a defined problem, no matter how serious or obvious it may be. They should step back to consider what the potential global harms and benefits are. In this case these would include better care for patients in the ED and waiting room versus potentially worse care for patients directly admitted. Had this project been billed and vetted as a human subjects experiment it is inconceivable that a rigorous and formal evaluation of patient-centered outcome data would not have been required. Although this would have made the project more expensive and complicated it would have resulted in more convincing and hence more generalizable information. Deciding how rigorously to do this would require balancing the estimated severity and frequency of potential harms against the potential benefits, as well as deciding if the cost of measurement is worth the increased accuracy of the conclusions that are potentially reached. Some interventions will always be done by straightforward managerial decision-making but others should be evaluated more formally. It may be necessary to overtly separate the functions. Even managers who are trained and competent to do the research will be less efficient if they need to step back and question every decision. But I suspect that at least considering process decisions as experiments would improve outcomes both locally and more generally. I do not mean to impugn the current study. I have spent much of my career doing QI projects and making similar command decisions. I suspect that in most cases, and in this one, that the changes resulted in “the greatest happiness for the greatest number.” But I also worry that sometimes we are missing the bigger picture and are then “merely haggling over the [physician's] price.”

Indications: Contraindications: Preparation: If done electively: Formal sterile prep; Infiltrate and inject the airway with local anesthetic; In an emergency no prep is needed. Procedure: Post-procedure: Complications: Too shallow = subcutaneous emphysema. Too deep = subcutaneous emphysema or injury to esophagus. Too cephalad (and leaving needle in too long) = laryngeal cord injury. Misplacement = nerve or artery injury. If the assistant does not release pressure or there is a block to exhalation = pulmonary barotrauma.

We were in Kathmandu during the earthquake. Our “Global Health Nepal” course had ended the day before and 12 of us were still in town. The earthquake itself was huge—far greater than any we had experienced in San Francisco, Japan, Alaska, or Utah, and it was a very prolonged slow wave. We were lucky. Two of our faculty were at the Hyatt Hotel, one of the few known earthquake-resistant buildings in the city, and the other two plus their 19-month-old twins were just outside Shechen Monastery and its large open courtyard. Three of our students were at higher risk in a multistory concrete building in the crowded tourist district of Thamel, but since our class had met with staff at the National Society for Earthquake Technology just days before, they knew to shelter under tables and were unhurt. Our group reconvened on the Hyatt lawn and helped treat the few injuries (one man had run through a glass door and had several small lacerations; two cooks had been cut in the kitchen). An hour after the earthquake pedestrians had returned, light vehicular traffic had resumed, and scattered small shops were reopening. We risked a trip to our guest house to retrieve our luggage. It had sustained a few very large cracks but none that looked catastrophic. We spent the night sleeping outdoors at the Hyatt and flew home 2 days later. So why did we leave? The four of us would seem the ideal disaster team—three academic emergency physicians and one OB/GYN, all with public health backgrounds. Two of us have extensive disaster training and were in Haiti with the federal Disaster Medical Assistance Team. Each faculty member has had years of experience in Nepal and one speaks fluent Nepali. We have many contacts in hospitals, medical schools, NGOs, and government offices, including the Ministry of Health and Population and the Department of Health Services. The short answer is that we were not needed, perhaps not even useful. Immediately after the quake we phoned our colleagues at Kathmandu University's large teaching hospital in Dhulikhel (yes, mobile phones and the Internet worked, at least intermittently). They were in full triage mode but almost every staff member had come in from home. They reported that the operating theaters were the only real bottleneck. Dhulikhel Hospital sits on the eastern rim of the Kathmandu valley and was among the busiest medical facilities in the country since the old city of Bhaktapur and