Dr. Matthew Strehlow is a Professor of Emergency Medicine at Stanford University. He received his doctorate from the University of Washington and completed his emergency medicine residency in the Stanford Kaiser Emergency Medicine Residency Program. Following the completion of the Global EM Fellowship at Stanford, he remained as faculty with a focus on global health. Currently, Dr. Strehlow serves as the Executive Vice Chair of the Department of Emergency Medicine and the Director of Stanford Emergency Medicine International (SEMI). In addition to these roles, Dr. Strehlow is a Fellow at the Center for Innovation in Global Health and an advisor to Stanford’s Digital Medic initiative. He collaborates across the campus to help advance Stanford University’s mission of improving health and education worldwide. Dr. Strehlow is a recognized educator both nationally and internationally, focusing on emergency care in developing countries, cardiology, and human and planetary health.

Dr. Strehlow’s research spans several critical areas in emergency medicine. He is deeply involved in advancing precision emergency medicine and co-chaired the 2023 Society for Academic Emergency Medicine Consensus Conference. His research interests also include the development and delivery of emergency care in Low- and Middle-Income Countries (LMICs), particularly focusing on the epidemiology of emergencies and referral systems. He has significantly contributed to inservice training of healthcare workers, partnering with OpenWHO to research effective approaches to information dissemination during health emergencies. His work also extends to maternal, child, newborn, and adolescent health, as well as exploring how EMS can serve as critical access points for victims of intimate partner violence.

Clinical Focus

  • Emergency Medicine

Academic Appointments

Administrative Appointments

  • Vice Chair of Strategy, Emergency Medicine (2016 - Present)
  • Director, Stanford Emergency Medicine International Fellowship (2015 - Present)
  • Director,, Stanford Emergency Medicine International (2015 - Present)
  • Fellow, Centers for Innovation in Global Health (2015 - Present)

Honors & Awards

  • Top 100 Courses for 2020 for "COVID-19: Training for Healthcare Workers", Coursera (2021)
  • Keynote Speaker, Society for Ambulance Paramedics, India (2020)
  • Contributions to Emergency Medicine Education, Global Emergency Medicine Academy, SAEM (2019)
  • Lifetime Achievement Award, Global Emergency Medicine Academy, SAEM (2019)
  • Extraordinary Contributions Award, Society for Ambulance Paramedics (2018)
  • Chair Development Program, Society for Academic Emergency Medicine (2017-2018)
  • Top Global Health Articles of 2016, Global Emergency Medicine, Society of Academic Emergency Medicine (2017)
  • Stanford Medicine Leadership Academy, Stanford School of Medicine (2016-2017)
  • Special Contributions to Emergency Medicine, King Saud University (2014)
  • Fellow, American College of Emergency Physicians (2011)
  • Lantern Award for exceptional and innovative performance by ED staff, National Emergency Nurses Association (2011)
  • Team Award International for development of of 1st prehospital EMS service Nepal, California Emergency Medical Services (2011)
  • Fellow, Stanford University Faculty Fellows Program (2010)
  • Malinda S. Mitchell Award for Service Quality, Stanford Hospital (2009)
  • Annual Resident Bedside Teaching Award, Stanford-Kaiser Emergency Medicine Residency (2007)
  • Annual Resident Bedside Teaching Award, Stanford-Kaiser Emergency Medicine Residency (2006)
  • Rising Star: Speaker Award, American College of Emergency Physicians (2006)
  • Outstanding Contributions in International Medical Education, Egyptian Ministry of Health (2005)

Boards, Advisory Committees, Professional Organizations

  • Chair, Annual Meeting, American College of Emergency Physicians (2020 - Present)
  • Board Member, Global Emergency Medicine Academy, SAEM (2018 - 2021)
  • Member, American College of Emergency Physicians Education Committee (2016 - Present)
  • Fellow, American College of Emergency Physicians (2010 - Present)
  • Fellow, American Academy of Emergency Medicine (2005 - Present)
  • Member, Society of Academic Emergency Medicine (2005 - Present)

Professional Education

  • Fellow, Stanford Emergency Medicine, Global Emergency Medicine (2006)
  • Internship: Stanford University Medical Center (2003) CA
  • Residency: Stanford University Medical Center (2005) CA
  • Board Certification: American Board of Emergency Medicine, Emergency Medicine (2006)
  • Medical Education: University of Washington School of Medicine (2002) WA
  • MD, University of Washington, Medicine (2002)
  • Bachelor of Science, Pacific Lutheran University, Biochemistry (1996)

Community and International Work

  • Online Medical Research, India


    EMS Research in India

    Partnering Organization(s)

    GVK Emergency Management and Research Institute

    Populations Served




    Ongoing Project


    Opportunities for Student Involvement


  • Pre-Service Education in Emergency Medicine, Cambodia


    Designing curriculum and training faculty in EM

    Partnering Organization(s)

    University Health Sciences

    Populations Served

    Students and Faculty



    Ongoing Project


    Opportunities for Student Involvement


  • Myanmar Emergency Medicine Training Program, Myanmar


    Emergency Care

    Partnering Organization(s)

    Golden Zaneka

    Populations Served




    Ongoing Project


    Opportunities for Student Involvement


  • Quality Health Services, Cambodia


    Maternal Child Health

    Partnering Organization(s)


    Populations Served




    Ongoing Project


    Opportunities for Student Involvement


  • Post-Graduate Program in Emergency Care, India


    EMS System Development

    Partnering Organization(s)




    Ongoing Project


    Opportunities for Student Involvement


Current Research and Scholarly Interests

Inservice Training of Healthcare Workers
Strengthening healthcare delivery requires a better understanding of how to train healthcare workers. While billions of dollars are spent annually on training healthcare workers across the globe little evidence exists on how to effectively reach and train healthcare workers in lower resource settings. We have utilized a number of different approaches depending on learner, resources, and local environment. With each of these we have advanced our understanding of how learners with different training backgrounds, cultures, and resources learn. I work in partnership with Stanford Digital Medic and the WHO to develop guidance and direct a research collaboration on learning during health emergencies.

Emergency Care Epidemiology
My research interests center around the development and delivery of emergency care in Low- and Middle-Income-Countries (LMICs), specifically the epidemiology of emergencies and referral systems in these nations. By improving our understanding of how medical and traumatic emergencies vary in these unique and diverse settings as compared to High-Income-Countries, nations and development agencies will be better equipped to advocate for emergency care and optimize the allocation of scarce healthcare resources. The foundation of my research efforts has been as part of Stanford Emergency Medicine International’s (SEMI’s) work developing, launching, and researching India’s prehospital care system from the ground up. In 2007, our Indian partner, GVK EMRI, introduced EMS service in a single city. A decade later, this service is now the largest provider of prehospital and interfacility emergency care in the world, serving over 750 million people. Our pivotal role in this expansive venture has been many-fold. Additionally, I have researched the causes and presentations of emergencies in Cambodia, Nepal, Pakistan, and Uganda.

Maternal Child Newborn and Adolescent Health
In HICs only a few mothers and newborns access care through EMS however, in a number of LMICs fledging EMS systems are becoming critical access mechanisms for pregnant women and infants. In India for example, nearly 40% of the millions of calls to EMS annually are for pregnant women and newborns. Further, we have very little understanding of how the different levels of the public hospital system integrate to form a continuous network of care and the role the private healthcare system plays. We received 7 years of USAID funding focused on maternal child health to strengthen the emergency care and referral system in Cambodia. Our program helped launch national EMS guidelines, standardized triage and EMS protocols, an integrated hospital referral network for pregnant women across one half the country, and stabilization and referral training for healthcare workers at over 650 health centers and hospitals. We continue to study how the maternal and newborn referral network impacts outcomes.

Intimate Partner Violence and Gender Equity
Working at the intersection of emergency care and maternal child health in LMICs has led me to explore how EMS can serve as critical access points for victims of intimate partner violence (IPV). As we researched the epidemiology of medical emergencies across South and Southeast Asia, we identified that victims were presenting with a variety of life-threatening conditions such as poisonings, severe burns, and traumatic injuries. Our work prompted the State Government of Gujarat in India to launch a novel women’s helpline operated by our EMS partner and supported by the police, Home Department, and local NGOs. Our team has analyzed the reach and impact of this helpline working to refine its operations. In conjunction with my partners, I aim to advance our understanding of help seeking behavior for victims of IPV.

Clinical Trials

  • Protocolized Care for Early Septic Shock Not Recruiting

    The ProCESS study is large, 5-year, multicenter study of alternative resuscitation strategies for septic shock. The study hypothesizes that there are "golden hours" in the initial management of septic shock where prompt, rigorous, standardized care can improve clinical outcomes.

    Stanford is currently not accepting patients for this trial. For more information, please contact Valerie Ojha, (650) 498 - 6210.

    View full details

  • Reevaluation Of Systemic Early Neuromuscular Blockade Not Recruiting

    This study evaluates whether giving a neuromuscular blocker (skeletal muscle relaxant) to a patient with acute respiratory distress syndrome will improve survival. Half of the patients will receive a neuromuscular blocker for two days and in the other half the use of neuromuscular blockers will be discouraged.

    Stanford is currently not accepting patients for this trial. For more information, please contact SPECTRUM, (650) 723 - 6576.

    View full details


  • GVK EMRI Prehospital Emergency Care



  • Myanmar Post Graduate Education Program in Emergency Medicine, Stanford University (9/1/2015 - Present)



  • USAID Quality Health Services Cambodia, Stanford University (2/17/2014 - Present)



  • COVID-19: Training for Healthcare Workers, Stanford EM International, Digital Medic, Coursera, YouTube (6/1/2020)

    COVID-19 is rapidly spreading across the globe and all providers must be prepared to recognize, stabilize and treat patients with novel coronavirus infection. Following completion of this short course physicians, nurses, and other healthcare professionals will have a unified, evidenced-based approach to saving the lives of patients with COVID-19, including those who are critically ill.

    Learning modules are broken into short videos presented in a richly illustrated and compelling manner. The course is self paced and providers can schedule their learning to fit with their schedules. Topics include symptoms and signs in patients with COVID-19, early stabilization of patients, preventing the need for intubation, and ventilator management. The best evidence and guidelines are summarized while accompanying handouts provide written learning points and links to online resources. Simple infographics are available for providers to utilize within their care facilities to educate and promote optimal care across their entire institution.



2023-24 Courses

All Publications

  • Precision emergency medicine. Academic emergency medicine : official journal of the Society for Academic Emergency Medicine Strehlow, M., Alvarez, A., Blomkalns, A. L., Caretta-Wyer, H., Gharahbaghian, L., Imler, D., Khan, A., Lee, M., Lobo, V., Newberry, J. A., Riberia, R., Sebok-Syer, S., Shen, S., Gisondi, M. A. 2024


    Precision health is a burgeoning scientific discipline that aims to incorporate individual variability in biological, behavioral, and social factors to develop personalized health solutions. To date, emergency medicine has not deeply engaged in the precision health movement. However, rapid advances in health technology, data science, and medical informatics offer new opportunities for emergency medicine to realize the promises of precision health.In this article, we conceptualize precision emergency medicine as an emerging paradigm and identify key drivers of its implementation into current and future clinical practice. We acknowledge important obstacles to the specialty-wide adoption of precision emergency medicine and offer solutions that conceive a successful path forward.Precision emergency medicine is defined as the use of information and technology to deliver acute care effectively, efficiently, and authentically to individual patients and their communities. Key drivers and opportunities include leveraging human data, capitalizing on technology and digital tools, providing deliberate access to care, advancing population health, and reimagining provider education and roles. Overcoming challenges in equity, privacy, and cost is essential for success. We close with a call to action to proactively incorporate precision health into the clinical practice of emergency medicine, the training of future emergency physicians, and the research agenda of the specialty.Precision emergency medicine leverages new technology and data-driven artificial intelligence to advance diagnostic testing, individualize patient care plans and therapeutics, and strategically refine the convergence of the health system and the community.

