Brian Rice is a Clinical Assistant Professor in the Department of Emergency Medicine at the Stanford University School of Medicine. He is a new member of the Stanford Emergency Medicine International group with a focus on research including applied epidemiology to guide development efforts.
Dr. Rice was granted his MDCM from the McGill University Faculty of Medicine in 2008. He did a preliminary year in Internal Medicine at St. Mary Medical Center in Long Beach, CA followed by the completion of his Emergency Medicine Residency at Los Angeles County + USC, graduating in 2012. After residency, he completed a Fellowship in Global Health and International Emergency Medicine via a combined program at Yale University and the London School of Hygiene and Tropical Medicine where he received a MSc in Tropical Medicine and International Health as well as a Diploma in Tropical Medicine and Hygiene in 2014. His first attending job was at NYU/Bellevue where he worked clinically and continued his role as Research Director of Global Emergency Care, a US and Ugandan-based NGO focused on providing “task-shifting” training in emergency medicine for non-physician clinicians in regions that did not have physician services.
His research work has focused on validating task-shifting in emergency medicine by looking at outcomes and quality indicators, as well as applied epidemiological studies attempting to link chief complaints to outcomes in low-resource settings to rationally develop models for care. His clinical interests are focused on fever in the returned traveler and zoonotic infections. He has worked clinically in Thailand, Cambodia, Liberia and Uganda and has been an invited speaker both nationally and internationally for his research work.
- Emergency Medicine
- Applied Epidemiology
- Global Health
Clinical Associate Professor, Emergency Medicine
Residency: LACplusUSC Emergency Medicine Residency (2012) CA
Fellowship: Yale University Office of the Registrar (2014) CT
Board Certification: American Board of Emergency Medicine, Emergency Medicine (2013)
Internship: St Mary Medical Center Internal Medicine Residency (2009) CA
Medical Education: McGill University Faculty of Medicine (2008) Canada
Current Research and Scholarly Interests
Developing data-driven approaches to defining and comparing chief complaints fro emergency and unscheduled acute care in low- and middle-income countries
Bias at Warp Speed: How AI may Contribute to the Disparities Gap in the Time of COVID-19.
Journal of the American Medical Informatics Association : JAMIA
The COVID-19 pandemic is presenting a disproportionate impact on minorities in terms of infection rate, hospitalizations and mortality. Many believe Artificial Intelligence (AI) is a solution to guide clinical decision making for this novel disease, resulting in the rapid dissemination of under-developed and potentially biased models, which may exacerbate the disparities gap. We believe there is an urgent need to enforce the systematic use of reporting standards and develop regulatory frameworks for a shared COVID-19 data source to address the challenges of bias in AI during this pandemic. There is hope that AI can help guide treatment decisions within this crisis yet given the pervasiveness of biases, a failure to proactively develop comprehensive mitigation strategies during the COVID-19 pandemic risks exacerbating existing health disparities.
View details for DOI 10.1093/jamia/ocaa210
View details for PubMedID 32805004
Medevac Utilization and Patient Characteristics in Rural Alaska 2010 to 2018.
Air medical journal
2020; 39 (5): 393–98
Little is known about medevac utilization in remote, rural Alaska where there is no road access and communities are reliant on medevacs for emergency care. With high financial costs and risks to flight crews, there is an urgent need to understand medevac utilization in rural Alaska. This article aimed to describe medevac utilization and patient characteristics over 9 years in the remote, air transport dependent in Alaska.Deidentified data (2010-2018) were obtained for all medevacs originating within the Yukon-Kuskokwim Delta. Descriptive statistics were calculated, and chi-square tests of independence were conducted to identify differences.Four thousand nine hundred ninety-one medevacs were performed, averaging 555 (standard deviation = 67.7) per year. Medevacs for respiratory complaints were predominant for children, whereas trauma predominated for adults 18 to 40 years old. Traumatic injury was more common in males than females aged < 65 years but was more common in females than males aged ≥ 65 years. Significant variability occurred in medevacs based on the community and the hour of the day.Medevacs are a critical part of health care in rural, remote Alaska but appear subject to clinical and nonclinical determinants. These baseline data provide a foundation for future studies aiming to increase medevac safety and provide decision-making support.