much of the hardest hit district, Sindhupalchok, referred to them. Damage to the road would have made it difficult for us to get to Dhulikhel, but on the plus side it helped spread out patient flow. The morning after the quake we went to Tribhuvan University Teaching Hospital, one of Kathmandu's major trauma referral institutions and the coordinating center for disaster management. Our colleagues there had worked all night but by that time the rush was over, the outdoor triage area and disaster management center were closing, and the emergency department volume was back to near normal. Traffic had increased to a steady flow, and more shops were open. Evidence of damage could be seen throughout the streets, but was generally limited to collapsed low walls around buildings and bricks that had fallen off upper floors—potentially fatal if you were under them but only a nuisance otherwise. Only a few percentage of the buildings that we saw appeared to be severely damaged. We were in the street when the biggest aftershock occurred but we witnessed no significant additional damage, as was the case in most parts of the city. Our biggest shock really occurred after we returned to the United States. The media coverage gave the illusion that Nepal had collapsed into a pile of rubble. Although there was major damage and significant mortality, compared with Haiti, where 95% of the buildings and all of the hospitals in the capital were destroyed or severely damaged, and the medical system was overwhelmed, Nepal had fared pretty well. Nepal suffered 8,000 deaths out of a population of 28 million; Haiti lost 160,000 in a population one-third as large. This was primarily due to the fact that the quake was less powerful than the predicted “big one,” which had been expected to leave as many as 100,000 dead and 100,000 seriously injured in Kathmandu alone. Additionally, Nepal's medical infrastructure is much more robust, with 17 medical schools, a high concentration of private hospitals, and a well-integrated government health system. There have been widespread media efforts to educate the public about earthquake safety and response, and a number of neighborhoods were ready with plans and supply depots. So how did the media coverage make the event seem like a rerun of Haiti? It focused coverage heavily on the worst hit sites, most notably the historic palace squares of Kathmandu, Bhaktapur, and Patan (the three ancient kingdoms of the Kathmandu Valley, which have now been incorporated into one large urban sprawl). Temples of brick and hand-carved wood, which had collapsed during the 1934 earthquake and been meticulously rebuilt in traditional style, collapsed once again. Some of the coverage had been, as the British say, “sexed up.” One of the buildings we saw in Kathmandu had slumped but the photographer shot from a low angle near the corner so it appeared to have completely collapsed. Photo series and drone footage surfacing on the Internet revealed a tendency to disguise a single scene as many. Even the 7.3 magnitude earthquake 2 weeks later, which caused far less damage than the first one, was played up. Despite the somewhat misleading nature of the coverage, such practices are to be expected, since the purpose of newspapers is to sell newspapers. Perhaps more disconcerting was the way the aid industry, particularly the medical aid industry, manipulated the situation. A shot in a hospital that showed it to be “overwhelmed” looked remarkably like a typical day in such a facility. In addition to images of police and army response activities, there was ample photodocumentation of medical aid groups picking through debris and setting up impromptu clinics, with the implication that such activities were providing a substantial impact. This reflects one of the major realities of funding: NGOs need photos of their staff treating desperate people to mobilize their donors, and in fact more donations are needed to rebuild Nepal. Similarly, governments are motivated to exaggerate damage to maximize aid, which is never enough to fully rebuild, and to show that they can function even during such desperate circumstances. Indeed the Haitian government's death estimates were almost double those of more neutral groups. Do not misunderstand our message. Nepal desperately needs support. The country is very poor and the estimated cost of rebuilding is 10 billion USD. Some self-contained medical and rescue groups did have a major impact, particularly in isolated areas, but there are hundreds of isolated villages in Nepal that could have used help. Specialist physicians (primarily orthopedic surgeons) and additional operating facilities were needed immediately after the