Volunteer-Operated Field Medical Tents During Civilian Protests in Beirut, Lebanon: Challenges and Lessons

In October 2019, the worsening political, economic, and perceived corruption in Lebanon led to civil unrest. In anticipation of injuries, a group of healthcare professionals and social activists summoned paramedics, nurses, and physicians through social media, to provide medical assistance in the protest area. These volunteers established a physician-led advanced first-aid tent, whose aim was to reduce the patient load on Emergency Departments in local hospitals. We present the experience of volunteers, lessons learned, and challenges faced during the establishment of the physician-led first aid tent. In this manuscript, we discuss the following aspects of our efforts that can serve as relevant lessons we learned about medical volunteerism: spontaneity in volunteerism, operations, location and storage, supplies, roaming team, coordination with emergency services, safety, documentation, communication, special situations, and transition from acute to primary care.

Reforming Healthcare Practice in View of the Economic Crisis in Lebanon: The Case of Cardiovascular Care

Since the fall of 2019, Lebanon has been facing an economic crisis that has imposed many challenges on its healthcare system in its entirety. In this review, we propose a methodology to inform healthcare policy and apply it on cardiovascular disease (CVD) healthcare with emphasis on ischemic heart disease (IHD). The main goal of this methodology is reducing unnecessary expenditure while maintaining quality and access. CVD, and particularly IHD, is the most common reason for hospitalizations in Lebanon. Lebanon also has a high density of catheterization labs, higher than countries with higher prevalence of disease. Additionally, we found coronary to be are more expensive in comparison to other countries. To reduce healthcare costs without compromising quality and access we propose solutions targeting healthcare financing, payment for services, healthcare organizations, behaviors of providers, payers, and patients, and above all government regulation.

Evaluating Disparities Affecting Time from Emergency Department Door to Electrocardiogram in Chest Pain Patients

Introduction: For patients presenting to an emergency department with a chief complaint of chest pain, current American Heart Association guidelines recommend that time from emergency department arrival to completion of electrocardiogram be 10 minutes or less. The aim of this study is to evaluate if differences still exist amongst a diverse patient population presenting to a busy urban emergency department with a chief complaint of chest pain. Methods: This retrospective study looked at 3,419 patients who presented to the Emergency Department with any complaint of chest pain during the medical screening examination. Arrival time and time of first electrocardiogram along with age, gender, race, ethnicity and primary language were extracted from electronic health records. Results: For all patients, the mean time to electrocardiogram was 12.5 minutes (95% CI: 12.1-12.7) and 49.9% of all patients received an electrocardiogram within 10 minutes of arrival. Mean time for men was 11.6 minutes and for women 13.3 minutes (P<0.0001); in addition 54% of men and 44.4% of women had electrocardiogram done within 10 minutes of arrival (P<0.0001). No differences were found with regards to primary language, race or ethnicity of patients. Mean time to electrocardiogram for patients less than 40 years old was 14.6 minutes, which was significantly longer than patients equal or older than 40 years, who’s mean time was 11.9 minutes (p<0.0001). The effect of age was observed across gender, race, ethnicity and primary language spoken by the patients. Conclusions: Patient presenting to the emergency department with chest pain are subject to several biases that potentially create health disparities. In this study we show that younger patients and women had a delay in time to electrocardiogram showing biases are still an issue.

Mass Casualty Management in the Emergency Department – Lessons Learned in Beirut, Lebanon - Part II

The first article in this series (Part I) discussed the abundant exposure of our emergency department (ED) to mass casualty incidents (MCIs), particularly over the past 14 years. This experience led us to define practical strategies that emergency departments can use to develop their own MCI response plans. In the first part, our main focus was to highlight the abrupt nature of MCIs and the subsequent need to use disaster drills. Additionally, we discussed the importance of having a tiered response and activation as well as other lessons learned from our experience to maximize the preparedness of the emergency department to receive mass casualty.In this article, we discuss the optimal way to triage patients. In addition, we will tackle the best methods for documentation and communication, which are vital yet overlooked during mass casualty incidents. We will also elaborate on what we learned from dealing with outbursts of anger and violence in the ED during MCIs and how to ensure the safety of the ED staff.