View details for DOI 10.1016/j.amj.2020.05.013
View details for PubMedID 33012479
Defining high-risk emergency chief complaints: data-driven triage for low- and middle-income countries.
Academic emergency medicine : official journal of the Society for Academic Emergency Medicine
Emergency medicine in low- and middle-income countries (LMICs) is hindered by lack of research into patient outcomes. Chief complaints are fundamental to emergency care but have only recently been uniquely codified for an LMIC setting in Uganda. It is not known whether chief complaints independently predict emergency unit patient outcomes.Patient data collected in a Ugandan emergency unit between 2009-2018 were randomized into validation and derivation datasets. A recursive partitioning algorithm stratified chief complaints by three-day mortality risk in each group. The process was repeated in 10,000 bootstrap samples to create an averaged risk ranking. Based on this ranking, chief complaints were categorized as "high-risk" (>2x baseline mortality), "medium-risk" (between 2 and 0.5x baseline mortality) and "low-risk" (<0.5x baseline mortality). Risk categories were then included in a logistic regression model to determine if chief complaints independently predicted three-day mortality.Overall, the derivation dataset included 21,953 individuals with 7,313 in the validation dataset. In total, 43 complaints were categorized, and 12 chief complaints were identified as high-risk. When controlled for triage data including age, sex, HIV status, vital signs, level of consciousness, and number of complaints, high-risk chief complaints significantly increased three-day mortality odds (OR 2.39, 95% CI 1.95 - 2.93, p<0.001) while low-risk chief complaints significantly decreased three-day mortality odds (OR 0.16, 95% CI 0.09 - 0.29, p<0.001).High-risk chief complaints were identified and found to predict increased three-day mortality independent of vital signs and other data available at triage. This list can be used to expand local triage systems and inform emergency training programs. The methodology can be reproduced in other LMIC settings to reflect their local disease patterns.
View details for DOI 10.1111/acem.14013
View details for PubMedID 32416022
Derivation and validation of a chief complaint shortlist for unscheduled acute and emergency care in Uganda
2018; 8 (6): e020188
Derive and validate a shortlist of chief complaints to describe unscheduled acute and emergency care in Uganda.A single, private, not-for profit hospital in rural, southwestern Uganda.From 2009 to 2015, 26 996 patient visits produced 42 566 total chief complaints for the derivation dataset, and from 2015 to 2017, 10 068 visits produced 20 165 total chief complaints for the validation dataset.A retrospective review of an emergency centre quality assurance database was performed. Data were abstracted, cleaned and refined using language processing in Stata to produce a longlist of chief complaints, which was collapsed via a consensus process to produce a shortlist and turned into a web-based tool. This tool was used by two local Ugandan emergency care practitioners to categorise complaints from a second longlist produced from a separate validation dataset from the same study site. Their agreement on grouping was analysed using Cohen's kappa to determine inter-rater reliability. The chief complaints describing 80% of patient visits from automated and consensus shortlists were combined to form a candidate chief complaint shortlist.Automated data cleaning and refining recognised 95.8% of all complaints and produced a longlist of 555 chief complaints. The consensus process yielded a shortlist of 83 grouped chief complaints. The second validation dataset was reduced in Stata to a longlist of 451 complaints. Using the shortlist tool to categorise complaints produced 71.5% agreement, yielding a kappa of 0.70 showing substantial inter-rater reliability. Only one complaint did not fit into the shortlist and required a free-text amendment. The two shortlists were identical for the most common 14 complaints and combined to form a candidate list of 24 complaints that could characterise over 80% of all emergency centre chief complaints.Shortlists of chief complaints can be generated to improve standardisation of data entry, facilitate research efforts and be employed for paper chart usage.
View details for PubMedID 29950461
Mortality in Children Under Five Receiving Nonphysician Clinician Emergency Care in Uganda.