earthquake, and there will be a longer-term need for rehabilitation specialists. But many of the critical challenges are not medical in nature, such as the provision of clean water, food, shelter, and sanitation. Structural engineers are also in high demand, as one-third of the buildings may be unsafe, and determining which are really in danger, much less reinforcing them, will be a long and expensive process. Although the population centers in the low-elevation areas along the Indian border were mostly spared, things were much worse in some of the hill and mountain regions. We have been working in the remote Nubri valley in the northern part of the Gorka district. There had only been two confirmed deaths in the entire upper valley; but the village of Sama, at 11,200 feet/3,390 meters near the Tibetan border, lost 30 of its 150 buildings, and Prok, which was nearer the epicenter, was almost entirely destroyed. The monsoon usually starts in June and lasts until September. Heavy rains and mudslides will keep villages in higher elevations cut off from their usual supply lines for months. Helicopters are simply too expensive to be used as long-term means of provisioning. These problems are real, but not really emergencies. To some degree this is a function of the nature of the disaster. Famously, all disasters are different. In Nepal the damage was spread out; the country had recently put effort into disaster preparation; and the earthquake occurred at a relatively good time of day, day of the week, and season. Had it been a category 8.9, centered in Kathmandu, on a workday, in the middle of the night, or during monsoon season, things would have been much worse. Earthquake emergencies tend to be over quickly. Most of the deaths occur in the first minutes and most of the serious injuries must be treated by local providers in the first hours and days. Even as early as postearthquake day 5, physicians staffing a mobile clinic in Sindhupalchok district saw only 51 patients, and other than a few infected abrasions and one abscess, most patients had chronic primary care issues. By day 7 the government was asking medical relief teams to leave unless they were working in very rural areas. The health problems in Nepal are those of other low-resource countries: motor vehicle trauma (4,000 deaths per year), deaths in pregnancy (1,200 or maybe 2,500 since all health statistics come with large confidence intervals), malnutrition (41% of children are stunted), pollution (second worst in the world according to WHO), and the double burden of disease (an aging population with both chronic and infectious diseases). Nepal has been working on these issues. Helmets are now required for motorcycle drivers, new sewage lines are being installed in Kathmandu, the vaccination rate is better than in much of the United States, midwives are being posted to most of the rural clinics, and pregnant women are offered subsidies to offset the cost of obtaining care. Kathmandu has banned both plastic bags and two-stroke minibuses. Still, passengers almost never wear helmets, the holy rivers flow with raw sewage, and it is common for government health staff in rural clinics to abandon their posts while continuing to collect their salaries. When we left the country, the airport had overflowing toilets and ran out of drinking water, so the 8 hours we spent there were rather unpleasant—but sewage issues and lack of water are just normal at the country's only international airport, which does not even have an Instrument Landing System. What needs to be done? Nepal needs to rebuild. Porters were carrying bags of cement over the 5,000-meter Larkya pass into Sama 5 days after the earthquake—but Nepal needs lots of cement and rebar, masons, and structural engineers. Aid will help—if it goes to those who actually need it and not to government officials or to buy SUVs for administrators. What will we do? We have given money to groups that we know have little overhead, are not corrupt, and have had a long-term presence in the country. We are continuing to work with our colleagues in Nepali universities to help increase their capacity and with civil society organizations to improve the care of needy and marginalized groups. We are academics; we cannot fix everything. Nepal needs better infrastructure and better preparation for the next disaster—which will certainly come. It needs earthquake-proof construction and retrofitting, even more education to prepare communities, and improvements in the health care system. What Nepal needs most is to become a truly efficient civil society and that is something only the Nepali people can do. We can help and that is what we plan on doing—for the long run.