    View details for DOI 10.1111/acem.14962

    View details for PubMedID 38940478

  • Health Care Workers' Motivations for Enrolling in Massive Open Online Courses During a Public Health Emergency: Descriptive Analysis. JMIR medical education Jones, J., Johnston, J. S., Ndiaye, N. Y., Tokar, A., Singla, S., Skinner, N. A., Strehlow, M., Utunen, H. 2024; 10: e51915


    Background: Massive open online courses (MOOCs) are increasingly used to educate health care workers during public health emergencies. In early 2020, the World Health Organization (WHO) developed a series of MOOCs for COVID-19, introducing the disease and strategies to control its outbreak, with 6 courses specifically targeting health care workers as learners. In 2020, Stanford University also launched a MOOC designed to deliver accurate and timely education on COVID-19, equipping health care workers across the globe to provide health care safely and effectively to patients with the novel infectious disease. Although the use of MOOCs for just-in-time training has expanded during the pandemic, evidence is limited regarding the factors motivating health care workers to enroll in and complete courses, particularly in low-income countries (LICs) and lower-middle-income countries (LMICs).Objective: This study seeks to gain insights on the characteristics and motivations of learners turning to MOOCs for just-in-time training, to provide evidence that can better inform MOOC design to meet the needs of health care workers. We examine data from learners in 1 Stanford University and 6 WHO COVID-19 courses to identify (1) the characteristics of health care workers completing the courses and (2) the factors motivating them to enroll.Methods: We analyze (1) course registration data of the 49,098 health care workers who completed the 7 focal courses and (2) survey responses from 6272 course completers. The survey asked respondents to rank their motivations for enrollment and share feedback about their learning experience. We use descriptive statistics to compare responses by health care profession and by World Bank country income classification.Results: Health care workers completed the focal courses from all regions of the world, with nearly one-third (14,159/49,098, 28.84%) practicing in LICs and LMICs. Survey data revealed a diverse range of professional roles among the learners, including physicians (2171/6272, 34.61%); nurses (1599/6272, 25.49%); and other health care professionals such as allied health professionals, community health workers, paramedics, and pharmacists (2502/6272, 39.89%). Across all health care professions, the primary motivation to enroll was for personal learning to improve clinical practice. Continuing education credit was also an important motivator, particularly for nonphysicians and learners in LICs and LMICs. Course cost (3423/6272, 54.58%) and certification (4238/6272, 67.57%) were also important to a majority of learners.Conclusions: Our results demonstrate that a diverse range of health care professionals accessed MOOCs for just-in-time training during a public health emergency. Although all health care workers were motivated to improve their clinical practice, different factors were influential across professions and locations. These factors should be considered in MOOC design to meet the needs of health care workers, particularly those in lower-resource settings where alternative avenues for training may be limited.

    View details for DOI 10.2196/51915

    View details for PubMedID 38904474

  • 2023 Society for Academic Emergency Medicine Consensus Conference on Precision Emergency Medicine: Development of a policy-relevant, patient-centered research agenda. Academic emergency medicine : official journal of the Society for Academic Emergency Medicine Strehlow, M., Gisondi, M. A., Caretta-Weyer, H., Ankel, F., Brackett, A., Brar, P., Chan, T. M., Garabedian, A., Gunn, B., Isaacs, E., von Isenburg, M., Jarman, A., Kuehl, D., Limkakeng, A. T., Lydston, M., McGregor, A., Pierce, A., Raven, M. C., Salhi, R. A., Stave, C., Tan, J., Taylor, R. A., Wong, H. N., Yiadom, M. Y., Zachrison, K. S., Vogel, J. 2024


    Precision medicine is data-driven health care tailored to individual patients based on their unique attributes, including biologic profiles, disease expressions, local environments, and socioeconomic conditions. Emergency medicine (EM) has been peripheral to the precision medicine discourse, lacking both a unified definition of precision medicine and a clear research agenda. We convened a national consensus conference to build a shared mental model and develop a research agenda for precision EM.We held a conference to (1) define precision EM, (2) develop an evidence-based research agenda, and (3) identify educational gaps for current and future EM clinicians. Nine preconference workgroups (biomedical ethics, data science, health professions education, health care delivery and access, informatics, omics, population health, sex and gender, and technology and digital tools), comprising 84 individuals, garnered expert opinion, reviewed relevant literature, engaged with patients, and developed key research questions. During the conference, each workgroup shared how they defined precision EM within their domain, presented relevant conceptual frameworks, and engaged a broad set of stakeholders to refine precision EM research questions using a multistage consensus-building process.A total of 217 individuals participated in this initiative, of whom 115 were conference-day attendees. Consensus-building activities yielded a definition of precision EM and key research questions that comprised a new 10-year precision EM research agenda. The consensus process revealed three themes: (1) preeminence of data, (2) interconnectedness of research questions across domains, and (3) promises and pitfalls of advances in health technology and data science/artificial intelligence. The Health Professions Education Workgroup identified educational gaps in precision EM and discussed a training roadmap for the specialty.A research agenda for precision EM, developed with extensive stakeholder input, recognizes the potential and challenges of precision EM. Comprehensive clinician training in this field is essential to advance EM in this domain.

    View details for DOI 10.1111/acem.14932

    View details for PubMedID 38779704

  • Assessing the Efficacy of a Novel Massive Open Online Soft Skills Course for South Asian Healthcare Professionals. Journal of medical systems Mahadevan, A., Rivera, R., Najhawan, M., Saadat, S., Strehlow, M., Rao, G. V., Youm, J. 2024; 48 (1): 32


    In healthcare professions, soft skills contribute to critical thinking, decision-making, and patient-centered care. While important to the delivery of high-quality medical care, soft skills are often underemphasized during healthcare training in low-and-middle-income countries. Despite South Asia's large population, the efficacy and viability of a digital soft skills curriculum for South Asian healthcare practitioners has not been studied to date. We hypothesized that a web-based, multilingual, soft skills course could aid the understanding and application of soft skills to improve healthcare practitioner knowledge, confidence, attitudes, and intent-to-change clinical practice.In September 2019 a needs assessment observing soft skills practices was conducted in several Indian states. We developed a communication-focused soft skills curriculum that comprised seven 10-minute video lectures, recorded in spoken English and Hindi. Participants consisted of any practicing healthcare professionals and trainees in select South Asian countries age 18 and over. Participant knowledge, confidence, attitudes, and intent-to-change clinical practice were evaluated using pre- and post-course tests and surveys. Statistical analyses were performed using STATA and SPSS.From July 26, 2021 to September 26, 2021, 5750 registered and attempted the course, 2628 unique participants completed the pre-test, and 1566 unique participants completed the post-test. Participants demonstrated small but statistically significant gains in confidence (𝑝<0.001), attitudes toward course topics relevance (𝑝<0.001), and intent-to-change clinical practice (𝑝<0.001). There was no statistically significant gain in knowledge. A digital soft-skills massive open online course for healthcare practitioners in South Asia could serve as a viable approach to improve the quality of soft skills training in low-to-middle income countries.

    View details for DOI 10.1007/s10916-024-02051-5

    View details for PubMedID 38509201

    View details for PubMedCentralID 7489969

  • Utility of Prehospital Call-Center Ambulance-Dispatch Data for COVID-19 Cluster-Surveillance: A Retrospective Analysis. Academic emergency medicine : official journal of the Society for Academic Emergency Medicine Janagama, S. R., Strehlow, M. C., Rao, R. G., Kohn, M. A., Newberry, J. A. 2022


    INTRODUCTION: Cluster surveillance, identification, and containment are primary outbreak management techniques, however, adapting these for low- and middle-income countries is an ongoing challenge. We aimed to evaluate the utility of prehospital call-center ambulance dispatch (CCAD) data for surveillance by examining the correlation between influenza-like illness-related (ILI) dispatch calls and COVID-19 cases.METHODS: We performed a retrospective analysis of state-level CCAD and COVID-19 data recorded between January 1 and April 30, 2020, in Telangana, India. The primary outcome was a time-series correlation between ILI calls in CCAD and COVID-19 case counts. Secondarily, we looked for a year-to-year correlation of ILI calls in the same period over 2018, 2019, and 2020.RESULTS: On average, ILI calls comprised 12.9% (95%CI: 11.7%-14.1%) of total daily calls in 2020, compared to 7.8% (95%CI: 7.6-8.0%) in 2018, and 7.7% (95%CI: 7.5-7.7%) in 2019. ILI call counts from 2018, 2019, and 2020 aligned closely until March 19, when 2020 ILI calls increased, representing 16% of all calls by March 23 and 27.5% by April 7. In contrast to the significant correlation observed between 2020 and previous years' January-February calls (2020&2019: DW=0.749, p<0.001; 2020&2018: DW=1.232, p<0.001), no correlation was observed for March-April calls (2020&19: DW=2.012, p=0.476; 2020&2018: DW=1.820, p=0.208). In March-April 2020, the daily reported COVID-19 cases by time series significantly correlated with the ILI calls (DW=0.977, p<0.001). The ILI calls on a specific day significantly correlated with the COVID-19 cases reported seven days prior and up to 14days after (cross-correlation >0.251, the 95% upper confidence limit).CONCLUSIONS: The statistically significant time-series correlation between ILI calls and COVID-19 cases suggests prehospital CCAD can be part of early warning systems aiding outbreak cluster surveillance, identification, and containment.

    View details for DOI 10.1111/acem.14612

    View details for PubMedID 36271649

  • Paediatric use of emergency medical services in India: A retrospective cohort study of one million children. Journal of global health Newberry, J. A., Rao, S. J., Matheson, L., Anurudran, A. S., Acker, P., Darmstadt, G. L., Mahadevan, S. V., Rao, G. V., Strehlow, M. 2022; 12: 04080


    Millions of children in low- and middle-income countries (LMICs) experience illness or trauma amenable to emergency medical interventions, but local resources are not sufficient to treat them. Emergency medical services (EMS), including ambulance transport, bridge the gap between local services and higher-level hospital care, and data collected by EMS could be used to elucidate patterns of paediatric health care need and use. Here we conducted a retrospective observational study of patterns of paediatric use of EMS services by children who used EMS in India, a leader in maternal and child EMS development, to inform public health needs and system interventions to improve EMS effectiveness.We analysed three years (2013-2015) of data from patients <18 years of age from a large prehospital EMS system in India, including 1 101 970 prehospital care records across 11 states and a union territory.Overall, 38.3% of calls were for girls (n = 422 370), 40.5% were for adolescents (n = 445 753), 65.9% were from rural areas (n = 726 154), and most families were from a socially disadvantaged caste or lower economic status (n = 834 973, 75.8%). The most common chief complaints were fever (n = 247 594, 22.5%), trauma (n = 231 533, 21.0%), and respiratory difficulty (n = 161 120, 14.6%). However, transport patterns, including patient sex and age and type of destination hospital, varied by state, as did data collection.EMS in India widely transports children with symptoms of the leading causes of child mortality and provides access to higher levels of care for geographically and socioeconomically vulnerable populations, including care for critically ill neonates, mental health and burn care for girls, and trauma care for adolescents. EMS in India is an important mechanism for overcoming transport and cost as barriers to access, and for reducing the urban-rural gap found across causes of child mortality. Further standardisation of data collection will provide the foundation for assessing disparities and identifying targets for quality improvement of paediatric care.

