Brian Travis Rice

All Publications

• Where the road ends: emergency care sensitive conditions drive excess mortality in medevac-dependent rural Alaska. Emergency medicine journal : EMJ Rice, B., Britton, C., Rasmus, S., Hernandez-Boussard, T. 2024

  View details for DOI 10.1136/emermed-2024-214444

  View details for PubMedID 39658217

• AI-based approach for transcribing and classifying unstructured emergency call data: A methodological proposal. PLOS digital health Costa, D. B., Pinna, F. C., Joiner, A. P., Rice, B., Souza, J. V., Gabella, J. L., Andrade, L., Vissoci, J. R., Neto, J. C. 2023; 2 (12): e0000406

  Abstract

  Emergency care-sensitive conditions (ECSCs) require rapid identification and treatment and are responsible for over half of all deaths worldwide. Prehospital emergency care (PEC) can provide rapid treatment and access to definitive care for many ECSCs and can reduce mortality in several different settings. The objective of this study is to propose a method for using artificial intelligence (AI) and machine learning (ML) to transcribe audio, extract, and classify unstructured emergency call data in the Servico de Atendimento Movel de Urgencia (SAMU) system in southern Brazil. The study used all "1-9-2" calls received in 2019 by the SAMU Novo Norte Emergency Regulation Center (ERC) call center in Maringa, in the Brazilian state of Parana. The calls were processed through a pipeline using machine learning algorithms, including Automatic Speech Recognition (ASR) models for transcription of audio calls in Portuguese, and a Natural Language Understanding (NLU) classification model. The pipeline was trained and validated using a dataset of labeled calls, which were manually classified by medical students using LabelStudio. The results showed that the AI model was able to accurately transcribe the audio with a Word Error Rate of 42.12% using Wav2Vec 2.0 for ASR transcription of audio calls in Portuguese. Additionally, the NLU classification model had an accuracy of 73.9% in classifying the calls into different categories in a validation subset. The study found that using AI to categorize emergency calls in low- and middle-income countries is largely unexplored, and the applicability of conventional open-source ML models trained on English language datasets is unclear for non-English speaking countries. The study concludes that AI can be used to transcribe audio and extract and classify unstructured emergency call data in an emergency system in southern Brazil as an initial step towards developing a decision-making support tool.

  View details for DOI 10.1371/journal.pdig.0000406

  View details for PubMedID 38055710

• Mortality after emergency unit fluid bolus in febrile Ugandan children. PloS one Rice, B., Hawkins, J., Nakato, S., Kamara, N. 2023; 18 (8): e0290790

  Abstract

  Pediatric fluid resuscitation in sub-Saharan Africa has traditionally occurred in inpatients. The landmark Fluid Expansion as Supportive Therapy (FEAST) trial showed fluid boluses for febrile children in this inpatient setting increased mortality. As emergency care expands in sub-Saharan Africa, fluid resuscitation increasingly occurs in the emergency unit. The objective of this study was to determine the mortality impact of emergency unit fluid resuscitation on febrile pediatric patients in Uganda.This retrospective cohort study used data from 2012-2019 from a single emergency unit in rural Western Uganda to compare three-day mortality for febrile patients that did and did not receive fluids in the emergency unit. Propensity score matching was used to create matched cohorts. Crude and multivariable logistic regression analysis (using both complete case analysis and multiple imputation) were performed on matched and unmatched cohorts. Sensitivity analysis was done separately for patients meeting FEAST inclusion and exclusion criteria.The analysis included 3087 febrile patients aged 2 months to 12 years with 1,526 patients receiving fluids and 1,561 not receiving fluids. The matched cohorts each had 1,180 patients. Overall mortality was 4.0%. No significant mortality benefit or harm was shown in the crude unmatched (Odds Ratio [95% Confidence Interval] = 0.88 [0.61-1.26] or crude matched (1.00 [0.66-1.50]) cohorts. Adjusted cohort analysis (including both complete case analysis and multiple imputation) and sensitivity analysis of patients meeting FEAST inclusion and exclusion criteria all also failed to show benefit or harm. Post-hoc power calculations showed the study was powered to detect the absolute harm seen in FEAST but not the relative risk increase.This study's primary finding is that fluid resuscitation in the emergency unit did not significantly increase or decrease three-day mortality for febrile children in Uganda. Universally aggressive or fluid-sparing emergency unit protocols are unlikely to be best practices, and choices about fluid resuscitation should be individualized.