2016; 137 (3): e20153201
A nonphysician clinician (NPC) training program was started in Uganda in 2009. NPC care was initially supervised by a physician and subsequent care was independent. The mortality of children under 5 (U5) was analyzed to evaluate the impact of transitioning NPC care from physician-supervised to independent care.A retrospective review was performed of a quality assurance database including 3-day follow-up for all patients presenting to the emergency department (ED). Mortality rates were calculated and χ(2) tests used for significance of proportions. Multiple logistic regression was used to assess independent predictors of mortality.Overall, 68.8% of 4985 U5 patients were admitted and 28.6% were "severely ill." The overall mortality was significantly lower in physician-supervised versus independent NPC care (2.90% vs 5.04%, P = .05). No significant mortality difference was seen between supervised and unsupervised care (2.17% vs 3.01%, P = .43) for the majority of patients that were not severely ill. Severely ill patients analyzed separately showed a significant mortality difference (4.07% vs 10.3%, P = .01). Logistic regression revealed physician supervision significantly reduced mortality for patients overall (odds ratio = 0.52, P = .03), but not for nonseverely ill patients analyzed separately (odds ratio = 0.73, P = .47).Though physician supervision reduced mortality for the severely ill subset of patients, physicians are not available full-time in most EDs in Sub-Saharan Africa. Training NPCs in emergency care produced noninferior mortality outcomes for unsupervised NPC care compared with physician-supervised NPC care for the majority of U5 patients.
View details for DOI 10.1542/peds.2015-3201
View details for PubMedID 26921282
Household economic impact of road traffic injury versus routine emergencies in a low-income country.
INTRODUCTION: Road traffic injuries (RTIs) are increasing and have disproportionate impact on residents of low- and middle-income countries (LMICs) where 90% of deaths occur. RTIs are a leading cause of death for those aged 15 - 29 years with costs estimated to be up to 3% of GDP. Despite this fact, little primary research has been done on the household economic impact of these events.METHODS: From July to October 2016, 860 consecutive emergency department patients were enrolled and followed up at 6-8 weeks to assess the household financial impacts of these emergency presentations. At follow-up, patients were queried regarding health status, lost wages or schooling, household costs incurred due to their injury or illness, and assets sold.RESULTS: 860 patients were enrolled and 675 patients (78%) completed follow-up surveys. Of those, 660 had a confirmed reason for visit - 303 (45%) road traffic injuries, 357 (53%) other emergency presentations (non-RTI) - encompassing medical presentations and other types of injury, and reason for visit was missing for 15 patients (2%). More than 90% of RTI patients were working or in school prior to their injury. In the economically productive ages (15-44 years) RTI predominated (70%) vs non-RTI (39%). RTI patients were more likely to report residual disability (78.2% RTI vs 68.1% non-RTI, p=0.004). All emergency patients reported difficulty paying for basic needs (food, housing and medical expenses). More than ⅓ of emergency patients reported having to sell assets in order to meet basic needs after their illness or injury. Despite similar hospital costs and fewer lost days of work for both patients and caregivers, the mean financial impact on households of RTI patients was 37% more than for non-RTI patients. These costs equalled between 6-16 weeks of income for patients based on their occupation type and median reported pre-hospitalization income.DISCUSSION: Ugandan emergency care patients suffered significant personal and household economic hardship. In addition to the need for policy and infrastructural changes to improve road safety, these findings highlight the need for basic emergency care systems to secure economic gains in vulnerable households and prevent medical impoverishment of marginal communities.
View details for DOI 10.1016/j.injury.2021.06.007
View details for PubMedID 34210454
- A Short-Term Medical Mission in Rural Nepal: Chief Complaints, Medications Dispensed, and Unmet Health Needs CUREUS 2021; 13 (6)
A Short-Term Medical Mission in Rural Nepal: Chief Complaints, Medications Dispensed, and Unmet Health Needs.
2021; 13 (6): e15427
Background Although Nepal is striving to expand primary health services for its citizens, many remote areas have limited access to basic health care. Short-term medical missions (STMMs) are one way of supplementing human resources for health in underserved areas. This article describes the chief complaints, medications dispensed, and unmet health needs during an STMM in rural Nepal. Methods This study is a retrospective analysis of data collected during an STMM that occurred in October 2017. Deidentified data from clinic intake forms were entered into an Excel spreadsheet, and formatted and cleaned. Demographics, chief complaints, medications, and unmet health needs were analyzed using descriptive statistics. Results During a two-day health camp, 443 patients were seen. The most common chief complaint was dental (33.4%) followed by musculoskeletal (28.2%) and gastrointestinal (21.2%). Medications were dispensed to 94.8% of patients, primarily analgesics, antibiotics, and ophthalmologic preparations. Of the patients, 21% had unmet health needs, including specialty care and labs or imaging that were beyond the scope of the STMM. One patient was referred urgently to a hospital for treatment of dyspnea and markedly elevated blood pressure. Conclusion While STMMs cannot replace access to primary health services, they can provide insight into acute care needs in a system that has limited surveillance. This information describing an acute care patient population should inform future development work.