    View details for DOI 10.7189/jogh.12.04080

    View details for PubMedID 36243953

  • A Deadly Infodemic: Social Media and the Power of COVID-19 Misinformation. Journal of medical Internet research Gisondi, M. A., Barber, R., Faust, J. S., Raja, A., Strehlow, M., Westafer, L., Gottlieb, M. 1800


    UNSTRUCTURED: COVID-19 is currently the third leading cause of death in the United States and unvaccinated people continue to die in high numbers. Vaccine hesitancy and vaccine refusal are fueled by COVID-19 misinformation and disinformation on social media platforms. This online 'COVID-19 Infodemic' has deadly consequences. In this editorial, the authors examine the roles that social media companies play in The COVID-19 Infodemic and their obligations to end it. They describe how 'fake news' about the virus developed on social media and acknowledge the initially muted response by the scientific community to counteract misinformation. The authors then challenge social media companies to better mitigate The COVID-19 Infodemic, describing legal and ethical imperatives to do so. They close with recommendations for better partnerships with community influencers and implementation scientists, and they provide next steps for all readers to consider. This guest editorial accompanies the JMIR special theme issue, "Social Media, Ethics, and COVID-19 Misinformation."

    View details for DOI 10.2196/35552

    View details for PubMedID 35007204

  • "So Why Should I Call Them?": Survivor Support Service Characteristics as Drivers of Help-Seeking in India. Journal of interpersonal violence Newberry, J. A., Kaur, J. n., Gurrapu, S. n., Behl, R. n., Darmstadt, G. L., Halpern-Felsher, B. n., Rao, G. V., Mahadevan, S. V., Strehlow, M. C. 2020: 886260520970306


    Women in South Asia face the highest lifetime prevalence of intimate partner violence in the world, which is just one form of violence against women (VAW). In India, few women seek help after experiencing violence, particularly from formal resources, such as physicians or the police. While many studies have investigated the impact of survivor characteristics and patterns of violence on help-seeking behaviors, there is scant research on support service characteristics and their impact on help-seeking. The introduction of a novel crisis helpline in Gujarat, India provided an opportunity to better understand how successful help-seeking can be driven by the perceived and experienced characteristics of the helpline. We conducted in-depth interviews with helpline users to identify factors and pathways that promoted or discouraged help-seeking in general, help-seeking from a formal source, and help-seeking from this particular helpline. We analyzed 32 interviews of women who used the helpline. Participants were from eight districts across the state, representing a diverse range of sociodemographic backgrounds. After conducting a thematic analysis, we found that action-oriented service, timeliness, and women-focused staff influenced (positively and negatively) participants' feelings of safety, empowerment, and trust in the helpline, which ultimately impacted their decision to seek help from the helpline or even to seek help at all. This study illuminates how service characteristics, in and of themselves, can influence the likelihood that survivors will seek help, emphasizing the need for survivors to have a voice in the growth and refinement of VAW support services. Consequently, these areas must be a focus of future research and initiatives to improve help-seeking by VAW survivors.

    View details for DOI 10.1177/0886260520970306

    View details for PubMedID 33150827

  • 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


    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

  • Acute respiratory illness among a prospective cohort of pediatric patients using emergency medical services in India: Demographic and prehospital clinical predictors of mortality. PloS one Bills, C. B., Newberry, J. A., Rao, G. V., Matheson, L. W., Rao, S. n., Mahadevan, S. V., Strehlow, M. C. 2020; 15 (4): e0230911


    In India, acute respiratory illnesses, including pneumonia, are the leading cause of early childhood death. Emergency medical services are a critical component of India's public health infrastructure; however, literature on the prehospital care of pediatric patients in low- and middle-income countries is minimal. The aim of this study is to describe the demographic and clinical characteristics associated with 30-day mortality among a cohort of pediatric patients transported via ambulance in India with an acute respiratory complaint.Pediatric patients less than 18 years of age using ambulance services in one of seven states in India, with a chief complaint of "shortness of breath", or a "fever" with associated "difficulty breathing" or "cough", were enrolled prospectively. Patients were excluded if evidence of choking, trauma or fire-related injury, patient was absent on ambulance arrival, or refused transport. Primary exposures included demographic, environmental, and clinical indicators, including hypoxemia and respiratory distress. The primary outcome was 7 and 30-day mortality. Multivariable logistic regression, stratified by transport type, was constructed to estimate associations between demographic and clinical predictors of mortality.A total of 1443 patients were enrolled during the study period: 981 (68.5%) were transported from the field, and 452 (31.5%) were interfacility transports. Thirty-day response was 83.4% (N = 1222). The median age of all patients was 2 years (IQR: 0.17-10); 93.9% (N = 1347) of patients lived on family incomes below the poverty level; and 54.1% (N = 706) were male. Cumulative mortality at 2, 7, and 30-days was 5.2%, 7.1%, and 7.7%, respectively; with 94 deaths by 30 days. Thirty-day mortality was greatest among those 0-28 days (N = 38,17%); under-5 mortality was 9.8%. In multivariable modeling prehospital oxygen saturation <95% (OR: 3.18 CI: 1.77-5.71) and respiratory distress (OR: 3.72 CI: 2.17-6.36) were the strongest predictors of mortality at 30 days.This is the first study to detail prehospital predictors of death among pediatric patients with shortness of breath in LMICs. The risk of death is particularly high among neonates and those with documented mild hypoxemia, or respiratory distress. Early recognition of critically ill children, targeted prehospital interventions, and diversion to higher level of care may help to mitigate the mortality burden in this population.

    View details for DOI 10.1371/journal.pone.0230911

    View details for PubMedID 32240227

  • Workplace violence among prehospital care providers in India: a cross-sectional study. BMJ open Lindquist, B., Koval, K., Mahadevan, A., Gennosa, C., Leggio, W., Niknam, K., Rao, G. V., Newberry, J. A., Strehlow, M. 2019; 9 (11): e033404


    OBJECTIVES: The purpose of this study was twofold: (1) establish the prevalence of safety threats and workplace violence (WPV) experienced by emergency medical technicians (EMTs) in a low/middle-income country with a new prehospital care system, India and (2) understand which EMTs are at particularly high risk for these experiences.SETTING: EMTs from four Indian states (Gujarat, Karnataka, Tamil Nadu and Telangana) were eligible to participate during the study period from July through November 2017.METHODS: Cross-sectional survey study.PARTICIPANTS: 386 practicing EMTs from four Indian states.RESULTS: The overall prevalence of any WPV was 67.9% (95%CI 63.0% to 72.5%). The prevalence of physical assault was 58% (95% CI 52.5% to 63.4%) and verbal assault was 59.8% (95% CI 54.5% to 65%). Of physical assault victims, 21.7% were injured and 30.2% sought medical attention after the incident. Further, 57.3% (n=216) of respondents reported they were 'somewhat worried' and 28.4% (n=107) reported they were 'very worried' about their safety at work.CONCLUSION: WPV and safety fears were found to be common among EMTs in India. Focused initiatives to counter WPV in countries developing prehospital care systems are necessary to build a healthy and sustainable prehospital healthcare workforce.

    View details for DOI 10.1136/bmjopen-2019-033404

    View details for PubMedID 31772106

  • Reducing early infant mortality in India: results of a prospective cohort of pregnant women using emergency medical services BMJ OPEN Bills, C. B., Newberry, J. A., Darmstadt, G., Pirrotta, E. A., Rao, G., Mahadevan, S. V., Strehlow, M. C. 2018; 8 (4): e019937


    To describe the demographic characteristics and clinical outcomes of neonates born within 7 days of public ambulance transport to hospitals across five states in India.Prospective observational study.Five Indian states using a centralised emergency medical services (EMS) agency that transported 3.1 million pregnant women in 2014.Over 6 weeks in 2014, this study followed a convenience sample of 1431 neonates born to women using a public-private ambulance service for a 'pregnancy-related' problem. Initial calls were deemed 'pregnancy related' if categorised by EMS dispatchers as 'pregnancy', 'childbirth', 'miscarriage' or 'labour pains'. Interfacility transfers, patients absent on ambulance arrival, refusal of care and neonates born to women beyond 7 days of using the service were excluded.death at 2, 7 and 42 days after delivery.Among 1684 women, 1411 gave birth to 1431 newborns within 7 days of initial ambulance transport. Median maternal age at delivery was 23 years (IQR 21-25). Most mothers were from rural/tribal areas (92.5%) and lower social (79.9%) and economic status (69.9%). Follow-up rates at 2, 7 and 42 days were 99.8%, 99.3% and 94.1%, respectively. Cumulative mortality rates at 2, 7 and 42 days follow-up were 43, 53 and 62 per 1000 births, respectively. The perinatal mortality rate (PMR) was 53 per 1000. Preterm birth (OR 2.89, 95% CI 1.67 to 5.00), twin deliveries (OR 2.80, 95% CI 1.10 to 7.15) and caesarean section (OR 2.21, 95% CI 1.15 to 4.23) were the strongest predictors of mortality.The perinatal mortality rate associated with this cohort of patients with high-acuity conditions of pregnancy was nearly two times the most recent rate for India as a whole (28 per 1000 births). EMS data have the potential to provide more robust estimates of PMR, reduce inequities in timely access to healthcare and increase facility-based care through service of marginalised populations.

    View details for PubMedID 29654018

  • The scale, scope, coverage, and capability of childbirth care LANCET Campbell, O. M., Calvert, C., Testa, A., Strehlow, M., Benova, L., Keyes, E., Donnay, F., Macleod, D., Gabrysch, S., Rong, L., Ronsmans, C., Sadruddin, S., Koblinsky, M., Bailey, P. 2016; 388 (10056): 2193-2208


    All women should have access to high quality maternity services-but what do we know about the health care available to and used by women? With a focus on low-income and middle-income countries, we present data that policy makers and planners can use to evaluate whether maternal health services are functioning to meet needs of women nationally, and potentially subnationally. We describe configurations of intrapartum care systems, and focus in particular on where, and with whom, deliveries take place. The necessity of ascertaining actual facility capability and providers' skills is highlighted, as is the paucity of information on maternity waiting homes and transport as mechanisms to link women to care. Furthermore, we stress the importance of assessment of routine provision of care (not just emergency care), and contextualise this importance within geographic circumstances (eg, in sparsely-populated regions vs dense urban areas). Although no single model-of-care fits all contexts, we discuss implications of the models we observe, and consider changes that might improve services and accelerate response to future challenges. Areas that need attention include minimisation of overintervention while responding to the changing disease burden. Conceptualisation, systematic measurement, and effective tackling of coverage and configuration challenges to implement high quality, respectful maternal health-care services are key to ensure that every woman can give birth without risk to her life, or that of her baby.