  View details for DOI 10.1371/journal.pone.0290790

  View details for PubMedID 37651354

• Emergency care of sepsis in sub-Saharan Africa: Mortality and non-physician clinician management of sepsis in rural Uganda from 2010 to 2019. PloS one Rice, B., Calo, S., Kamugisha, J. B., Kamara, N., Chamberlain, S., Global Emergency Care Investigator Study Group 2022; 17 (5): e0264517

  Abstract

  INTRODUCTION: Little data exists from sub-Saharan Africa describing incidence and outcomes of sepsis in emergency units and uncertainty exists surrounding optimal management of sepsis in low-income settings. There exists limited data regarding quality care metrics for non-physician clinicians trained in emergency care. The objective of this study was to describe changes in septic patients over time and evaluate associations between sepsis care and mortality.METHODS: Secondary analysis of a prospective cohort of all consecutive patients seen from 2010-2019 in a rural Ugandan emergency unit staffed by non-physician clinicians was performed using an electronic database based on paper charts. Sepsis was defined as suspected infection with a quick Sequential Organ Failure Assessment score (qSOFA)≥1. Multi-variable logistic regression was used to analyze three-day mortality.RESULTS: Overall, 48,653 patient visits from 2010-2019 yielded 17,490 encounters for patients age≥18 who had suspected infection, including 10,437 with sepsis. The annual proportion of patients with sepsis decreased from 45.0%% to 21.3% and the proportion with malarial sepsis decreased from 17.7% to 2.1% during the study period. Rates of septic patients receiving quality care ("both fluids and anti-infectives") increased over time (21.2% in 2012 to 32.0% in 2019, p<0.001), but mortality did not significantly improve (4.5% in 2012 to 6.4% in 2019, p = 0.50). The increasing quality of non-physician clinician care was not associated with reduced mortality, and treatment with "both fluids and antibiotics" was associated with increased mortality (RR = 1.55, 95%CI 1.10-2.00).CONCLUSION: The largest study of sepsis management and outcomes ever published in both Uganda and sub-Saharan Africa showed sepsis and malarial sepsis decreasing from 2010 to 2019. The increasing quality of non-physician clinician care did not significantly reduce mortality and treatment with "both fluids and antibiotics" increased mortality. With causal associations between antibiotics and mortality deemed implausible, associations between sepsis mortality and interventions likely represent confounding by indication. Defining optimal sepsis care regionally will likely require randomized controlled trials.

  View details for DOI 10.1371/journal.pone.0264517

  View details for PubMedID 35544466

• 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 Roosli, E., Rice, B., Hernandez-Boussard, T. 2020

  Abstract

  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 Rice, B. n., Wood, J. n., Britton, C. n., Strehlow, M. n., Goodwin, S. n. 2020; 39 (5): 393–98

  Abstract

  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 Rice, B. n., Leanza, J. n., Mowafi, H. n., Thadeus Kamara, N. n., Mulogo, E. M., Bisanzo, M. n., Nikam, K. n., Kizza, H. n., Newberry, J. A., Strehlow, M. n., Kohn, M. n. 2020

  Abstract

  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

• Clinical emergency care quality indicators in Africa: a scoping review and data summary. BMJ open Pickering, A. E., Malherbe, P., Nambuba, J., Bills, C. B., Hynes, E. C., Rice, B. 2023; 13 (5): e069494

  Abstract

  OBJECTIVES: Emergency care services are rapidly expanding in Africa; however, development must focus on quality. The African Federation of Emergency Medicine consensus conference (AFEM-CC)-based quality indicators were published in 2018. This study sought to increase knowledge of quality through identifying all publications from Africa containing data relevant to the AFEM-CC process clinical and outcome quality indicators.DESIGN: We conducted searches for general quality of emergency care in Africa and for each of 28 AFEM-CC process clinical and five outcome clinical quality indicators individually in the medical and grey literature.DATA SOURCES: PubMed (1964-2 January 2022), Embase (1947-2 January 2022) and CINAHL (1982-3 January 2022) and various forms of grey literature were queried.ELIGIBILITY CRITERIA: Studies published in English, addressing the African emergency care population as a whole or large subsegment of this population (eg, trauma, paediatrics), and matching AFEM-CC process quality indicator parameters exactly were included. Studies with similar, but not exact match, data were collected separately as 'AFEM-CC quality indicators near match'.DATA EXTRACTION AND SYNTHESIS: Document screening was done in duplicate by two authors, using Covidence, and conflicts were adjudicated by a third. Simple descriptive statistics were calculated.RESULTS: One thousand three hundred and fourteen documents were reviewed, 314 in full text. 41 studies met a priori criteria and were included, yielding 59 unique quality indicator data points. Documentation and assessment quality indicators accounted for 64% of data points identified, clinical care for 25% and outcomes for 10%. An additional 53 'AFEM-CC quality indicators near match' publications were identified (38 new publications and 15 previously identified studies that contained additional 'near match' data), yielding 87 data points.CONCLUSIONS: Data relevant to African emergency care facility-based quality indicators are highly limited. Future publications on emergency care in Africa should be aware of, and conform with, AFEM-CC quality indicators to strengthen understanding of quality.