View details for DOI 10.7759/cureus.15427
View details for PubMedID 34249572
View details for PubMedCentralID PMC8254532
Developing Emergency Triage Systems in Cambodia.
2020; 12 (10): e11233
As Cambodia works to rebuild its public health system, an area of focus has been improving the quality of emergency services. After a needs assessment in 2011, project partners identified the implementation of a patient triage system as the first target for development efforts. A context-specific triage system was created using the input of a spectrum of local stakeholders. It was tailored to fit the needs and resources available within the Cambodian health system. The system was implemented through a series of educational interventions at 35 public hospitals throughout nine Cambodian provinces. Follow-up quality improvement visits occurred on a quarterly basis between February 2016 and September 2018, during which feedback on the system was gathered using both quantitative and qualitative methods, and additional system updates were implemented. In this technical report we aim to describe the triage system design, implementation and quality improvement processes utilized with the hope of informing and supporting colleagues working to address similar challenges in other areas of the world. Through this assessment process a number of key observations were made: 1) Establishment of context-specific emergency triage systems is feasible in low resource settings; 2) Development of new triage processes requires an iterative approach; 3) Successful uptake of new practice systems requires flexibility from both the implementers and end-users in the development relationship; 4) Process improvement requires consistent retraining and reinforcement.
View details for DOI 10.7759/cureus.11233
View details for PubMedID 33269161
View details for PubMedCentralID PMC7706145
The Association of Malnutrition and Disease Conditions in Mortality of Pediatric Patients Presenting to a Rural Emergency Department in Uganda.
Pediatric emergency care
The main objectives of this study were to determine the effect of concurrent malnutrition on disease condition and the primary outcome of mortality in children younger than 5 years hospitalized after presenting to a rural emergency department (ED) in Uganda and to identify a high-risk patient population who may benefit from acute ED intervention.A retrospective, observational study was performed to examine the effect of any form of malnutrition on the primary disease conditions of lower-respiratory tract infection (LRTI), malaria, and diarrheal illness. This study was conducted via review of a quality assurance database between January 2010 and July 2014.Of 3428 hospitalized children, the mean age (SD) was 19.8 months (13.9 months) and 56% were boys. Children diagnosed with malaria, an LRTI, or diarrheal illness all had a higher rate of mortality with concurrent malnutrition versus those without malnutrition (malaria, 6.2% [3.6-8.8%] vs 2.8% [2.0-3.7%]; P < 0.01; LRTI, 8.7% [5.0-12.4%] vs. 3.7% [2.6-4.9%], P < 0.01; and diarrheal illness, 10.9% [1.9-19.9%] vs 1.7% [0.1-3.4%], P < 0.01). In children with an LRTI or malaria with concurrent malnutrition, they were statistically significantly less likely to have abnormal temperature and heart rate during the ED encounter than those without concurrent malnutrition.Based on these results, children with malnutrition and concurrent diseases with known high morbidity may not present with abnormal vital signs. This may have clinical relevance in patient management to the acute care provider in identifying and triaging children with malnutrition and acute disease conditions.
View details for DOI 10.1097/PEC.0000000000002102
View details for PubMedID 32398596
Negative pressure patient isolation device to enable non-invasive respiratory support for COVID-19 and beyond.
View details for DOI 10.1136/bmjinnov-2020-000551
What resources are used in emergency departments in rural sub-Saharan Africa? A retrospective analysis of patient care in a district-level hospital in Uganda
2018; 8 (2): e019024
To determine the most commonly used resources (provider procedural skills, medications, laboratory studies and imaging) needed to care for patients.A single emergency department (ED) of a district-level hospital in rural Uganda.26 710 patient visits.Procedures were performed for 65.6% of patients, predominantly intravenous cannulation, wound care, bladder catheterisation and orthopaedic procedures. Medications were administered to 87.6% of patients, most often pain medications, antibiotics, intravenous fluids, antimalarials, nutritional supplements and vaccinations. Laboratory testing was used for 85% of patients, predominantly malaria smears, rapid glucose testing, HIV assays, blood counts, urinalyses and blood type. Radiology testing was performed for 17.3% of patients, including X-rays, point-of-care ultrasound and formal ultrasound.This study describes the skills and resources needed to care for a large prospective cohort of patients seen in a district hospital ED in rural sub-Saharan Africa. It demonstrates that the vast majority of patients were treated with a small formulary of critical medications and limited access to laboratories and imaging, but providers require a broad set of decision-making and procedural skills.