    View details for DOI 10.1016/S0140-6736(16)31528-8

    View details for Web of Science ID 000386332400039

    View details for PubMedID 27642023

  • Using an emergency response infrastructure to help women who experience gender-based violence in Gujarat India BULLETIN OF THE WORLD HEALTH ORGANIZATION Newberry, J. A., Mahadevan, S., Gohil, N., Jamshed, R., Prajapati, J., Rao, G. V., Strehlow, M. 2016; 94 (5): 388-392


    Many women who experience gender-based violence may never seek any formal help because they do not feel safe or confident that they will receive help if they try.A public-private-academic partnership in Gujarat, India, established a toll-free telephone helpline - called 181 Abhayam - for women experiencing gender-based violence. The partnership used existing emergency response service infrastructure to link women to phone counselling, nongovernmental organizations (NGOs) and government programmes.In India, the lifetime prevalence of gender-based violence is 37.2%, but less than 1% of women will ever seek help beyond their family or friends. Before implementation of the helpline, there were no toll-free helplines or centralized coordinating systems for government programmes, NGOs and emergency response services.In February 2014, the helpline was launched across Gujarat. In the first 10 months, the helpline assisted 9767 individuals, of which 8654 identified themselves as women. Of all calls, 79% (7694) required an intervention by phone or in person on the day they called and 43% (4190) of calls were by or for women experiencing violence.Despite previous data that showed women experiencing gender-based violence rarely sought help from formal sources, women in Gujarat did use the helpline for concerns across the spectrum of gender-based violence. However, for evaluating the impact of the helpline, the operational definitions of concern categories need to be further clarified. The initial triage system for incoming calls was advantageous for handling high call volumes, but may have contributed to dropped calls.

    View details for DOI 10.2471/BLT.15.163741

    View details for PubMedID 27147769

  • Stanford Emergency Medicine Partnership Program: a novel approach to streamlining the evaluation and implementation of emerging health technologies through academic-industry partnerships BMJ INNOVATIONS Dayton, J., Yiadom, M. B., Shen, S., Strehlow, M. C., Rose, C., Bunney, G., Ribeira, R. 2024
  • Observational study of organisational responses of 17 US hospitals over the first year of the COVID-19 pandemic. BMJ open Choo, E. K., Strehlow, M., Del Rios, M., Oral, E., Pobee, R., Nugent, A., Lim, S., Hext, C., Newhall, S., Ko, D., Chari, S. V., Wilson, A., Baugh, J. J., Callaway, D., Delgado, M. K., Glick, Z., Graulty, C. J., Hall, N., Jemal, A., Kc, M., Mahadevan, A., Mehta, M., Meltzer, A. C., Pozhidayeva, D., Resnick-Ault, D., Schulz, C., Shen, S., Southerland, L., Du Pont, D., McCarthy, D. M. 2023; 13 (5): e067986


    The COVID-19 pandemic has required significant modifications of hospital care. The objective of this study was to examine the operational approaches taken by US hospitals over time in response to the COVID-19 pandemic.This was a prospective observational study of 17 geographically diverse US hospitals from February 2020 to February 2021.We identified 42 potential pandemic-related strategies and obtained week-to-week data about their use. We calculated descriptive statistics for use of each strategy and plotted percent uptake and weeks used. We assessed the relationship between strategy use and hospital type, geographic region and phase of the pandemic using generalised estimating equations (GEEs), adjusting for weekly county case counts.We found heterogeneity in strategy uptake over time, some of which was associated with geographic region and phase of pandemic. We identified a body of strategies that were both commonly used and sustained over time, for example, limiting staff in COVID-19 rooms and increasing telehealth capacity, as well as those that were rarely used and/or not sustained, for example, increasing hospital bed capacity.Hospital strategies during the COVID-19 pandemic varied in resource intensity, uptake and duration of use. Such information may be valuable to health systems during the ongoing pandemic and future ones.

    View details for DOI 10.1136/bmjopen-2022-067986

    View details for PubMedID 37156578

  • 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


    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

  • Is AVPU comparable to GCS in critical prehospital decisions? - A cross-sectional study. The American journal of emergency medicine Janagama, S. R., Newberry, J. A., Kohn, M. A., Rao, G. V., Strehlow, M. C., Mahadevan, S. V. 2022; 59: 106-110


    BACKGROUND: Advanced Trauma Life Support field triage utilizes the Glasgow Coma Scale (GCS) to assess the level of consciousness. However, prehospital care providers in low- and middle-income countries (LMICs) often use the Alert, Verbal, Pain, and Unresponsive (AVPU) scale to assess the level of consciousness. This study aimed to determine whether prehospital AVPU categorization correlates with mortality rates in trauma victims, similarly to GCS.METHODS: In this cross-sectional study conducted between November 2015 and January 2016, we enrolled a convenience sample of prehospital trauma-related field activations. The primary outcome measure was the probability of death within 48 h for each category of AVPU.RESULTS: In a convenience sample of 4514 activations, 1606 (35.6%) met exclusion criteria, four did not have AVPU, and four did not have GCS, leaving 2900 (64.2%) trauma activations with both AVPU and GCS available for analysis. Forty-eight-hour follow-up data were available for 2184 (75.3%) activations out of these 2900. The 48-h mortality rates for each category of AVPU were 1.1% (Alert), 4.3% (Verbal), 17.9% (Pain), 53.2% (Unresponsive); and, for each GCS-based injury severity category, they were 0.9% (Mild, GCS 13-15), 8.1% (Moderate, GCS 9-12), 43.5% (Severe, GCS ≤ 8). Overall, there was a statistically significant difference in GCS for each category of AVPU (p < 0.001) except between patients responding to verbal commands and those responding to pain (p = 0.18). The discriminative ability of AVPU (AUC 79.7% (95% CI 73.4-86.1)) and GCS (AUC 81.5% (95% CI 74.8-88.2)) for death within 48-h following hospital drop-off were comparable.CONCLUSION: EMT assessments of AVPU and GCS relate to each other, and AVPU predicts mortality at 48 h. Future studies using AVPU to assess the level of consciousness in prehospital trauma protocols may simplify their global application without impacting the overall quality of care.

    View details for DOI 10.1016/j.ajem.2022.06.042

    View details for PubMedID 35820277

  • A qualitative study of an undergraduate online emergency medicine education program at a teaching Hospital in Kampala, Uganda. BMC medical education Ayoola, A. S., Acker, P. C., Kalanzi, J., Strehlow, M. C., Becker, J. U., Newberry, J. A. 2022; 22 (1): 84


    BACKGROUND: Globally, half of all years of life lost is due to emergency medical conditions, with low- and middle-income countries (LMICs) facing a disproportionate burden of these conditions. There is an urgent need to train the future physicians in LMICs in the identification and stabilization of patients with emergency medical conditions. Little research focuses on the development of effective emergency medicine (EM) medical education resources in LMICs and the perspectives of the students themselves. One emerging tool is the use of electronic learning (e-learning) and blended learning courses. We aimed to understand Uganda medical trainees' use of learning materials, perception of current e-learning resources, and perceived needs regarding EM skills acquisition during participation in an app-based EM course.METHODS: We conducted semi-structured interviews and focus groups of medical students and EM residents. Participants were recruited using convenience sampling. All sessions were audio recorded and transcribed verbatim. The final codebook was approved by three separate investigators, transcripts were coded after reaching consensus by all members of the coding team, and coded data were thematically analyzed.RESULTS: Twenty-six medical trainees were included in the study. Analysis of the transcripts revealed three major themes: [1] medical trainees want education in EM and actively seek EM training opportunities; [2] although the e-learning course supplements knowledge acquisition, medical students are most interested in hands-on EM-related training experiences; and [3] medical students want increased time with local physician educators that blended courses provide.CONCLUSIONS: Our findings show that while students lack access to structured EM education, they actively seek EM knowledge and practice experiences through self-identified, unstructured learning opportunities. Students value high quality, easily accessible EM education resources and employ e-learning resources to bridge gaps in their learning opportunities. However, students desire that these resources be complemented by in-person educational sessions and executed in collaboration with local EM experts who are able to contextualize materials, offer mentorship, and help students develop their interest in EM to continue the growth of the EM specialty.

    View details for DOI 10.1186/s12909-022-03157-5

    View details for PubMedID 35135519

  • Teaching From Afar: Development of a Telemedicine Curriculum for Healthcare Workers in Global Settings. Cureus Lowe, J. T., Patel, S. R., Hao, W. D., Butt, A., Strehlow, M., Lindquist, B. 2021; 13 (12): e20123


    The Stanford Department of Emergency Medicine joined forces with Digital Medic to create educational materials to teach global healthcare providers how to evaluate patients via telemedicine in the setting of COVID-19. Users then asked for additional education on best practices surrounding the use of telemedicine as a communication medium. Here, we describe our experience in the creation of this additional module and provide some basic feedback received from end-users. We scripted, filmed, and edited a video module for this application over the course of 14 weeks. It was subsequently deployed as part of the larger COVID-19 educational program. To date, the course has had over 28,000 participants. Each was asked to take a pre- and post-test to assess the knowledge of telemedicine best practices before and after the video module; 19,412 elected to take the pre-test and 19,364 took the post-test with overall scores of 84% and 95%, respectively. Anecdotal feedback has been positive. Telemedicine systems have proliferated rapidly around the world, but best practices for physician-to-patient interactions have not been similarly disseminated. We conclude that video modules can be used to fill this educational need quickly and economically.

    View details for DOI 10.7759/cureus.20123

    View details for PubMedID 35003963

    View details for PubMedCentralID PMC8721442

  • Development and implementation of a novel Web-based gaming application to enhance emergency medical technician knowledge in low- and middle-income countries. AEM education and training Lindquist, B., Gaiha, S. M., Vasudevan, A., Dooher, S., Leggio, W., Mulkerin, W., Zozula, A., Strehlow, M., Sebok-Syer, S. S., Mahadevan, S. V. 2021; 5 (3): e10602


    Background: Increasing access to high-quality emergency and prehospital care is an important priority in low- and middle-income countries (LMICs). However, ensuring that emergency medical technicians (EMTs) maintain their clinical knowledge and proficiency with procedural skills is challenging, as continuing education requirements are still being introduced, and clinical instructional efforts need strengthening. We describe the development and implementation of an innovative asynchronous learning tool for EMTs in the form of a Web-based trivia game.Methods: Over 500 case-based multiple-choice questions (covering 10 essential prehospital content areas) were created by experts in prehospital education, piloted with EMT educators from LMICs, and delivered to EMTs through a Web-based quiz game platform over a 12-week period. We enrolled 252 participants from nine countries.Results: Thirty-two participants (12.7%) completed the entire 12-week game. Participants who completed the game were administered a survey with a 100% response rate. Ninety-three percent of participants used their mobile phone to access the game. Overall, participants reported that the interface was easy to use (93.8% agreed or strongly agreed), the game improved their knowledge (100% agreed or strongly agreed), and they felt better prepared for their jobs (100% agreed or strongly agreed). The primary motivators for participation were improving patient care (37.5%) and being recognized on the game's leaderboard (31.3%). All participants reported that they would engage in the game again (43.8% agreed and 56.3% strongly agreed) and would recommend the game to their colleagues (34.4% agreed and 65.6% strongly agreed).Conclusions: In conclusion, a quiz game targeting EMT learners from LMICs was viewed as accessible and effective by participants. Future efforts should focus on increasing retention and trialing languages in addition to English.