  View details for DOI 10.1136/bmjopen-2022-069494

  View details for PubMedID 37130667

• Improved First Dose Conversion of Supraventricular Tachycardia Using Weight-Based Adenosine. Cureus Deck, C. M., Dang, B., Ashenburg, N., Rice, B. 2023; 15 (3): e35995

  Abstract

  Introduction Paroxysmal supraventricular tachycardia (PSVT) is an often-recurring tachyarrhythmia that frequently results in emergency department visits and is commonly treated using intravenous adenosine. Given the anecdotal variable success of adenosine, the question arose of which patient factors may affect its success. This retrospective cohort analysis seeks to test the hypothesis that adult patients who receive adenosine at doses of ≥0.1mg/kg will have greater rates of successful conversion upon receipt of the first dose of adenosine. Methods This retrospective cohort analysis examines the charts from patients with known paroxysmal supraventricular tachycardia from November 1, 2015, through March 31, 2020, who were treated with intravenous adenosine. The primary outcome was the first-dose success of adenosine when stratified by patient weight (greater than 0.1mg/kg or less than 0.1mg/kg). Baseline characteristics and adverse effects were also collected. Results Seventy-six patients were included in the analysis. Patients who received adenosine at doses greater than or equal to 0.1mg/kg were more likely to convert to sinus rhythm than those who received doses less than 0.1mg/kg (p=0.006). No difference in adverse effects was noted between the groups (p=0.75). Conclusion This retrospective cohort analysis found that patients who received adenosine at doses greater than or equal to 0.1mg/kg for the treatment of PSVT were more likely to convert to sinus rhythm than those who received lower doses, with no difference in adverse effects. This hypothesis-generating finding provides the basis for a subsequent randomized, controlled trial to investigate the effectiveness and safety of weight-based adenosine.

  View details for DOI 10.7759/cureus.35995

  View details for PubMedID 37041920

  View details for PubMedCentralID PMC10083097

• Natural language processing to classify electrocardiograms in patients with syncope: A preliminary study. Health science reports Quinn, J., Kim, D., Rice, B. T., Hao, W. D. 2022; 5 (6): e904

  View details for DOI 10.1002/hsr2.904

  View details for PubMedID 36324425

  View details for PubMedCentralID PMC9621468

• Arsenic Toxicity From the Ingestion of Terracotta Pottery. The Journal of emergency medicine Chiu, C., Fisk, C. A., Rice, B. T., Garcia, E. C. 2022

  Abstract

  BACKGROUND: Symptomatic arsenic toxicity has not been associated with terracotta pottery despite thousands of years of use in food storage and preparation. We describe a case of chronic arsenic toxicity from undiagnosed pica involving the ingestion of terracotta pots.CASE REPORT: A 49-year-old woman with a history of anemia and abnormal uterine bleeding presented to the Emergency Department complaining of lower extremity pain. She was also noted to have chronic lower extremity paresthesia, constipation, and fatigue. She admitted to ingesting glazed and unglazed terracotta pots for the past 5 years. This unusual craving was thought to be a manifestation of pica in the setting of chronic anemia. The patient was found to have an elevated urinary arsenic concentration of 116 g/24 h. An abdominal radiograph showed opacifications throughout her bowel, and she received whole bowel irrigation. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Pica is a common behavior in certain populations. Practicing clinicians should be familiar with the complications of pica, including chronic arsenic toxicity and its associated array of nonspecific symptoms.