The article by Oto et al.1 in this issue of Academic Emergency Medicine attempts to describe every case of neurologic injury that is purported to have been caused by postaccident emergency care in the medical literature. The underlying question is whether “immobilizing” the spine using standard methods (boards, straps, collars, etc.) is protective and beneficial. Spinal cord injuries are potentially devastating but because these standard methods cause harm—delay in transport, interference with care, respiratory compromise in certain cases, and decubiti in others—the question is critically important. The article unfortunately fails to resolve the question. The only cases that convincingly show deterioration caused by movement involved major force, such as falling and neurosurgical procedures that are known to risk cord damage, and do not reflect situations that are likely to be encountered in ambulances or the emergency department (ED). A surprising number of cases actually involved forcing patients with chronic deformities into “neutral” position with cervical collars and backboards. Thus these cases are not helpful. Most reports are of poor quality and at best show a temporal association between care and deterioration—an association that holds true regardless of what, if any, care is delivered. Other sources of information also fail to resolve the question.2 Historic data imply that cord injuries are less common and more likely to be incomplete than in the past,3 but much has changed in safety, neurosurgery, and rehabilitation over the past decades. Mandatory seatbelts and passive restraints are clearly more important than ambulance care in reducing spinal injuries. The only comparative study showed that standard prehospital care was associated with more neurologic injuries,4 but again this was only an association. No study provides enough information to make a reasonable risk/benefit calculation, much less an economic analysis such as quality-or disability-adjusted life-year versus cost. The problem is even more complicated because it is certainly true that the risk and potential benefit is different for different patients—delay is much more serious for the multitrauma patient than for one suffering an isolated injury, for example. This dilemma is not uncommon in medicine: what should the clinician do when there are not enough high-quality primary data to make the decision obvious? One solution is to just keep doing what one has always done. In this case, just keep tying every patient who might conceivably have an injured spine down to a board with tape, webbing, and collars. This solution has some merit, as it feeds into the understandably conservative nature of human behavior; changing what we believe and do is difficult and unpleasant. It has also been justified on the assumption that it minimizes risk to the provider, although this argument is ethically suspect and probably assumes that malpractice attorneys are not quite as bright as they actually are. After all, it would be difficult to argue that a decubitus ulcer was not caused by pressure from the board or that being immobilized in the supine position had nothing to do with an aspiration pneumonia. One popular variant is to wait for a definitive clinical trial, but in some cases this will result in doing the same thing forever. No conceivable care will change the outcome for the vast majority of trauma patients since they have no spinal injury, a complete and irrevocable one, or other fatal injuries. This means that a rigorous study would have to be enormous and even then would not be of very high quality; for example, it could never be double-blinded. Changing nothing is acceptable if a treatment is benign, but in this case it clearly is not and puts all trauma patients at risk to hopefully benefit the very small number who have acutely biomechanically unstable but modifiable neurologic injuries. None of these statements are really debatable, but none of them have the “Category 1” controlled clinical trial evidence so beloved by experts in evidence-based medicine. So what is reasonable? Oto et al. have demonstrated that the standard paradigm is not evidence-based. That does not mean it is wrong, but it does mean that there is no convincing evidence for or against the standard board/straps/collar method of acute spinal care. This essentially means we are at clinical equipoise. A reasonable approach would be to transport all patients on comfortably soft surfaces, preferably ones that are not slippery. Backboards, if used at all, should be limited to extrication and short transports. Formal “immobilization” of struggling or seizing patients should be avoided. These patients require reassurance, sedation, or antiseizure medication—not tighter straps and “brutane.” An ambulatory patient can be helped to sit on the ambulance cot and then the backrest can be slowly lowered until the patient is comfortable. Tying an ambulatory patient to a backboard while he or she is standing and then tilting it to the horizontal makes no sense. Restraining the sides of the patient with bolsters will reduce the potential for injury by dissipating energy. Cervical collars should perhaps be reserved for patients who have injuries that are known to be stable in distraction. Most importantly, care of a possible spinal injury cannot be viewed as an imperative to be done in isolation. Other aspects of care may take priority. For stable patients with isolated injuries, careful padding to absorb the energy generated by transport and a slow drive to definitive care is reasonable. For others airway management or rapid transport should be the top priority. These decisions are not based on “Category 1” evidence, but we know that even controlled clinical trials are subject to their own biases and flaws.10 The kind of logical decision making outlined above has been described as “science-based” in distinction to “evidence-based” medicine.11 It uses facts and analyses that actually have a much higher probability of reflecting the real world than controlled trial data alone does. In this world, there is never enough evidence to be certain; we must always make do with less than revealed truth.