    View details for DOI 10.1002/aet2.10602

    View details for PubMedID 34124530

  • SARS-CoV-2 IgG Seropositivity and Acute Asymptomatic Infection Rate Among Firefighter First Responders in an Early Outbreak County in California. Prehospital emergency care : official journal of the National Association of EMS Physicians and the National Association of State EMS Directors Newberry, J. A., Gautreau, M., Staats, K., Carrillo, E., Mulkerin, W., Yang, S., Kohn, M. A., Matheson, L., Boyd, S. D., Pinsky, B. A., Blomkalns, A. L., Strehlow, M. C., D'Souza, P. A. 2021: 1–10


    Objective: Firefighter first responders and other emergency medical services (EMS) personnel have been among the highest risk healthcare workers for illness during the SARS-CoV-2 pandemic. We sought to determine the rate of seropositivity for SARS-CoV-2 IgG antibodies and of acute asymptomatic infection among firefighter first responders in a single county with early exposure in the pandemic.Methods: We conducted a cross-sectional study of clinically active firefighters cross-trained as paramedics or EMTs in the fire departments of Santa Clara County, California. Firefighters without current symptoms were tested between June and August 2020. Our primary outcomes were rates of SARS-CoV-2 IgG antibody seropositivity and SARS-CoV-2 RT-PCR swab positivity for acute infection. We report cumulative incidence, participant characteristics with frequencies and proportions, and proportion positive and associated relative risk (with 95% confidence intervals).Results: We enrolled 983 out of 1339 eligible participants (response rate: 73.4%). Twenty-five participants (2.54%, 95% CI 1.65-3.73) tested positive for IgG antibodies and 9 (0.92%, 95% CI 0.42-1.73) tested positive for SARS-CoV-2 by RT-PCR. Our cumulative incidence, inclusive of self-reported prior positive PCR tests, was 34 (3.46%, 95% CI 2.41-4.80).Conclusion: In a county with one of the earliest outbreaks in the United States, the seroprevalence among firefighter first responders was lower than that reported by other studies of frontline health care workers, while the cumulative incidence remained higher than that seen in the surrounding community.

    View details for DOI 10.1080/10903127.2021.1912227

    View details for PubMedID 33819128

  • Telemedicine to Decrease Personal Protective Equipment Use and Protect Healthcare Workers. The western journal of emergency medicine Ribeira, R., Shen, S., Callagy, P., Newberry, J., Strehlow, M., Quinn, J. 2020

    View details for DOI 10.5811/westjem.2020.8.47802

    View details for PubMedID 33052823

  • Correction to: Epidemiology of patients presenting to a pediatric emergency department in Karachi, Pakistan. BMC emergency medicine Ijaz, N., Strehlow, M., Wang, N. E., Pirrotta, E., Tariq, A., Mahmood, N., Mahadevan, S. 2020; 20 (1): 66


    An amendment to this paper has been published and can be accessed via the original article.

    View details for DOI 10.1186/s12873-020-00364-5

    View details for PubMedID 32859173

  • Experiences of Workplace Violence Among Healthcare Providers in Myanmar: A Cross-sectional Survey Study. Cureus Lindquist, B., Feltes, M., Niknam, K., Koval, K. W., Ohn, H., Newberry, J., Strehlow, M., Walker, R. 2020; 12 (4): e7549


    Background Healthcare providers face enormous threats to personal safety from workplace violence (WPV). Prior investigations estimate a highly varied prevalence of WPV in the United States and around the world, including both verbal and physical assault. Little is known about WPV in Myanmar. Only a single prior study has evaluated WPV experiences among physicians in Myanmar, reporting an unusually low prevalence of verbal (8.7%) and physical (1.0%) assault. Given this much lower prevalence compared with similar studies in other low- and middle-income countries (LMICs), we embarked on a study to identify the prevalence of WPV in a separate cohort of healthcare providers in Myanmar. Methods This was a cross-sectional analysis of WPV prevalence among healthcare providers who attended a national emergency medicine conference in Myanmar in November 2018. The survey instrument was adapted from a validated survey from the Joint Program on Workplace Violence in the Healthcare Sector (International Labour Office, International Council of Nurses, World Health Organization, and Public Services International), which had been used in other global settings. Results Sixty-three participants completed the survey questionnaire, including 35 women (55.6%) and 26 men (41.3%). Among them, 25 (39.7%) were primary care providers. Overall, the combined prevalence of WPV in the previous 12 months was found to be 47.6% (n = 30; 95% CI: 34.9-60.6%). The prevalence of verbal assault was 47.6% (n = 30; 95% CI: 34.9-60.6%), and that of physical assault was 4.8% (n = 3; 95% CI: 1.0-13.3%). Twenty-four participants (42.4%) reported that they were encouraged to report violence in the workplace, and five (8.1%) reported they had received training on how to manage WPV. Respondents who were 30-34 years in age and those working in private facilities were significantly less likely to report WPV on univariate analysis. Conclusion Although our cohort comprised a limited sample of a select group of providers, we found a dramatically higher prevalence of WPV experiences among healthcare providers attending an emergency medicine conference in Myanmar when compared with a prior investigation. Very few participants had received training on WPV, and less than half reported a work culture where WPV reporting is encouraged. To combat healthcare provider shortages, more investigation is required into WPV to understand its impact and identify amelioration strategies.

    View details for DOI 10.7759/cureus.7549

    View details for PubMedID 32382453

    View details for PubMedCentralID PMC7202584

  • Fostering a Diverse Pool of Global Health Academic Leaders Through Mentorship and Career Path Planning. AEM education and training Newberry, J. A., Patel, S., Kayden, S., O'Laughlin, K. N., Cioe-Pena, E., Strehlow, M. C. 2020; 4 (Suppl 1): S98–S105


    Established in 2011, the Global Emergency Medicine Academy (GEMA) aims "to improve the global delivery of emergency care through research, education, and mentorship." Global health remains early in its development as an academic track in emergency medicine, and there are only a small number of global emergency medicine academic faculty in most institutions. Consequently, GEMA focused its efforts at the Society for Academic Emergency Medicine (SAEM) Annual Meeting in 2019 on developing a diverse pool of global health academics and leaders in emergency medicine. Current and previous members of the GEMA Executive Committee convened to appraise and describe how current GEMA efforts situate within existing knowledge in the arenas of professional development and mentorship. The 2019 SAEM Annual Meeting unveiled the Global Emergency Medicine Roadmap, a joint venture between GEMA and the residents and medical students (RAMS) group. The roadmap guides medical students, residents, and fellows in the exploration of global emergency medicine and career development. GEMA's mentorship roundtable complemented this effort by providing a version of speed mentoring across several critical areas: work-life balance, identifying near-peer and long-distance mentoring opportunities, negotiating with your Chair, finding funding, networking, and teaching abroad. Finally, the GEMA-sponsored panel "Empowering Women through Emergency Care Development in LMICs" underscored the potential for empowering women through global emergency medicine development, including policy advocacy, inclusive research approaches, and mentorship and sponsorship. In summary, GEMA is committed to developing a diverse group of future global health leaders to guide the expansion of emergency medicine worldwide. Our work indicates critical future directions in global emergency medicine education and training including building innovative mentoring networks across institutions and countries. Further, we will continue to focus on growing faculty diversity, empowering underrepresented populations through emergency care development, and supporting rising global emergency medicine faculty in their pursuit of advancement and promotion.

    View details for DOI 10.1002/aet2.10403

    View details for PubMedID 32072113

  • Continuing Education for Prehospital Healthcare Providers in India - A Novel Course and Concept. Open access emergency medicine : OAEM Lindquist, B. D., Koval, K. W., Acker, P. C., Bills, C. B., Khan, A. n., Zachariah, S. n., Newberry, J. A., Rao, G. V., Mahadevan, S. V., Strehlow, M. C. 2020; 12: 201–10


    Emergency medical services (EMS) in India face enormous challenges in providing care to a geographically expansive and diverse patient population. Over the last decade, the public-private-partnership GVK EMRI (Emergency Management and Research Institute) has trained over 100,000 emergency medical technicians (EMTs), with greater than 21,000 currently practicing, to address this critical gap in the healthcare workforce. With the rapid development and expansion of EMS, certain aspects of specialty development have lagged behind, including continuing education requirements. To date, there have been no substantial continuing education EMT skills and training efforts. We report lessons learned during development and implementation of a continuing education course (CEC) for EMTs in India.From 2014 to 2017, we employed an iterative process to design and launch a novel CEC focused on five core emergency competency areas (medicine and cardiology, obstetrics, trauma, pediatrics, and leadership and communication). Indian EMT instructors and providers partnered in design and content, and instructors were trained to independently deliver the CEC. Many challenges had to be overcome: scale (>21,000 EMTs), standardization (highly variable skill levels among providers and instructors), culture (educational emphasis on rote memorization rather than practical application), and translation (22 major languages and a few hundred local dialects spoken nationwide).During the assessment and development phases, we identified five key strategies for success: (1) use icon-based video instruction to ensure consistent quality and allow voice-over for easy translation; (2) incorporate workbooks during didactic videos and (3) employ low-cost simulation and case discussions to emphasize active learning; (4) focus on non-technical skills; (5) integrate a formal training-of-trainers prior to delivery of materials.These key strategies can be combined with innovation and flexibility to address unique challenges of language, system resources, and cultural differences when developing impactful continuing educational initiatives in bourgeoning prehospital care systems in low- and middle-income countries.

    View details for DOI 10.2147/OAEM.S249447

    View details for PubMedID 32982494

    View details for PubMedCentralID PMC7505709

  • Critical Communication: A Cross-sectional Study of Signout at the Prehospital and Hospital Interface. Cureus Janagama, S. R., Strehlow, M. n., Gimkala, A. n., Rao, G. V., Matheson, L. n., Mahadevan, S. n., Newberry, J. A. 2020; 12 (2): e7114


    Introduction Miscommunication during patient handoff contributes to an estimated 80% of serious medical errors and, consequently, plays a key role in the estimated five million excess deaths annually from poor quality of care in low- and middle-income countries (LMICs). Objective The objective of this study was to assess signout communication during patient handoffs between prehospital personnel and hospital staff. Methods This is a cross-sectional study, with a convenience sample of 931 interfacility transfers for pregnant women across four states from November 7 to December 13, 2016. A complete signout, as defined for this study, contains all necessary signout elements for patient care exchanged verbally or in written form between an emergency medical technician (EMT) and a physician or nurse. Results Enrollment of 786 cases from 931 interfacility transfers resulted in 1572 opportunities for signout. EMTs and a physician or nurse signed out in 1549 cases (98.5%). Signout contained all elements in 135 cases (8.6%). The mean percentage of signout elements included was 45.2% (95% CI, 43.9-46.6). Physician involvement was correlated with a higher mean percent (63.4% [95% CI, 62-64.8]) compared to nurse involvement (23.6% [95% CI, 22.5-24.8]). With respect to the frequency of signout communication, 63.1% of EMTs reported often or always giving signout, and 60.5% reported often or always giving signout; they reported feeling moderately to very comfortable with signout (73.7%) and 34.1% requested further training. Conclusions Physicians, nurses, and the EMTs conducted signout 99% of the time but often fell short of including all elements required for optimal patient care. Interventions aimed at improving the quality of patient care must include strengthening signout communication.

    View details for DOI 10.7759/cureus.7114

    View details for PubMedID 32140371

    View details for PubMedCentralID PMC7047340

  • First look at emergency medical technician wellness in India: Application of the Maslach Burnout Inventory in an unstudied population. PloS one Koval, K. W., Lindquist, B. n., Gennosa, C. n., Mahadevan, A. n., Niknam, K. n., Patil, S. n., Rao, G. V., Strehlow, M. C., Newberry, J. A. 2020; 15 (3): e0229954


    Professional wellness is critical to developing and maintaining a health care workforce. Previous work has identified burnout as a significant challenge to professional wellness facing emergency medical technicians (EMTs) in many countries worldwide. Our study fills a critical gap by assessing the prevalence of burnout among emergency medical technicians (EMTs) in India.This was a cross-sectional survey of EMTs within the largest prehospital care organization in India. We used the Maslach Burnout Inventory (MBI) to measure wellness. All EMTs presenting for continuing medical education between July-November 2017 from the states of Gujarat, Karnataka, and Telangana were eligible. Trained, independent staff administered anonymous MBI-Medical Personnel Surveys in local languages.Of the 327 EMTs eligible, 314 (96%) consented to participate, and 296 (94%) surveys were scorable. The prevalence of burnout was 28.7%. Compared to EMTs in other countries, Indian EMTs had higher levels of personal accomplishment but also higher levels of emotional exhaustion and moderate levels of depersonalization. In multivariate regression, determinants of burnout included younger age, perceived lack of respect from colleagues and administrators, and a sense of physical risk. EMTs who experienced burnout were four times as likely to plan to quit their jobs within one year.This is the first assessment of burnout in EMTs in India and adds to the limited body of literature among low- and middle-income country (LMIC) prehospital providers worldwide. Burnout was strongly associated with an EMT's intention to quit within a year, with potential implications for employee turnover and healthcare workforce shortages. Burnout should be a key focus of further study and possible intervention to achieve internationally recognized targets, including Sustainable Development Goal 3C and WHO's 2030 Milestone for Human Resources.