  View details for DOI 10.1016/j.jemermed.2022.06.004

  View details for PubMedID 36229316

• Emergency Medical Services (EMS) Utilization in Zimbabwe: Retrospective Review of Harare Ambulance System Reports. Annals of global health Muchatuta, M., Mudariki, S., Matheson, L., Rice, B., Chidzonga, M., Walker, R., Strehlow, M., Newberry, J. 2022; 88 (1): 70

  Abstract

  Emergency medical services (EMS) are a critical but often overlooked component of essential public health care delivery in low- and middle-income countries (LMICs). Few countries in Africa have established EMS and there is scant literature to provide guidance for EMS growth.This study aimed to characterize EMS utilization in Harare, Zimbabwe in order to guide system strengthening efforts.We performed a retrospective chart review of patient care reports (PCR) generated by the City of Harare ambulance system for patients transported and/or treated in the prehospital setting over a 14-month period (February 2018 - March 2019).A total of 875 PCRs were reviewed representing approximately 8% of the calls to EMS. The majority of patients were age 15 to 49 (76%) and 61% were female patients. In general, trauma and pregnancy were the most common chief complaints, comprising 56% of all transports. More than half (51%) of transports were for inter-facility transfers (IFTs) and 52% of these IFTs were maternity-related. Transports for trauma were mostly for male patients (63%), and 75% of the trauma patients were age 15-49. EMTs assessed and documented pulse and blood pressure for 72% of patients.In this study, EMS cared primarily for obstetric and trauma emergencies, which mirrors the leading causes of premature death in LMICs. The predominance of requests for maternity-related IFTs emphasizes the role for EMS as an integral player in peripartum maternal health care. Targeted public health efforts and chief complaint-specific training for EMTs in these priority areas could improve quality of care and patient outcomes. Moreover, a focus on strengthening prehospital data collection and research is critical to advancing EMS development in Zimbabwe and the region through quality improvement and epidemiologic surveillance.

  View details for DOI 10.5334/aogh.3649

  View details for PubMedID 36043040

  View details for PubMedCentralID PMC9374015

• Emergency medicine physician supervision and mortality among patients receiving care from non-physician clinicians in a task-sharing model of emergency care in rural Uganda: a retrospective analysis of a single-centre training programme. BMJ open Rice, B., Pickering, A., Laurence, C., Kizito, P. M., Leff, R., Kisingiri, S. J., Ndyamwijuka, C., Nakato, S., Adriko, L. F., Bisanzo, M. 2022; 12 (6): e059859

  Abstract

  To assess the association between emergency medicine physician supervision and 3-day mortality for patients receiving care from non-physician clinicians in a task-sharing model of emergency care in rural Uganda.Retrospective cohort analysis with multivariable logistic regression.Single rural Ugandan emergency unit.All patients presenting for care from 2009 to 2019.Three cohorts of patients receiving care from non-physician clinicians had three different levels of physician supervision: 'Direct Supervision' (2009-2010) emergency medicine physicians directly supervised all care; 'Indirect Supervision' (2010-2015) emergency medicine physicians were consulted as needed; 'Independent Care' (2015-2019) no emergency medicine physician supervision.Three-day mortality.38 033 ED visits met inclusion criteria. Overall mortality decreased significantly across supervision cohorts ('Direct' 3.8%, 'Indirect' 3.3%, 'Independent' 2.6%, p<0.001), but so too did the rates of patients who presented with ≥3 abnormal vitals ('Direct' 32%, 'Indirect' 19%, 'Independent' 13%, p<0.001). After controlling for vital sign abnormalities, 'Direct' and 'Indirect' supervision were both significantly associated with reduced OR for mortality ('Direct': 0.57 (0.37 to 0.90), 'Indirect': 0.71 (0.55 to 0.92)) when compared with 'Independent Care'. Sensitivity analysis showed that this mortality benefit was significant for the minority of patients (17.2%) with ≥3 abnormal vitals ('Direct': 0.44 (0.22 to 0.85), 'Indirect': 0.60 (0.41 to 0.88)), but not for the majority (82.8%) with two or fewer abnormal vitals ('Direct': 0.81 (0.44 to 1.49), 'Indirect': 0.82 (0.58 to 1.16)).Emergency medicine physician supervision of emergency care non-physician clinicians is independently associated with reduced overall mortality. This benefit appears restricted to the highest risk patients based on abnormal vitals. With over 80% of patients having equivalent mortality outcomes with independent non-physician clinician emergency care, a synergistic model providing variable levels of emergency medicine physician supervision or care based on patient acuity could safely address staffing shortages.