BACKGROUND:Obstetric hemorrhage remains the leading cause of maternal mortality in resource limited areas. An inexpensive pneumatic anti-shock garment was devised of bicycle tubes and tailored cloth which can be prepared from local materials in resource-limited settings. The main purposes of this study were: 1) to determine acceptability of the device by nurses and midwives and obtain suggestions for making the device more suitable for use in their particular work environments, 2) to determine whether a three hour training course provided adequate instruction in the use of this device for the application of circumferential abdominal pelvic pressure, and 3) determine production capability and cost in a resource-limited country.METHODS:Fifty-eight nurse and midwife participants took part in three sessions over eight months in Nepal. Correct device placement was assessed on non-pregnant participants using ultrasound measurement of distal aortic flow before and after device inflation, and analyzed using confidence intervals. Participants were surveyed to determine acceptability of the device, obtain suggestions for improvement, and to collect data on clinical use.RESULTS:Device placement achieved flow decreases with a mean of 39% (95% CI 25%-53%, p < 0.001) in the first session, 28% (95% CI 21%-33%, P < 0.001) after four months and 29% (95% CI 24%-34%, p < 0.001) at 8 months. All nurses and midwives thought the device would be acceptable for use in obstetric hemorrhage and that they could make, clean, and apply it. They quickly learned to apply the device, remembered how to apply it, and were willing and able to use the device clinically. Ten providers used the device, each on one patient, to treat obstetric hemorrhage after routine measures had failed; bleeding stopped promptly in all ten, two of whom were transported to the hospital. Production of devices in Kathmandu using local tailors and supplies cost approximately $40 per device, in a limited production setting.CONCLUSIONS:Preliminary data suggest that an inexpensive, easily-made device is potentially an appropriate addition to current obstetric hemorrhage treatment in resource-limited areas and that further study is warranted.

The Systematic Review Snapshot “Do Corticosteroids Benefit Patients With Sore Throat?”1Welch J.L. Cooper D.D. Do corticosteroids benefit patients with sore throat?.Ann Emerg Med. 2014; 63: 711-712Abstract Full Text Full Text PDF PubMed Scopus (3) Google Scholar illustrates some of the strengths and weaknesses of the “evidenced-based” review system. The authors state correctly that there is good evidence that steroids reduce the symptomatic period for sore throats, but, assuming that this is adequate evidence, also assuming that they are hence of overall benefit is quite unwarranted. Glucocorticoids reduce inflammation, which is the presumed reason they decrease pain, and were initially prescribed for many different infections.2Simpson S.L. Some recent advances in endocrinology.Br Med J. 1952; 1: 725-730Crossref PubMed Scopus (2) Google Scholar Unfortunately, they cause immunosuppression and a decrease in both B- and T-cell function and lead to worse outcomes (at least for most of the infections that have been studied). If steroid-mediated short-term immunosuppression increases by even a small amount the number of patients who develop local complications (such as peritonsillar or retropharyngeal abscesses), systemic disease (such as scarlet fever, streptococcal toxic shock syndrome, glomerulonephritis, or rheumatic fever, which are still major problems in much of the world), or recurrent infections (which they apparently do in streptococcal pneumonia3Garcia-Vidal C. Carratela J. Fernandez-Sabe N. et al.Aetiology of, and risk factors for, recurrent community-acquired pneumonia.Clin Microbiol Infect. 2009; 15: 1033-1038Abstract Full Text Full Text PDF PubMed Scopus (52) Google Scholar), or who become carriers, the harm will greatly outweigh the rather minor benefit.We do not know whether these complications are real problems because no studies have looked for them or were adequately powered to find them. The authors’ suggestion that “future studies examining the use of corticosteroids as stand-alone treatment, single versus multidose regimens, use in children, and further adverse event analysis are warranted” is appropriate, provided that these studies are adequately powered to find rare but serious complications, but their conclusion that steroids are “without significant adverse effects” is not supported by the evidence. We need a large trial to determine whether that judgment is true. The Systematic Review Snapshot “Do Corticosteroids Benefit Patients With Sore Throat?”1Welch J.L. Cooper D.D. Do corticosteroids benefit patients with sore throat?.Ann Emerg