Sean M. Kivlehan

Armed conflicts threaten the resilience of health systems and the continuity of medical education. The war in Ukraine has impacted the health infrastructur

Introduction: Blast injuries can occur by a multitude of mechanisms, including improvised explosive devices (IEDs), military munitions, and accidental detonation of chemical or petroleum stores. These injuries disproportionately affect people in low- and middle-income countries (LMICs), where there are often fewer resources to manage complex injuries and mass-casualty events. Study Objective: The aim of this systematic review is to describe the literature on the acute facility-based management of blast injuries in LMICs to aid hospitals and organizations preparing to respond to conflict- and non-conflict-related blast events. Methods: A search of Ovid MEDLINE, Scopus, Global Index Medicus, Web of Science, CINAHL, and Cochrane databases was used to identify relevant citations from January 1998 through July 2024. This systematic review was conducted in adherence with PRISMA guidelines. Data were extracted and analyzed descriptively. A meta-analysis calculated the pooled proportions of mortality, hospital admission, intensive care unit (ICU) admission, intubation and mechanical ventilation, and emergency surgery. Results: Reviewers screened 3,731 titles and abstracts and 173 full texts. Seventy-five articles from 22 countries were included for analysis. Only 14.7% of included articles came from low-income countries (LICs). Sixty percent of studies were conducted in tertiary care hospitals. The mean proportion of patients who were admitted was 52.1% (95% CI, 0.376 to 0.664). Among all in-patients, 20.0% (95% CI, 0.124 to 0.288) were admitted to an ICU. Overall, 38.0% (95% CI, 0.256 to 0.513) of in-patients underwent emergency surgery and 13.8% (95% CI, 0.023 to 0.315) were intubated. Pooled in-patient mortality was 9.5% (95% CI, 0.046 to 0.156) and total hospital mortality (including emergency department [ED] mortality) was 7.4% (95% CI, 0.034 to 0.124). There were no significant differences in mortality when stratified by country income level or hospital setting. Conclusion: Findings from this systematic review can be used to guide preparedness and resource allocation for acute care facilities. Pooled proportions for mortality and other outcomes described in the meta-analysis offer a metric by which future researchers can assess the impact of blast events. Under-representation of LICs and non-tertiary care medical facilities and significant heterogeneity in data reporting among published studies limited the analysis.

Objective: The Global Emergency Medicine Literature Review (GEMLR) highlights the highest‐quality research addressing emergency care in resource‐limited settings (ECRLS). This 18th edition reviews global emergency medicine (GEM) literature published during 2023.Methods: A scoping review of GEM articles published in 2023 was performed using a systematic PubMed search and manual gray literature (GRAY) search. Reviewers and editors from 10 countries screened articles utilizing case definitions of three categories of GEM research—disaster and humanitarian response (DHR), ECRLS, and emergency medicine development (EMD). After duplicates and those not meeting authorship equity and ethical review requirements were removed, articles were scored according to rubrics for original research (OR), review articles (RE), and GRAY. Those in the top 5% from any category were summarized and critiqued in narrative review.Results: There were 58,291 articles identified in the main search and 11,035 in the GRAY search. A total of 825 articles from the main search and 37 GRAY articles screened in and were scored. Fifty‐five main search articles and one GRAY article were included after scoring, a 52.8% increase from 2022 despite <1% change in search volume. ECRLS remained the largest category (63%). As in previous years, articles frequently addressed emergencies in pediatrics (10 articles), trauma (9), prehospital care (8), maternal/neonatal care (6), education/training (6), disaster medicine (4), and airway/sedation management (4). A total of 3.5% of screened‐in articles failed to meet GEMLR's new authorship equity and ethics standards.Conclusions: The quantity and quality of GEM research continues to grow as measured by the GEMLR scoring system. A revised search string identified relevant GEM articles with broad application in global settings. New equity guidelines were successfully implemented. This review summarizes the highest quality current GEM research while providing evolving guidelines for best practices in performing this important and rapidly growing work.