    View details for DOI 10.1371/journal.pone.0229954

    View details for PubMedID 32155192

  • 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


    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

  • A profile of traumatic injury in the prehospital setting in India: A prospective observational study across seven states. Injury Newberry, J. A., Bills, C. B., Matheson, L., Zhang, X., Gimkala, A., Ramana Rao, G. V., Janagama, S. R., Mahadevan, S. V., Strehlow, M. C. 2019


    BACKGROUND: Traumatic injury continues to be a leading cause of mortality and morbidity in low-income and middle-income countries (LMIC). The World Health Organization has called for a strengthening of prehospital care in order to improve outcomes from trauma. In this study we sought to profile traumatic injury seen in the prehospital setting in India and identify predictors of mortality in this patient population.METHODS: We conducted a prospective observational study of a convenience sample of patients using a single emergency medical services (EMS) system for traumatic injuries across seven states in India from November 2015 through January 2016. Any patient with a chief complaints indicative of a traumatic injury was eligible for enrollment. Our primary outcome was 30-day mortality.RESULTS: We enrolled 2905 patients. Follow-up rates were 76% at 2 days, 70% at 7 days, and 70% at 30 days. The median age was 36 years (IQR: 25-50) and were predominately male (72%, N=2088), of lower economic status (97%, N=2805 used a government issued ration card) and were from rural or tribal areas (74%, N=2162). Cumulative mortality at 2, 7, and 30 days, was 3%, 4%, and 4% respectively. Predictors of 30-day mortality were prehospital abnormal mental status (OR 7.5 (95% CI: 4-14)), presence of hypoxia or hypotension (OR 4.0 (95% CI: 2.2-7)), on-scene mobility (OR 2.8 (95% CI: 1.3-6)), and multisystem injury inclusive of head injury (OR 2.3 (95% CI: 1.1-5)).CONCLUSIONS: EMS in an LMIC can transport trauma patients from poor and rural areas that traditionally struggle to access timely trauma care to facilities in a timeframe consistent with current international recommendations. Information readily obtained by EMTs predicts 30-day mortality within this population and could be utilized for triaging patients with the potential to reduce morbidity and mortality.

    View details for DOI 10.1016/j.injury.2019.11.020

    View details for PubMedID 31761424

  • Timely access to care for patients with critical burns in India: a prehospital prospective observational study EMERGENCY MEDICINE JOURNAL Newberry, J. A., Bills, C. B., Pirrotta, E. A., Barry, M., Rao, G., Mahadevan, S., Strehlow, M. C. 2019; 36 (3): 176–82
  • Timely access to care for patients with critical burns in India: a prehospital prospective observational study. Emergency medicine journal : EMJ Newberry, J. A., Bills, C. B., Pirrotta, E. A., Barry, M., Ramana Rao, G. V., Mahadevan, S. V., Strehlow, M. C. 2019


    BACKGROUND: Low/middle-income countries carry a disproportionate burden of the morbidity and mortality from thermal burns. Nearly 70% of burn deaths worldwide are from thermal burns in India. Delays to medical care are commonplace and an important predictor of outcomes. We sought to understand the role of emergency medical services (EMS) as part of the healthcare infrastructure for thermal burns in India.METHODS: We conducted a prospective observational study of patients using EMS for thermal burns across five Indian states from May to August 2015. Our primary outcome was mortality at 2, 7 and 30 days. We compared observed mortality with expected mortality using the revised Baux score. We used Chi2 analysis for categorical variables and Wilcoxon two-sample test for continuous variables. ORs and 95% CIs are reported for all modelled predictor variables.RESULTS: We enrolled 439 patients. The 30-day follow-up rate was 85.9% (n=377). The median age was 30 years; 56.7% (n=249) lived in poverty; and 65.6% (n=288) were women. EMS transported 94.3% of patients (n=399) to the hospital within 2hours of their call. Median total body surface area (TBSA) burned was 60% overall, and 80% in non-accidental burns. Sixty-eight per cent of patients had revised Baux scores greater than 80. Overall 30-day mortality was 64.5%, and highest (90.2%) in women with non-accidental burns. Predictors of mortality by multivariate regression were TBSA (OR 7.9), inhalation injury (OR 5.5), intentionality (OR 4.7) and gender (OR 2.2).DISCUSSION: Although EMS rapidly connects critically burned patients to care in India, mortality remains high, with women disproportionally suffering self-inflicted burns. To combat the burn epidemic in India, efforts must focus on rapid medical care and critical care services, and on a burn prevention strategy that includes mental health and gender-based violence support services.

    View details for PubMedID 30635272

  • Epidemiology of patients presenting to a pediatric emergency department in Karachi, Pakistan BMC EMERGENCY MEDICINE Ijaz, N., Strehlow, M., Wang, N., Pirrotta, E., Tariq, A., Mahmood, N., Mahadevan, S. 2018; 18
  • Epidemiology of patients presenting to a pediatric emergency department in Karachi, Pakistan. BMC emergency medicine Ijaz, N., Strehlow, M., Ewen Wang, N., Pirrotta, E., Tariq, A., Mahmood, N., Mahadevan, S. 2018; 18 (1): 22


    BACKGROUND: There is little data describing pediatric emergencies in resource-poor countries, such as Pakistan. We studied the demographics, management, and outcomes of patients presenting to the highest-volume, public, pediatric emergency department (ED) in Karachi, Pakistan.METHODS: In this prospective, observational study, we approached all patients presenting to the 50-bed ED during 28 12-h study periods over four consecutive weeks (July 2013). Participants' chief complaints and medical care were documented. Patients were followed-up at 48-h and 14-days via telephone.RESULTS: Of 3115 participants, 1846 were triaged to the outpatient department and 1269 to the ED. Patients triaged to the ED had a median age of 2.0years (IQR 0.5-4.0); 30% were neonates (<28days). Top chief complaints were fever (45.5%), diarrhea/vomiting (32.3%), respiratory (23.1%), abdominal (7.5%), and otolaryngological problems (5.8%). Temperature, pulse and respiratory rate, and blood glucose were documented for 66, 42, and 1.5% of patients, respectively. Interventions included medications (92%), IV fluids (83%), oxygen (35%), and advanced airway management (5%). Forty-five percent of patients were admitted; 11 % left against medical advice. Outcome data was available at time of ED disposition, 48-h, and 14days for 83, 62, and 54% of patients, respectively. Of participants followed-up, 4.3% died in the ED, 11.5% within 48h, and 19.6% within 14days.CONCLUSIONS: This first epidemiological study at Pakistan's largest pediatric ED reveals dramatically high mortality, particularly among neonates. Future research in developing countries should focus on characterizing reasons for high mortality through pre-ED arrival tracking, ED care quality assessment, and post-ED follow-up.

    View details for PubMedID 30075749

  • Comparing Teaching Methods in Resource-Limited Countries. AEM education and training Mahadevan, S. V., Walker, R., Kalanzi, J., Stone, L. T., Bills, C., Acker, P., Apfeld, J. C., Newberry, J., Becker, J., Mantha, A., Tecklenburg Strehlow, A. N., Strehlow, M. C. 2018; 2 (3): 238

    View details for PubMedID 30051096

  • Comparing Teaching Methods in Resource-Limited Countries AEM EDUCATION AND TRAINING Mahadevan, S. V., Walker, R., Kalanzi, J., Stone, L., Bills, C., Acker, P., Apfeld, J. C., Newberry, J., Becker, J., Mantha, A., Strehlow, A., Strehlow, M. C. 2018; 2 (3): 238

    View details for DOI 10.1002/aet2.10100

    View details for Web of Science ID 000770023600008

  • Characteristics and outcomes of pediatric patients presenting at Cambodian referral hospitals without appointments: an observational study INTERNATIONAL JOURNAL OF EMERGENCY MEDICINE Yore, M. A., Strehlow, M. C., Yan, L. D., Pirrotta, E. A., Woods, J. L., Somontha, K., Sovannra, Y., Auerbach, L., Backer, R., Grundmann, C., Mahadevan, S. V. 2018; 11: 17


    Emergency medicine is a young specialty in many low- and middle-income countries (LMICs). Although many patients seeking emergency or acute care are children, little information is available about the needs and current treatment of this group in LMICs. In this observational study, we sought to describe characteristics, chief complaints, management, and outcomes of children presenting for unscheduled visits to two Cambodian public hospitals.Children enrolled in the study presented without appointment for treatment at one of two Cambodian public referral hospitals during a 4-week period in 2012. Researchers used standardized questionnaires and hospital records to collect demographic and clinical data. Patients were followed up at 48 h and 14 days after initial presentation. Multivariate logistic regression identified factors associated with hospital admission.This study included 867 unscheduled visits. Mean patient age was 5.7 years (standard deviation 4.8 years). Of the 35 different presenting complaints, fever (63%), respiratory problems (25%), and skin complaints (24%) were most common. The majority of patients were admitted (51%), while 1% were transferred to another facility. Seven patients (1%) died within 14 days. Follow-up rates were 83% at 48 h and 75% at 14 days. Predictors of admission included transfer or referral from another health provider, seeking prior care for the presenting problem, low socioeconomic status, onset of symptoms within 24 h of seeking care, abnormal vital signs or temperature, and chief complaint of abdominal pain or fever.While the admission rate in this study was high, mortality was low. More effective identification and management of children who can be treated and released may free up scarce inpatient resources for children who warrant admission.

    View details for PubMedID 29536212

  • Comparison of Online and Classroom-based Formats for Teaching Emergency Medicine to Medical Students in Uganda. AEM education and training Mahadevan, S. V., Walker, R., Kalanzi, J., Stone, L. T., Bills, C., Acker, P., Apfeld, J. C., Newberry, J., Becker, J., Mantha, A., Tecklenburg Strehlow, A. N., Strehlow, M. C. 2018; 2 (1): 5-9


    Severe global shortages in the health care workforce sector have made improving access to essential emergency care challenging. The paucity of trained specialists in low- and middle-income countries translates to large swathes of the population receiving inadequate care. Efforts to expand emergency medicine (EM) education are similarly impeded by a lack of available and appropriate teaching faculty. The development of comprehensive, online medical education courses offers a potentially economical, scalable, and lasting solution for universities experiencing professional shortages.An EM course addressing core concepts and patient management was developed for medical students enrolled at Makerere University College of Health Sciences in Kampala, Uganda. Material was presented to students in two comparable formats: online video modules and traditional classroom-based lectures. Following completion of the course, students were assessed for knowledge gains.Forty-two and 48 students enrolled and completed all testing in the online and classroom courses, respectively. Student knowledge gains were equivalent (classroom 25 ± 8.7% vs. online 23 ± 6.5%, p = 0.18), regardless of the method of course delivery.A summative evaluation of Ugandan medical students demonstrated that online teaching modules are effectively equivalent and offer a viable alternative to traditional classroom-based lectures delivered by on-site, visiting faculty in their efficacy to teach expertise in EM. Web-based curriculum can help alleviate the burden on universities in developing nations struggling with a critical shortage of health care educators while simultaneously satisfying the growing community demand for access to emergency medical care. Future studies assessing the long-term retention of course material could gauge its incorporation into clinical practice.