Med. 2014; 63: 711-712Abstract Full Text Full Text PDF PubMed Scopus (3) Google Scholar illustrates some of the strengths and weaknesses of the “evidenced-based” review system. The authors state correctly that there is good evidence that steroids reduce the symptomatic period for sore throats, but, assuming that this is adequate evidence, also assuming that they are hence of overall benefit is quite unwarranted. Glucocorticoids reduce inflammation, which is the presumed reason they decrease pain, and were initially prescribed for many different infections.2Simpson S.L. Some recent advances in endocrinology.Br Med J. 1952; 1: 725-730Crossref PubMed Scopus (2) Google Scholar Unfortunately, they cause immunosuppression and a decrease in both B- and T-cell function and lead to worse outcomes (at least for most of the infections that have been studied). If steroid-mediated short-term immunosuppression increases by even a small amount the number of patients who develop local complications (such as peritonsillar or retropharyngeal abscesses), systemic disease (such as scarlet fever, streptococcal toxic shock syndrome, glomerulonephritis, or rheumatic fever, which are still major problems in much of the world), or recurrent infections (which they apparently do in streptococcal pneumonia3Garcia-Vidal C. Carratela J. Fernandez-Sabe N. et al.Aetiology of, and risk factors for, recurrent community-acquired pneumonia.Clin Microbiol Infect. 2009; 15: 1033-1038Abstract Full Text Full Text PDF PubMed Scopus (52) Google Scholar), or who become carriers, the harm will greatly outweigh the rather minor benefit. We do not know whether these complications are real problems because no studies have looked for them or were adequately powered to find them. The authors’ suggestion that “future studies examining the use of corticosteroids as stand-alone treatment, single versus multidose regimens, use in children, and further adverse event analysis are warranted” is appropriate, provided that these studies are adequately powered to find rare but serious complications, but their conclusion that steroids are “without significant adverse effects” is not supported by the evidence. We need a large trial to determine whether that judgment is true. Do Corticosteroids Benefit Patients With Sore Throat?Annals of Emergency MedicineVol. 63Issue 6PreviewThe literature search identified 712 studies, 12 of which met the inclusion criteria for full-text review. Four studies were excluded (duplicate study, no placebo group, hospitalized patients, no randomization of participants). In the 8 included randomized controlled trials, 743 total patients (369 children and 374 adults) were included from emergency departments or general practice settings in 4 countries: United States, Canada, Israel, and Turkey. Exudative sore throat was reported for 47% (348) and group A β-hemolytic streptococcus (GABHS) was positive for 44% (330). Full-Text PDF Nonsteroidal Anti-Inflammatory Drugs Are an Effective Alternative to Corticosteroids to Treat Pain in PharyngitisAnnals of Emergency MedicineVol. 64Issue 6PreviewIn their recent review article, Welch and Cooper1 describe 8 trials that clearly demonstrate the benefit of corticosteroids for pain in pharyngitis. We wish to highlight a parallel body of high-quality evidence showing the efficacy of nonsteroidal anti-inflammatory drugs in pharyngitis and suggest this as an alternative.2,3 Indeed, a recent practice guideline from the Infectious Diseases Society of America gave a “strong” recommendation for nonsteroidal anti-inflammatory drugs for symptom relief in bacterial pharyngitis, grading the quality of supporting evidence as high. Full-Text PDF In replyAnnals of Emergency MedicineVol. 64Issue 6PreviewWe appreciate Drs. Shy and Strayer’s comment on the use of nonsteroidal anti-inflammatory drugs as an alternative therapy to the treatment of pain in pharyngitis. We would like to point out that this evidence is based on a 2000 systematic review examining all treatments for pharyngitis1; in this review, there was only 1 study that assessed the effectiveness of corticosteroids, to our knowledge. This systematic review did find nonsteroidal anti-inflammatory drugs to be an effective treatment; however, the heterogeneity precluded meta-analysis or calculation of number needed to treat. Full-Text PDF

