Developing and implementing a global emergency medicine course: Lessons learned from Rwanda

BACKGROUND

There is a growing demand by medical trainees for meaningful, short-term global emergency medicine (EM) experiences. EM programs in high-income countries (HICs) have forged opportunities for their trainees to access this experience in low-and middle-income countries (LMICs). However, few programs in LMICs have created and managed such courses. As more LMICs establish EM programs, these settings are ideal for developing courses beneficial for all participants. We describe our experience of creating and implementing a short-term global EM course in Rwanda.

OBJECTIVES

The objectives of this study were to (1) provide EM trainees from HICs with an opportunity to observe global clinical practice and to learn from local experts, (2) provide EM trainees from an LMIC with an opportunity to share their expert knowledge and skills with HIC trainees, (3) create a sustainable model for a short-term global EM course in an LMIC context.

METHODS

A global EM curriculum and course were developed in Rwanda, entitled EM in the Tropics Emergency Medicine in the Tropics (EMIT). The following topics were covered: EM systems development, public health, trauma/triage, pediatrics, disaster management, and tropical EM. A one-and two-week course program was created and implemented.

RESULTS

EMIT participants rotated through pediatric and adult EDs, Intensive Care Unit, trauma surgery, internal medicine, emergency medical services, and ultrasound training. Activities included bedside teaching, case presentations, ultrasound practice, group lectures, simulation and skills workshops, and a rotation to a district hospital. A total of 11 participants attended: six for both weeks and five for 1 week. The course raised $5000 USD, which was dedicated in full to sponsoring local EM residents to attend international conferences.

DISCUSSION

The EMIT course in Rwanda achieved its objectives of teaching and learning between all participants. Benefits of this in-person experience for both visiting and local participants are clear in clinical, intercultural, and professional ways.

CONCLUSION

Our experience of developing and implementing EMIT in Rwanda demonstrates that EM programs in LMICs can provide short-term global EM courses that are not only beneficial to all participants, but also logistically and financially sustainable.

Specialization in acute care surgery in low-income and middle-income countries

Traumatic injuries represent the highest portion of surgical conditions worldwide, and the groups most vulnerable to these injuries are disproportionately in low-income and middle-income countries (LMICs). It is in this context that we recognize and propose an urgent opportunity for developing and strengthening the field of acute care surgery (ACS) in LMICs. In this article, we will briefly review the history and advantages of ACS as a specialty and recognize the unique opportunity and benefit it may have in LMICs.

Evaluating the potential for tactical hunting in the Middle Stone Age: Insights from a bonebed of the extinct bovid, Rusingoryx atopocranion

The foraging behaviors of Middle Stone Age (MSA) early modern humans have largely been based on evidence from well-stratified cave sites in South Africa. Whereas these sites have provided an abundance of data for behavioral reconstruction that are unmatched elsewhere in Africa, they are unlikely to preserve evidence of the diversity of foraging strategies employed by MSA hunters who lived in a variety of ecological and landscape settings across the African continent. Here we describe the results of recent excavations at the open-air site of Bovid Hill at Wakondo, Rusinga Island, Kenya, which yielded 24 in situ MSA artifacts within an assemblage of bones comprised exclusively of the extinct alcelaphin bovid Rusingoryx atopocranion. The excavated faunal assemblage is characterized by a prime-age-dominated mortality profile and includes cut-marked specimens and an associated MSA Levallois blade-based artifact industry recovered from a channel deposit dated to 68 ± 5 ka by optically stimulated luminescence. Taphonomic, geologic, and faunal evidence points to mass exploitation of Rusingoryx by humans at Bovid Hill, which likely represents an initial processing site that was altered post-depositionally by fluvial processes. This site highlights the importance of rivers and streams for mass procurement in an open and seasonal landscape, and provides important new insights into MSA behavioral variability with respect to environmental conditions, site function, and tactical foraging strategies in eastern Africa. Bovid Hill thus joins a growing number of MSA and Middle Paleolithic localities that are suggestive of tactical hunting behaviors and mass capture of gregarious ungulate prey.