View details for DOI 10.1136/bmjopen-2017-019024
View details for Web of Science ID 000433129800031
View details for PubMedID 29478017
View details for PubMedCentralID PMC5855402
- Pediatric Burn Management by Emergency Medicine Trained Non-Physician Clinicians in Rural Uganda EC Paediatrics 2018; 7 (4): 239-245
Pediatric Poisonings in a Rural Ugandan Emergency Department.
Pediatric emergency care
This study aims to describe pediatric poisonings presenting to a rural Ugandan emergency department (ED), identifying demographic factors and causative agents.This retrospective study was conducted in the ED of a rural hospital in the Rukungiri District of Uganda. A prospectively collected quality assurance database of ED visits was queried for poisonings in patients under the age of 5 who were admitted to the hospital. Cases were included if the chief complaint or final diagnosis included anything referable to poisoning, ingestion, or intoxication, or if a toxicologic antidote was administered. The database was coded by a blinded investigator, and descriptive statistics were performed.From November 9, 2009, to July 11, 2014, 3428 patients under the age of 5 were admitted to the hospital. A total of 123 cases (3.6%) met the inclusion criteria. Seventy-two patients were male (58.5%). The average age was 2.3 (SD, 0.97) years with 45 children (36.6%) under the age of 2 years. There were 19 cases (15.4%) lost to 3-day follow-up. The top 3 documented exposures responsible for pediatric poisonings were cow tick or organophosphates (36 cases, 29.2%), general poison or drug overdose (26 cases, 21.1%), and paraffin or hydrocarbon (24 cases, 19.5%).Of the admitted patients, 1 died in the ED and 2 died at 72-hour follow-up, for an overall 72-hour mortality of 2.4%. Patients who died were exposed to iron, cow tick, and rat poison.Pediatric poisoning affects patients in rural sub-Saharan Africa. The mortality rate at one rural Ugandan hospital was greater than 2%.
View details for DOI 10.1097/PEC.0000000000001265
View details for PubMedID 29016517
Not your regular high: cardiac dysrhythmias caused by loperamide.
Clinical toxicology (Philadelphia, Pa.)
2016; 54 (5): 454–58
Loperamide, a non-prescription anti-diarrheal agent, is a peripheral mu-opioid receptor agonist that is excluded from the blood-brain barrier by p-glycoprotein at therapeutic doses. Overdoses of loperamide penetrate the central nervous system (CNS), leading to abuse. We report cardiac conduction abnormalities and dysrhythmias after ingestion of a recreational supra-therapeutic dose of loperamide confirmed with an elevated blood loperamide concentration.A 48-year-old woman with a history of alcohol and benzodiazepine abuse presented to the emergency department (ED) with somnolence, weakness and slurred speech. She was taking 20 to 40 tablets of 2 mg loperamide 1-2 times/day for weeks along with clonazepam and whiskey. Vital signs were: blood pressure (BP), 124/90 mmHg; heart rate (HR), 88/min; respiratory rate(RR), 20/min; T, 36.9 °C; O2 saturation 100% on room air (RA). Glucose was 6.4 mmol/L. Electrocardiogram (ECG) had a ventricular rate of 58/min, QRS 164 ms, QT 582 ms with no discernable p-waves. Lactate was 3.5 mmol/L and potassium was 6.2 mEq/L. Labs were notable for an anion gap of 20 mEq/L, ethanol of 3.9 mmol/L, creatinine of 2.3 mg/dL and loperamide concentration of 210 ng/mL (average therapeutic plasma concentration 1.2 ng/mL). She became hypotensive, but responded to fluids. Following treatment for hyperkalemia with calcium, insulin, dextrose, and hypertonic sodium bicarbonate a repeat ECG had a ventricular rate of 66/min, QRS 156 ms, and QT 576 ms. Magnesium was given and pacer pads were placed. During the infusion of magnesium, her BP fell to 92/58 mmHg with a HR of 54/min, RR 14/min, O2 saturation of 97% on RA so the infusion was stopped. The ECG after the magnesium infusion had a ventricular rate of 51/min, QRS of 134 ms, and QT 614 ms. In the ICU she had multiple runs of non-sustained ventricular tachycardia that did not require therapy. Over the next 48 h she improved and was transferred to a floor bed. On day four of hospitalization the patient