Characteristics of Attempted Suicide in the Middle East and North Africa Region: The Mediating Role of Arab Culture and Religion

The general lack of awareness of mental health in the Middle East and North Africa (MENA) region, particularly within its Arab countries, accounts for limited mental health services and stigmatization of psychiatric conditions in the region. Suicide is a drastic consequence of mental health neglect. Suicidal attempts are one form of presentation to emergency departments (ED) in healthcare centers across the Arab countries in the MENA region. We collected data from various research studies in the region to narrate such presentations. This epidemiological country-by-country summary includes the characteristics of suicidal attempts in the Arab region, with a focus on methods, causes, and management of cases. The summary demonstrates that suicidal attempts in this part of the world share sociocultural and logistic grounds. The prominent archetypes of suicidal attempts are middle-aged Arab women ingesting poisonous substances secondary to familial or interpersonal stressors. We also link these presentations to the Arab culture and its associated beliefs, which at times can dictate privacy and stigmatization of mental health and suicide. Even though religion plays a role in mollifying suicidal attempts, it might exacerbate stigma regarding suicide among Arab societies. Lastly, we recommend management measures that enhance suicide risk detection in the ED and provide an ameliorated understanding of suicidal ideations and behaviors of patients in the Arab countries of the MENA region.

A Brief Report on the Beirut Port Explosion

Over the past year, Beirut has witnessed a civil revolution, the COVID-19 pandemic, its worst economic crisis in decades, and most recently one of the largest non-nuclear explosions in history. This explosion had devastating effects on the city’s social, economic, and health infrastructure.

USMLE Scores Do Not Predict the Clinical Performance of Emergency Medicine Residents

Background: Scores on “high-stakes” multiple choice exams such as the United States Medical Licensing Examination® (USMLE) are important screening and applicant ranking criteria used by residencies.Objective: We tested the hypothesis that USMLE scores do not predict overall clinical performance of emergency medicine (EM) residents.Methods: All graduates from our University-based EM residency between the years 2008 and 2015 were included. Residents who had incomplete USMLE records were terminated, transferred out of the program, or did not graduate within this timeframe were excluded from the analysis. Clinical performance was defined as a gestalt of the residency program’s leadership and was classified into three sets: top, average, and lowest clinical performer. Dissimilarities of the initial blind rankings were adjudicated during a consensus conference.Results: During the eight years of the study period, there were a total of 115 graduating residents: 73 men (63%) and 42 women. Nearly all of them (109; 95%) had allopathic medical degrees; the remainder had osteopathic degrees. There was not a statistically significant correlation between our ranking of clinical performance and the Step 2 Clinical Knowledge score. There was a non-significant correlation between clinical performance and the Step 1 score.Conclusion: Neither USMLE Step 1 nor Step 2 Clinical Knowledge were good predictors of the actual clinical performance of residents during their training. We feel that their scores are overemphasized in the resident selec­tion process.

Non-Invasive Ventilation in the Elderly at Emergency Department: Epidemiological Data and Results

Introduction: Non-invasive ventilation (NIV) could be a good alternative in elderly people with acute respiratory failure (ARF), to procure them a respiratory support while avoiding as much as possible the complications of invasive ventilation. Methods: This is an observational retrospective study conducted at the emergency department (ED) of a tertiary care, university-based teaching hospital. Data of elderly patients (≥ 65 years) admitted to ED between January 2017 and April 2018 for ARF and requiring NIV were collected and analyzed using SPSS 22 software. Results: Sixty six patients (≥ 65 years) requiring NIV for acute respiratory failure (ARF) were included. The mean age was 76 years (± 7), the median Charlson index was 5. Acute respiratory failure was related to acute heart failure in 68%, acute exacerbation of chronic obstructive pulmonary disease in 53% and pneumonia in 39% of cases. Forty eight percent had more than one etiologic diagnosis. Hypercapnic acute respiratory failure was observed in 61%. On initiation of NIV, the average pH was 7.31 (± 0.11) and PaCO2 56 mmHg (± 21), After NIV, the average pH was 7.38 (± 0.11) and PaCO2 53 mmHg (± 26). Improvement of pH was significant (p < 0.05). 61% of patients were discharged at home, 9% were admitted to intensive care unit. Invasive ventilation was performed in 4%, of which 23% died. Success of NIV was observed in 68% of patients. Conclusion: NIV can be of a great interest in elderly people. Our study showed that it can be used successfully in the studied settings.

The International Medical Graduate

International medical graduates (IMGs) are graduates of medical schools located outside the United States (U.S.) and Canada. IMGs face various challenges on the road to U.S. residency training. These challenges include sitting for the United States Medical Licensing Examinations (USMLEs) to obtain certification from the Educational Commission for Foreign Medical Graduates (ECFMG). After that, IMGs are faced with a foreign application process whereby they must apply for and secure a position in a residency program through the Electronic Residency Application System (ERAS) and the National Resident Matching Program (NRMP). Once accepted into a residency program, IMGs who are not US citizens or legal permanent residents are challenged with securing a visa to be able to practice in the U.S. In this article, we elaborate on these processes and highlight the challenges IMGs may face along the way.