Introduction Civilian healthcare workers (HCW) and medical facilities are directly and indirectly impacted by armed conflict. In the Russia-Ukraine war, acute trauma care needs grew, the workforce was destabilised by HCW migrating or shifting roles to meet conflict needs, and facilities faced surge events. Chemical, biological, radiological, nuclear and explosive (CBRNE) exposure risks created unique preparedness needs. In response, an academic and international non-governmental organisation partnership was formed to design, implement and evaluate a locally prioritised training programme in Ukraine. Methods Seven in-person training courses (Advanced Trauma Life Support, Trauma Nursing Fundamentals, Pediatric Trauma Fundamentals, Prehospital Trauma Fundamentals, Stop the Bleed, Mass Casualty Management and CBRNE Preparedness) were adapted, translated, taught and evaluated in seven Ukrainian oblasts (regions; Kyiv, Dnipropetrovsk, Zaporizhzhia, Odesa, Lviv, Chernihiv and Mykolaiv) during the war. Topics were determined by available needs assessments and further adapted based on course participant feedback and evolving logistic and security challenges. Change in participant knowledge and confidence levels was assessed through precourse and postcourse knowledge and self-confidence evaluations and follow-up surveys. Initial courses were taught by international instructors and transitioned to Ukrainian instructors as they were trained. Web-based asynchronous videos in Ukrainian were developed to complement and reinforce in-person training. Results 4368 participants were trained in 164 courses from August 2022 to April 2023. 223 instructors were trained. Aggregate participant knowledge and self-confidence significantly improved in all courses. Interval follow-up responses indicated that the training was useful and 83.3% had used the skills within 8 weeks of training. Twenty-seven training videos were created which, as of April 2023, have been viewed over 1 700 000 times in 500 cities throughout Ukraine. Conclusions Locally prioritised training can be rapidly developed and delivered in an armed conflict setting providing civilians and frontline HCW with the skills and knowledge required to care for patients. Logistics, communication, equipment and security challenges can be overcome through strategic in-country partnerships. Short asynchronous video learning can complement and scale in-person training.

Critical illness represents any immediately life-threatening disease or injury that, if left untreated, can lead to death [1]. It is not specific to a single disease category, patient population or age group and may be encountered throughout the health care system, including intensive care unit (ICU) settings, emergency care units, operating rooms, post-anesthetic care units, […]

Objective: The objective was to identify the highest quality global emergency medicine (GEM) research published in 2022. The top articles are compiled in a comprehensive list of all the year's GEM articles and narrative summaries are performed on those included.Methods: A systematic PubMed search was conducted to identify all GEM articles published in 2022 and included a manual supplemental screen of 11 organizational websites for gray literature (GRAY). A team of trained reviewers and editors screened all identified titles and abstracts, based on three case definition categories: disaster and humanitarian response (DHR), emergency care in resource‐limited settings (ECRLS), and emergency medicine development (EMD). Articles meeting these definitions were independently scored by two reviewers using rubrics for original research (OR), review (RE) articles, and GRAY. Articles that scored in the top 5% from each category as well as the overall top 5% of articles were included for narrative summary.Results: The 2022 search identified 58,510 articles in the main review, of which 524 articles screened in for scoring, respectively, 30% and 18% increases from last year. After duplicates were removed, 36 articles were included for narrative summary. The GRAY search identified 7755 articles, of which 33 were scored and one was included for narrative summary. ECRLS remained the largest category (27; 73%), followed by DHR (7; 19%) and EMD (3; 8%). OR articles remained more common than RE articles (64% vs. 36%).Conclusions: The waning of the COVID‐19 pandemic has not affected the continued growth in GEM literature. Articles related to prehospital care, mental health and resilience among patients and health care workers, streamlining pediatric infectious disease care, and disaster preparedness were featured in this year's review. The continued lack of EMD studies despite the global growth of GEM highlights a need for more scholarly dissemination of best practices.

Acute respiratory infections (ARIs) are the leading cause of paediatric morbidity and mortality in low- and middle-income countries (LMICs), with pneumonia being the leading infectious cause of death in children under five years globally, causing over 800 000 deaths in 2019 [1,2]. ARIs encompass a broad range of conditions from a simple “cold” or upper respiratory […]

Objective: The aim of this study was to evaluate the change in knowledge and skill confidence after implementation of a chemical, biological, radiological, nuclear, and explosive (CBRNE) training course during the Russia-Ukraine War. Methods: Pre/post-test study in the Ukrainian cities of Kyiv, Dnipro, Zaporizhzhia, and Odesa. Fifteen CBRNE courses were conducted over a 3-mo period, August to October 2022. Change in knowledge and skills confidence were evaluated with pre/post-course written exams and practical skill assessments that were observed during the training exercises. Changes were analyzed based on nonparametric Wilcoxon matched-pairs signed-rank testing. Pre/post self-efficacy surveys were analyzed with McNemar’s test for paired data. Course evaluations were conducted with standardized questions which assessed instruction quality, teaching relevance, knowledge gained, and post-course skills confidence. Results: A total of 523 participants registered and completed 1 of the 15 courses. Overall mean pre-course test score: 57.8% (SD 20.7%); mean post-course test score: 81.4% (SD 11.3%); participants with increasing test scores: 90.7%; mean difference in score (95% confidence interval) 23.6% (21.2%-25.9%), P < 0.0001. Pre/post self-efficacy surveys (4-point Likert scale) noted participants recognized signs and symptoms of a CBRNE incident, and necessary skills to manage CBRNE exposures, P < 0.0001. Conclusions: The implementation of this CBRNE course for front-line providers in Ukraine was successful. To our knowledge, it was the first implementation of a field course during the current Russian-Ukraine war. Future research should evaluate knowledge retention and impact of our innovative Train-the-Trainer model. Further iterations should emphasize expanding the quantity of training equipment and practical skill sessions.