left against medical advice. At that time, her ECG showed sinus tachycardia with a heart rate 114/min, QRS 82 ms, QT 334 ms.Loperamide produces both QRS and QT prolongation at supra-therapeutic dosing. A blood loperamide concentration of 210 ng/mL is among the highest concentrations reported. Supra-therapeutic dosing of loperamide is promoted on multiple drug-use websites and online forums as a treatment for opioid withdrawal, as well as for euphoric effects. With the current epidemic of prescription opioid abuse, toxicity related to loperamide, an opioid agonist that is readily available without a prescription is occurring more frequently. It is important for clinicians to be aware of the potentially life-threatening toxicity related to loperamide abuse in order to provide proper diagnosis, management and patient education.
View details for DOI 10.3109/15563650.2016.1159310
View details for PubMedID 27022002
Survey of point of care ultrasound usage in emergency medicine by Vietnamese physicians.
Emergency medicine Australasia : EMA
2015; 27 (6): 580–83
Emergency medicine (EM) is rapidly developing as a specialty in Vietnam. Point of care ultrasound (POCUS) is currently taught as part of formal EM curriculums though limited literature exists to describe current POCUS usage in EDs in Vietnam. A survey was developed to understand current POCUS utilisation and guide future training efforts.A survey was administered to 104 Vietnamese physicians attending a national emergency medicine symposium regarding POCUS utilisation, access, training and preference. Data were analysed using multiple logistic regression to identify independent variables associated with POCUS usage.Increased access to ultrasound machines was significantly associated with increased POCUS usage, with 'all the time' access (OR = 92.9, 95% CI 7.15-1207.6, P = 0.001) being more strongly associated than 'sometimes' access (OR = 41.4, 95% CI 4.08-419.8, P = 0.002). Formal training did not significantly increase POCUS usage and 50.0% of respondents who regularly used POCUS had no formal training. There was no significant difference in physician preference or comfort for any single application of POCUS. There were 98.0% of trainees and 96.3% of independently practising physicians who reported a desire for additional POCUS training.Regular access to ultrasound machines increases the frequency of POCUS usage in EDs in Vietnam. POCUS training was not as clearly associated with POCUS usage as those without formal training were equally likely to use POCUS as those with formal training. No single POCUS application stood out as strongly preferred by physicians in this survey.
View details for DOI 10.1111/1742-6723.12476
View details for PubMedID 26449621
Fever in the returning traveler.
Emergency medicine clinics of North America
2013; 31 (4): 927–44
Fever in ill travelers returning home from developing nations is common. Most travelers present with undifferentiated febrile syndromes. Regional proportionate morbidity rates and patients' travel histories are essential in narrowing the differential diagnosis. Most patients in whom a diagnosis is confirmed have malaria, dengue fever, enteric fever, or rickettsial disease. Empiric treatment based on the clinical presentation is required in many cases, because acquisition of confirmatory laboratory data is often delayed. The focus of this article is travel-related illness that falls within the spectrum of the acute febrile syndrome.
View details for DOI 10.1016/j.emc.2013.07.001
View details for PubMedID 24176472
Intramedullary spinal neurocysticercosis presenting as brown-sequard syndrome.
The western journal of emergency medicine
2012; 13 (5): 434–36
Cysticercosis is an emerging disease in the United States. Neurocysticercosis may rarely cause disease within the spinal cord, but the occurrence of such pathology can produce debilitating symptoms for patients. We present the second report in the literature of intramedullary spinal neurocysticercosis presenting with a Brown-Sequard syndrome.
View details for DOI 10.5811/westjem.2011.10.6909
View details for PubMedID 23316264
View details for PubMedCentralID PMC3541882