    View details for DOI 10.1002/aet2.10066

    View details for PubMedID 30051058

    View details for PubMedCentralID PMC6001592

  • Comparison of Live Versus Online Instruction of a Novel Soft Skills Course in Mongolia CUREUS Mahadevan, A., Strehlow, M. C., Dorjsuren, K., Newberry, J. A. 2017; 9 (11): e1900


    Background Soft skills are essential for employee success in the global marketplace; however, many developing countries lack content experts to provide the requisite instruction to an emerging workforce. One possible solution is to use an online, open-access curriculum. To date, no studies on soft skills curricula using an online learning platform have been undertaken in Mongolia. Objective To evaluate the efficacy of an online versus classroom platform to deliver a novel soft skills course in Mongolia. Methods A series of eight lectures along with corresponding surveys and multiple choice question tests were developed and translated into the Mongolian language. Two different delivery modalities, online and traditional classroom lectures, were then compared for knowledge gain, comfort level, and satisfaction. Knowledge gain and comfort level were assessed pre- and post-course, while satisfaction was assessed only post-course. Results Enrollment in the online and classroom courses was 89 students and 291 students, respectively. Sixty-two online students (68% female) and 114 classroom students (77% female) completed the entire course and took the post-test. The online cohort had higher pre-test scores than the classroom cohort (46.4% and 37.3%, respectively, p < 0.01). The online cohort's overall knowledge gain was not significant (0.4%, p=0.87), but the classroom cohort's knowledge gain was significant (13.9%, p < 0.01). Both the online and classroom cohorts demonstrated significant improvement in overall comfort level for all soft skills topics (p < 0.01). Both cohorts were also highly satisfied with the course, as assessed on a Likert scale (4.59 for online, 4.40 for classroom). Conclusion The study compared two cohorts of Mongolian college students who took either an online or classroom-based soft skills course, and it was found that knowledge gain was significantly higher for the classroom group, while comfort and satisfaction with individual course topics was comparable.

    View details for PubMedID 29399428

  • Preparing for International Travel and Global Medical Care EMERGENCY MEDICINE CLINICS OF NORTH AMERICA Mahadevan, S. V., Strehlow, M. C. 2017; 35 (2): 465-?


    Thorough pretravel preparation and medical consultation can mitigate avoidable health and safety risks. A comprehensive pretravel medical consultation should include an individualized risk assessment, immunization review, and discussion of arthropod protective measures, malaria prophylaxis, traveler's diarrhea, and injury prevention. Travel with children and jet lag reduction require additional planning and prevention strategies; travel and evacuation insurance may prove essential when traveling to less resourced countries. Consideration should also be given to other high-risk travel scenarios, including the provision of health care overseas, adventure and extreme sports, water environments and diving, high altitude, and terrorism/unstable political situations.

    View details for DOI 10.1016/j.emc.2017.01.006

    View details for PubMedID 28411937

  • Adaptive leadership curriculum for Indian paramedic trainees. International journal of emergency medicine Mantha, A., Coggins, N. L., Mahadevan, A., Strehlow, R. N., Strehlow, M. C., Mahadevan, S. V. 2016; 9 (1): 9-?


    Paramedic trainees in developing countries face complex and chaotic clinical environments that demand effective leadership, communication, and teamwork. Providers must rely on non-technical skills (NTS) to manage bystanders and attendees, collaborate with other emergency professionals, and safely and appropriately treat patients. The authors designed a NTS curriculum for paramedic trainees focused on adaptive leadership, teamwork, and communication skills critical to the Indian prehospital environment.Forty paramedic trainees in the first academic year of the 2-year Advanced Post-Graduate Degree in Emergency Care (EMT-paramedic equivalent) program at the GVK-Emergency Management and Research Institute campus in Hyderabad, India, participated in the 6-day leadership course. Trainees completed self-assessments and delivered two brief video-recorded presentations before and after completion of the curriculum.Independent blinded observers scored the pre- and post-intervention presentations delivered by 10 randomly selected paramedic trainees. The third-party judges reported significant improvement in both confidence (25 %, p < 0.01) and body language of paramedic trainees (13 %, p < 0.04). Self-reported competency surveys indicated significant increases in leadership (2.6 vs. 4.6, p < 0.001, d = 1.8), public speaking (2.9 vs. 4.6, p < 0.001, d = 1.4), self-reflection (2.7 vs. 4.6, p < 0.001, d = 1.6), and self-confidence (3.0 vs. 4.8, p < 0.001, d = 1.5).Participants in a 1-week leadership curriculum for prehospital providers demonstrated significant improvement in self-reported NTS commonly required of paramedics in the field. The authors recommend integrating focused NTS development curriculum into Indian paramedic education and further evaluation of the long term impacts of this adaptive leadership training.

    View details for DOI 10.1186/s12245-016-0103-x

    View details for PubMedID 26897379

    View details for PubMedCentralID PMC4761349

  • One-two-triage: validation and reliability of a novel triage system for low-resource settings. Emergency medicine journal Khan, A., Mahadevan, S. V., Dreyfuss, A., Quinn, J., Woods, J., Somontha, K., Strehlow, M. 2016; 33 (10): 709-715


    To validate and assess reliability of a novel triage system, one-two-triage (OTT), that can be applied by inexperienced providers in low-resource settings.This study was a two-phase prospective, comparative study conducted at three hospitals. Phase I assessed criterion validity of OTT on all patients arriving at an American university hospital by comparing agreement among three methods of triage: OTT, Emergency Severity Index (ESI) and physician-defined acuity (the gold standard). Agreement was reported in normalised and raw-weighted Cohen κ using two different scales for weighting, Expert-weighted and triage-weighted κ. Phase II tested reliability, reported in Fleiss κ, of OTT using standardised cases among three groups of providers at an urban and rural Cambodian hospital and the American university hospital.Normalised for prevalence of patients in each category, OTT and ESI performed similarly well for expert-weighted κ (OTT κ=0.58, 95% CI 0.52 to 0.65; ESI κ=0.47, 95% CI 0.40 to 0.53) and triage-weighted κ (κ=0.54, 95% CI 0.48 to 0.61; ESI κ=0.57, 95% CI 0.51 to 0.64). Without normalising, agreement with gold standard was less for both systems but performance of OTT and ESI remained similar, expert-weighted (OTT κ=0.57, 95% CI 0.52 to 0.62; ESI κ=0.6, 95% CI 0.58 to 0.66) and triage-weighted (OTT κ=0.31, 95% CI 0.25 to 0.38; ESI κ=0.41, 95% CI 0.35 to 0.4). In the reliability phase, all triagers showed fair inter-rater agreement, Fleiss κ (κ=0.308).OTT can be reliably applied and performs as well as ESI compared with gold standard, but requires fewer resources and less experience.

    View details for DOI 10.1136/emermed-2015-205430

    View details for PubMedID 27466347

  • Characteristics and outcomes of women using emergency medical services for third-trimester pregnancy-related problems in India: a prospective observational study. BMJ open Strehlow, M. C., Newberry, J. A., Bills, C. B., Min, H. E., Evensen, A. E., Leeman, L., Pirrotta, E. A., Rao, G. V., Mahadevan, S. V. 2016; 6 (7): e011459


    Characterise the demographics, management and outcomes of obstetric patients transported by emergency medical services (EMS).Prospective observational study.Five Indian states using a centralised EMS agency that transported 3.1 million pregnant women in 2014.This study enrolled a convenience sample of 1684 women in third trimester of pregnancy calling with a 'pregnancy-related' problem for free-of-charge ambulance transport. Calls were deemed 'pregnancy related' if categorised by EMS dispatchers as 'pregnancy', 'childbirth', 'miscarriage' or 'labour pains'. Interfacility transfers, patients absent on ambulance arrival and patients refusing care were excluded.Emergency medical technician (EMT) interventions, method of delivery and death.The median age enrolled was 23 years (IQR 21-25). Women were primarily from rural or tribal areas (1550/1684 (92.0%)) and lower economic strata (1177/1684 (69.9%)). Time from initial call to hospital arrival was longer for rural/tribal compared with urban patients (66 min (IQR 51-84) vs 56 min (IQR 42-73), respectively, p<0.0001). EMTs assisted delivery in 44 women, delivering the placenta in 33/44 (75%), performing transabdominal uterine massage in 29/33 (87.9%) and administering oxytocin in none (0%). There were 1411 recorded deliveries. Most women delivered at a hospital (1212/1411 (85.9%)), however 126/1411 (8.9%) delivered at home following hospital discharge. Follow-up rates at 48 hours, 7 days and 42 days were 95.0%, 94.4% and 94.1%, respectively. Four women died, all within 48 hours. The caesarean section rate was 8.2% (116/1411). On multivariate regression analysis, women transported to private hospitals versus government primary health centres were less likely to deliver by caesarean section (OR 0.14 (0.05-0.43)) CONCLUSIONS: Pregnant women from vulnerable Indian populations use free-of-charge EMS for impending delivery, making it integral to the healthcare system. Future research and health system planning should focus on strengthening and expanding EMS as a component of emergency obstetric and newborn care (EmONC).

    View details for DOI 10.1136/bmjopen-2016-011459

    View details for PubMedID 27449891

    View details for PubMedCentralID PMC4964166

  • Implementing an Innovative Prehospital Care Provider Training Course in Nine Cambodian Provinces. Cure¯us Acker, P., Newberry, J. A., Hattaway, L. B., Socheat, P., Raingsey, P. P., Strehlow, M. C. 2016; 8 (6)


    Despite significant improvements in health outcomes nationally, many Cambodians continue to experience morbidity and mortality due to inadequate access to quality emergency medical services. Over recent decades, the Cambodian healthcare system and civil infrastructure have advanced markedly and now possess many of the components required to establish a well functioning emergency medical system. These components include enhanced access to emergency transportation through large scale road development efforts, widspread availability of emergency communication channels via the spread of cellphone and internet technology, and increased access to health services for poor patients through the implementation of health financing schemes. However, the system still lacks a number of key elements, one of which is trained prehospital care providers. Working in partnership with local providers, our team created an innovative, Cambodia-specific prehospital care provider training course to help fill this gap. Participants received training on prehospital care skills and knowledge most applicable to the Cambodian healthcare system, which was divided into four modules: Basic Prehospital Care Skills and Adult Medical Emergencies, Traumatic Emergencies, Obstetric Emergencies, and Neonatal/Pediatric Emergencies. The course was implemented in nine of Cambodia's most populous provinces, concurrent with a number of overarching emergency medical service system improvement efforts. Overall, the course was administered to 1,083 Cambodian providers during a 27-month period, with 947 attending the entire course and passing the course completion exam.