BACKGROUND:As the specialty of emergency medicine (EM) continues to spread around the world, a growing number of academic emergency physicians have become involved in global EM development, research, and teaching. While academic departments have always found this work laudable, they have only recently begun to accept global EM as a rigorous academic pursuit in its own right. OBJECTIVE:This article describes how emergency physicians can translate their global health work into "academic currency" within both the clinician-educator and clinician-researcher tracks. DISCUSSION:The authors discuss the impact of various types of additional training, including global EM fellowships, for launching a career in global EM. Clearly delineated clinician-researcher and clinician-educator tracks are important for documenting achievement in global EM. CONCLUSIONS:Reflecting a growing interest in global health, more of today's EM faculty members are ascending the academic ranks as global EM specialists. Whether attempting to climb the academic ladder as a clinician-educator or clinician-researcher, advanced planning and the firm support of one's academic chair is crucial to the success of the promotion process. Given the relative youth of the subspecialty of global EM, however, it will take time for the pathways to academic promotion to become well delineated.

The emergency care of patients who may have spinal injuries has become highly ritualised. There is little scientific support for many of the recommended interventions and there is evidence that at least some methods now used in the field and emergency department are harmful. Since prospective clinical trials are not likely to resolve these issues I propose a reconceptualisation of spinal trauma to allow a more rational approach to treatment. To do this I analyse the basic physics, biomechanics and physiology involved. I then develop a list of recommended treatment variations that are more in keeping with the actual causes of post impact neurological deterioration than are current methods. Discarding the fundamentally flawed emphasis on decreasing post injury motion and concentrating on efforts to minimise energy deposition to the injured site, while minimising treatment delays, can simplify and streamline care without subjecting patients to procedures that are not useful and potentially harmful. Specific treatments that are irrational and which can be safely discarded include the use of backboards for transportation, cervical collar use except in specific injury types, immobilisation of ambulatory patients on backboards, prolonged attempts to stabilise the spine during extrication, mechanical immobilisation of uncooperative or seizing patients and forceful in line stabilisation during airway management.

The chief complaint is a patient's self-reported primary reason for presenting for medical care. The clinical utility and analytical importance of recording chief complaints have been widely accepted in highly developed emergency care systems, but this practice is far from universal in global emergency care, especially in limited-resource areas. It is precisely in these settings, however, that the use of chief complaints may have particular benefit. Chief complaints may be used to quantify, analyze, and plan for emergency care and provide valuable information on acute care needs where there are crucial data gaps. Globally, much work has been done to establish local practices around chief complaint collection and use, but no standards have been established and little work has been done to identify minimum effective sets of chief complaints that may be used in limited-resource settings. As part of the Academic Emergency Medicine consensus conference, "Global Health and Emergency Care: A Research Agenda," the breakout group on data management identified the lack of research on emergency chief complaints globally-especially in low-income countries where the highest proportion of the world's population resides-as a major gap in global emergency care research. This article reviews global research on emergency chief complaints in high-income countries with developed emergency care systems and sets forth an agenda for future research on chief complaints in limited-resource settings.

Barriers to global emergency care development include a critical lack of data in several areas, including limited documentation of the acute disease burden, lack of agreement on essential components of acute care systems, and a lack of consensus on key analytic elements, such as diagnostic classification schemes and regionally appropriate metrics for impact evaluation. These data gaps obscure the profound health effects of lack of emergency care access in low- and middle-income countries (LMICs). As part of the Academic Emergency Medicine consensus conference "Global Health and Emergency Care: A Research Agenda," a breakout group sought to develop a priority research agenda for data collection and management within global emergency care systems.

In this commentary, common misperceptions about education research, and specifically for emergency medicine education research, are addressed. Recommendations for designing and publishing high-quality projects are also provided.