Occurrences and toxicological risk assessment of eight heavy metals in agricultural soils from Kenya, Eastern Africa

The concentration distribution and toxicological assessment of eight heavy metals including lead (Pb), cadmium (Cd), copper (Cu), chromium (Cr), nickel (Ni), mercury (Hg), arsenic (As), and zinc (Zn) in agricultural soils from Kenya, Eastern Africa, were investigated in this study. The results showed mean concentrations of eight heavy metals of Zn, Pb, Cr, Cu, As, Ni, Hg, and Cd in agricultural soils as 247.39, 26.87, 59.69, 88.59, 8.93, 12.56, 8.06, and 0.42 mg kg(-1), respectively. These mean values of eight heavy metals were close to the toxicity threshold limit of USEPA standard values of agricultural soils, indicating potential toxicological risk to the food chain. Pollution index values revealed that eight heavy metals severely decreased in the order Hg > Cd > As > Cu > Pb > Zn > Ni > Cr and the mean value of the overall pollution index of Hg and Cd was 20.31, indicating severe agriculture ecological risk. Potential pollution sources of eight heavy metals in agricultural soils were mainly from anthropogenic activities and natural dissolution. The intensification of human agricultural activities, the growing industrialization, and the rapid urbanization largely influenced the concentration levels of heavy metals in Kenya, Eastern Africa. Moreover, the lack of agricultural normalization management and poor enforcement of environmental laws and regulations further intensified the widespread pollution of agricultural soils in Kenya.

A review of 40 years of enteric antimicrobial resistance research in Eastern Africa: what can be done better?

The emergence and persistence of antimicrobial resistance is driven by varied factors including the indiscriminate use of antibiotics and variable drug efficacy and presents a major threat to the control of infectious diseases. Despite the high burden of disease in sub-Saharan Africa and the potential health and economic consequences, the level of research on antimicrobial resistance in the region remains unknown. Little data exists to quantify the contribution of different factors to the current levels of antimicrobial resistance. To identify the factors that contribute most to the emergence, amplification, persistence and dissemination of antimicrobial resistance in humans and animals, we used the PRISMA 2009 guidelines to conduct a systematic review of studies on antibiotic-resistant enteric bacteria in Eastern Africa. We searched PubMed and Google Scholar databases and identified 2,155 probable articles, of which 89 studies on humans and 28 on animals remained after full-text review. These were articles from Kenya, Tanzania, Uganda, Ethiopia, Rwanda and Burundi, published between 1974 and 2013, that reported resistance in Salmonella, Shigella, Escherichia coli and Vibrio sp. The majority (98%) of human studies were based on hospital- (rather than community-wide) sampling and although they report high levels of antimicrobial resistance in the region, study design and methodological differences preclude conclusions about the magnitude and trends of antimicrobial resistance. To remedy this, we discuss and propose minimum reporting guidelines for the level of detail that should be explicitly provided for antimicrobial resistance study designs, testing of samples and reporting of results that would permit comparative inferences and enable meta-analyses. Further, we advocate for increased focus on community- rather than hospital-based sampling to provide a better indication of population-wide trends in antimicrobial resistance. This approach, together with the establishment of a robust regional surveillance network, should over time build a pool of evidence-based data useful for policy decisions and interventions aimed at controlling antimicrobial resistance.

A qualitative pilot study of food insecurity among Maasai women in Tanzania

BACKGROUND

Food insecurity is an ongoing threat in rural sub-Saharan Africa and is complicated by cultural practices, the rise of chronic conditions such as HIV and land use availability. In order to develop a successful food security intervention program, it is important to be informed of the realities and needs of the target population. The purpose of this study was to pilot a qualitative method to understand food insecurity based on the lived experience of women of the Maasai population in the Ngorongoro Conservation Area of Tanzania.

METHODS

Short semi-structured qualitative interviews with 4 Maasai women.

RESULTS

FOOD INSECURITY WAS PRESENT IN THE MAASAI COMMUNITY: the participants revealed that they did not always have access to safe and nutritious food that met the needs of themselves and their families. Themes that emerged from the data fell into three categories: Current practices (food sources, planning for enough, food preparation, and food preservation), food Insecurity (lack of food, emotions, coping strategies, and possible solutions), and division (co-wives, food distribution, and community relationships).

CONCLUSION

This pilot study suggested the presence of food insecurity in the Maasai community. Larger sample studies are needed to clarify the extent and severity of food insecurity among this population. Having a detailed understanding of the various aspects of the food insecurity lived experience could inform a targeted intervention program.

Late-onset Visual Loss in Osteopetrosis

Late-onset visual loss is a complication of nerve entrapment and increased intracranial pressure. We hereby describe the first case in Eastern Africa. A 23 year-old lady presented with sudden blindness, headaches and body weakness. She had previously had treatment for multiple unexplained fractures. Findings of optic nerve entrapment explained this blindness. This case highlights the need to have a high index of suspicion in cases of unexplained fractures with late-onset blindness.