  View details for DOI 10.1136/bmjopen-2021-059859

  View details for PubMedID 35768107

• Essential Emergency and Critical Care: a consensus among global clinical experts BMJ GLOBAL HEALTH Schell, C., Khalid, K., Wharton-Smith, A., Oliwa, J., Sawe, H. R., Roy, N., Sanga, A., Marshall, J. C., Rylance, J., Hanson, C., Kayambankadzanja, R. K., Wallis, L. A., Jirwe, M., Baker, T., EECC Collaborators 2021; 6 (9)

  Abstract

  Globally, critical illness results in millions of deaths every year. Although many of these deaths are potentially preventable, the basic, life-saving care of critically ill patients are often overlooked in health systems. Essential Emergency and Critical Care (EECC) has been devised as the care that should be provided to all critically ill patients in all hospitals in the world. EECC includes the effective care of low cost and low complexity for the identification and treatment of critically ill patients across all medical specialties. This study aimed to specify the content of EECC and additionally, given the surge of critical illness in the ongoing pandemic, the essential diagnosis-specific care for critically ill patients with COVID-19.In a Delphi process, consensus (>90% agreement) was sought from a diverse panel of global clinical experts. The panel iteratively rated proposed treatments and actions based on previous guidelines and the WHO/ICRC's Basic Emergency Care. The output from the Delphi was adapted iteratively with specialist reviewers into a coherent and feasible package of clinical processes plus a list of hospital readiness requirements.The 269 experts in the Delphi panel had clinical experience in different acute medical specialties from 59 countries and from all resource settings. The agreed EECC package contains 40 clinical processes and 67 requirements, plus additions specific for COVID-19.The study has specified the content of care that should be provided to all critically ill patients. Implementing EECC could be an effective strategy for policy makers to reduce preventable deaths worldwide.

  View details for DOI 10.1136/bmjgh-2021-006585

  View details for Web of Science ID 000698427900001

  View details for PubMedID 34548380

  View details for PubMedCentralID PMC8458367

• Household economic impact of road traffic injury versus routine emergencies in a low-income country. Injury Mowafi, H., Rice, B., Nambaziira, R., Nirere, G., Wongoda, R., James, M., Group, G. W., Bisanzo, M., Post, L. 2021

  Abstract

  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 Bitter, C. C., Dornbush, C., Khoyilar, C., Hull, C., Elsner-Boldt, H., Mainali, S., Rice, B., Visser, E. 2021; 13 (6): e15427

  Abstract

  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

• Negative pressure patient isolation device to enable non-invasive respiratory support for COVID-19 and beyond. BMJ innovations August, A., Bolhouse, M., Rice, B., Wall, J. K. 2021; 7 (2): 292-296

  View details for DOI 10.1136/bmjinnov-2020-000551

  View details for PubMedID 37556246

  View details for PubMedCentralID PMC7736963

• Developing Emergency Triage Systems in Cambodia. Cureus Khan, A., Rice, B., Acker, P. 2020; 12 (10): e11233

  Abstract

  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 Ku, B. C., Zonfrillo, M. R., Periyanayagam, U., Bisanzo, M., Rice, B., Maling, S., Cohn, K. A. 2020

  Abstract

  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

• Derivation and validation of a chief complaint shortlist for unscheduled acute and emergency care in Uganda BMJ OPEN Rice, B., Bisanzo, M., Maling, S., Joseph, R., Mowafi, H., Global Emergency Care Investigator, Study Grp 2018; 8 (6): e020188

  Abstract

  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

• 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 BMJ OPEN Bitter, C., Rice, B., Periyanayagam, U., Dreifuss, B., Hammerstedt, H., Nelson, S. W., Bisanzo, M., Maling, S., Chamberlain, S. 2018; 8 (2): e019024

  Abstract

  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 Pelis, M., Miller, S., Terry, B., Bisanzo, M., Maling, S., Modi, P., Periyanayagam, U., Rice, B. 2018; 7 (4): 239-245
• Pediatric Poisonings in a Rural Ugandan Emergency Department. Pediatric emergency care Boyle, K. L., Periyanayagam, U., Babu, K. M., Rice, B. T., Bisanzo, M. 2017

  Abstract

  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.) Wightman, R. S., Hoffman, R. S., Howland, M. A., Rice, B., Biary, R., Lugassy, D. 2016; 54 (5): 454-8

  Abstract

  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

• Mortality in Children Under Five Receiving Nonphysician Clinician Emergency Care in Uganda. Pediatrics Rice, B., Periyanayagam, U., Chamberlain, S., Dreifuss, B., Hammerstedt, H., Nelson, S., Maling, S., Bisanzo, M. 2016; 137 (3): e20153201

  Abstract

  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

• Survey of point of care ultrasound usage in emergency medicine by Vietnamese physicians. Emergency medicine Australasia : EMA Rice, B. T., Vu, H., Tran, L. D., Vo, Q. X., Mowafi, H. 2015; 27 (6): 580-583

  Abstract

  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 Kotlyar, S., Rice, B. T. 2013; 31 (4): 927-44

  Abstract

  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 Rice, B., Perera, P. 2012; 13 (5): 434-6

  Abstract

  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