    View details for DOI 10.7759/cureus.656

    View details for PubMedID 27489749

    View details for PubMedCentralID PMC4963230

  • Characteristics and outcomes of women using emergency medical services for third-trimester pregnancy-related problems in India: a prospective observational study. BMJ open Strehlow, M. C., Newberry, J. A., Bills, C. B., Min, H. E., Evensen, A. E., Leeman, L., Pirrotta, E. A., Rao, G. V., Mahadevan, S. V. 2016; 6 (7)


    Characterise the demographics, management and outcomes of obstetric patients transported by emergency medical services (EMS).Prospective observational study.Five Indian states using a centralised EMS agency that transported 3.1 million pregnant women in 2014.This study enrolled a convenience sample of 1684 women in third trimester of pregnancy calling with a 'pregnancy-related' problem for free-of-charge ambulance transport. Calls were deemed 'pregnancy related' if categorised by EMS dispatchers as 'pregnancy', 'childbirth', 'miscarriage' or 'labour pains'. Interfacility transfers, patients absent on ambulance arrival and patients refusing care were excluded.Emergency medical technician (EMT) interventions, method of delivery and death.The median age enrolled was 23 years (IQR 21-25). Women were primarily from rural or tribal areas (1550/1684 (92.0%)) and lower economic strata (1177/1684 (69.9%)). Time from initial call to hospital arrival was longer for rural/tribal compared with urban patients (66 min (IQR 51-84) vs 56 min (IQR 42-73), respectively, p<0.0001). EMTs assisted delivery in 44 women, delivering the placenta in 33/44 (75%), performing transabdominal uterine massage in 29/33 (87.9%) and administering oxytocin in none (0%). There were 1411 recorded deliveries. Most women delivered at a hospital (1212/1411 (85.9%)), however 126/1411 (8.9%) delivered at home following hospital discharge. Follow-up rates at 48 hours, 7 days and 42 days were 95.0%, 94.4% and 94.1%, respectively. Four women died, all within 48 hours. The caesarean section rate was 8.2% (116/1411). On multivariate regression analysis, women transported to private hospitals versus government primary health centres were less likely to deliver by caesarean section (OR 0.14 (0.05-0.43)) CONCLUSIONS: Pregnant women from vulnerable Indian populations use free-of-charge EMS for impending delivery, making it integral to the healthcare system. Future research and health system planning should focus on strengthening and expanding EMS as a component of emergency obstetric and newborn care (EmONC).

    View details for DOI 10.1136/bmjopen-2016-011459

    View details for PubMedID 27449891

    View details for PubMedCentralID PMC4964166

  • Barriers to Real-Time Medical Direction via Cellular Communication for Prehospital Emergency Care Providers in Gujarat, India. Cure¯us Lindquist, B., Strehlow, M. C., Rao, G. V., Newberry, J. A. 2016; 8 (7)


    Many low- and middle-income countries depend on emergency medical technicians (EMTs), nurses, midwives, and layperson community health workers with limited training to provide a majority of emergency medical, trauma, and obstetric care in the prehospital setting. To improve timely patient care and expand provider scope of practice, nations leverage cellular phones and call centers for real-time online medical direction. However, there exist several barriers to adequate communication that impact the provision of emergency care. We sought to identify obstacles in the cellular communication process among GVK Emergency Management and Research Institute (GVK EMRI) EMTs in Gujarat, India.A convenience sample of practicing EMTs in Gujarat, India were surveyed regarding the barriers to call initiation and completion.108 EMTs completed the survey. Overall, ninety-seven (89.8%) EMTs responded that the most common reason they did not initiate a call with the call center physician was insufficient time. Forty-six (42%) EMTs reported that they were unable to call the physician one or more times during a typical workweek (approximately 5-6 twelve-hour shifts/week) due to their hands being occupied performing direct patient care. Fifty-eight (54%) EMTs reported that they were unable to reach the call center physician, despite attempts, at least once a week.This study identified multiple barriers to communication, including insufficient time to call for advice and inability to reach call center physicians. Identification of simple interventions and best practices may improve communication and ensure timely and appropriate prehospital care.

    View details for DOI 10.7759/cureus.676

    View details for PubMedID 27551654

    View details for PubMedCentralID PMC4977222

  • Epidemiology of Shortness of Breath in Prehospital Patients in Andhra Pradesh, India. journal of emergency medicine Mercer, M. P., Mahadevan, S. V., Pirrotta, E., Ramana Rao, G. V., Sistla, S., Nampelly, B., Danthala, R., Strehlow, A. N., Strehlow, M. C. 2015; 49 (4): 448-454


    Shortness of breath is a frequent reason for patients to request prehospital emergency medical services and is a symptom of many life-threatening conditions. To date, there is limited information on the epidemiology of, and outcomes of patients seeking emergency medical services for, shortness of breath in India.This study describes the characteristics and outcomes of patients with a chief complaint of shortness of breath transported by a public ambulance service in the state of Andhra Pradesh, India.This prospective, observational study enrolled patients with a chief complaint of shortness of breath during twenty-eight, 12-h periods. Demographic and clinical data were collected from emergency medical technicians using a standardized questionnaire. Follow-up information was collected at 48-72 h and 30 days.Six hundred and fifty patients were enrolled during the study period. The majority of patients were male (63%), from rural communities (66%), and of lower socioeconomic status (78%). Prehospital interventions utilized included oxygen (76%), physician consultation (40%), i.v. placement (15%), nebulized medications (13%), cardiopulmonary resuscitation (5%), and bag-mask ventilation (4%). Mortality ratios before hospital arrival, at 48-72 h, and 30 days were 12%, 27%, and 35%, respectively. Forty-six percent of patients were confirmed to have survived to 30 days. Predictors of death before hospital arrival were symptoms of chest pain (16% vs. 12%; p < 0.05) recent symptoms of upper respiratory infection (7.5% vs. 4%; p < 0.05), history of heart disease (14% vs. 7%; p < 0.05), and prehospital hypotension, defined as systolic blood pressure <90 mm Hg (6.3% vs. 3.7%; p < 0.05).Among individuals seeking prehospital emergency medical services in India, the chief complaint of shortness of breath is associated with a substantial early and late mortality, which may be in part due to the underutilization of prehospital interventions.

    View details for DOI 10.1016/j.jemermed.2015.02.041

    View details for PubMedID 26014761

  • Cerebrospinal fluid and plasma oxytocin concentrations are positively correlated and negatively predict anxiety in children MOLECULAR PSYCHIATRY Carson, D. S., Berquist, S. W., Trujillo, T. H., Garner, J. P., Hannah, S. L., Hyde, S. A., Sumiyoshi, R. D., Jackson, L. P., MOSS, J. K., Strehlow, M. C., Cheshier, S. H., Partap, S., Hardan, A. Y., Parker, K. J. 2015; 20 (9): 1085-1090


    The neuropeptide oxytocin (OXT) exerts anxiolytic and prosocial effects in the central nervous system of rodents. A number of recent studies have attempted to translate these findings by investigating the relationships between peripheral (e.g., blood, urinary and salivary) OXT concentrations and behavioral functioning in humans. Although peripheral samples are easy to obtain in humans, whether peripheral OXT measures are functionally related to central OXT activity remains unclear. To investigate a possible relationship, we quantified OXT concentrations in concomitantly collected cerebrospinal fluid (CSF) and blood samples from child and adult patients undergoing clinically indicated lumbar punctures or other CSF-related procedures. Anxiety scores were obtained in a subset of child participants whose parents completed psychometric assessments. Findings from this study indicate that plasma OXT concentrations significantly and positively predict CSF OXT concentrations (r=0.56, P=0.0064, N=27). Moreover, both plasma (r=-0.92, P=0.0262, N=10) and CSF (r=-0.91, P=0.0335, N=10) OXT concentrations significantly and negatively predicted trait anxiety scores, consistent with the preclinical literature. Importantly, plasma OXT concentrations significantly and positively (r=0.96, P=0.0115, N=10) predicted CSF OXT concentrations in the subset of child participants who provided behavioral data. This study provides the first empirical support for the use of blood measures of OXT as a surrogate for central OXT activity, validated in the context of behavioral functioning. These preliminary findings also suggest that impaired OXT signaling may be a biomarker of anxiety in humans, and a potential target for therapeutic development in individuals with anxiety disorders.Molecular Psychiatry advance online publication, 4 November 2014; doi:10.1038/mp.2014.132.

    View details for DOI 10.1038/mp.2014.132

    View details for Web of Science ID 000360175500009

  • Septris: a novel, mobile, online, simulation game that improves sepsis recognition and management. Academic medicine Evans, K. H., Daines, W., Tsui, J., Strehlow, M., Maggio, P., Shieh, L. 2015; 90 (2): 180-184


    Annually affecting over 18 million people worldwide, sepsis is common, deadly, and costly. Despite significant effort by the Surviving Sepsis Campaign and other initiatives, sepsis remains underrecognized and undertreated.Research indicates that educating providers may improve sepsis diagnosis and treatment; thus, the Stanford School of Medicine has developed a mobile-accessible, case-based, online game entitled Septris ( Septris, launched online worldwide in December 2011, takes an innovative approach to teaching early sepsis identification and evidence-based management. The free gaming platform leverages the massive expansion over the past decade of smartphones and the popularity of noneducational gaming.The authors sought to assess the game's dissemination and its impact on learners' sepsis-related knowledge, skills, and attitudes. In 2012, the authors trained Stanford pregraduate (clerkship) and postgraduate (resident) medical learners (n = 156) in sepsis diagnosis and evidence-based practices via 20 minutes of self-directed game play with Septris. The authors administered pre- and posttests.By October 2014, Septris garnered over 61,000 visits worldwide. After playing Septris, both pre- and postgraduate groups improved their knowledge on written testing in recognizing and managing sepsis (P < .001). Retrospective self-reporting on their ability to identify and manage sepsis also improved (P < .001). Over 85% of learners reported that they would or would maybe recommend Septris.Future evaluation of Septris should assess its effectiveness among different providers, resource settings, and cultures; generate information about how different learners make clinical decisions; and evaluate the correlation of game scores with sepsis knowledge.This is an open-access article distributed under the terms of the Creative Commons Attribution-NonCommercial-NoDerivatives 3.0 License, where it is permissible to download and share the work provided it is properly cited. The work cannot be changed in any way or used commercially.

    View details for DOI 10.1097/ACM.0000000000000611

    View details for PubMedID 25517703

  • An observational study of adults seeking emergency care in Cambodia BULLETIN OF THE WORLD HEALTH ORGANIZATION Yan, L. D., Mahadevan, S. V., Yore, M., Pirrotta, E. A., Woods, J., Somontha, K., Sovannra, Y., Raman, M., Cornell, E., Grundmann, C., Strehlow, M. C. 2015; 93 (2): 84-92


    To describe the characteristics and chief complaints of adults seeking emergency care at two Cambodian provincial referral hospitals.Adults aged 18 years or older who presented without an appointment at two public referral hospitals were enrolled in an observational study. Clinical and demographic data were collected and factors associated with hospital admission were identified. Patients were followed up 48 hours and 14 days after presentation.In total, 1295 hospital presentations were documented. We were able to follow up 85% (1098) of patients at 48 hours and 77% (993) at 14 days. The patients' mean age was 42 years and 64% (823) were females. Most arrived by motorbike (722) or taxi or tuk-tuk (312). Most common chief complaints were abdominal pain (36%; 468), respiratory problems (15%; 196) and headache (13%; 174). Of the 1050 patients with recorded vital signs, 280 had abnormal values, excluding temperature, on arrival. Performed diagnostic tests were recorded for 539 patients: 1.2% (15) of patients had electrocardiography and 14% (175) had diagnostic imaging. Subsequently, 783 (60%) patients were admitted and 166 of these underwent surgery. Significant predictors of admission included symptom onset within 3 days before presentation, abnormal vital signs and fever. By 14-day follow-up, 3.9% (39/993) of patients had died and 19% (192/993) remained functionally impaired.In emergency admissions in two public hospitals in Cambodia, there is high admission-to-death ratio and limited application of diagnostic techniques. We identified ways to improve procedures, including better documentation of vital signs and increased use of diagnostic techniques.

    View details for DOI 10.2471/BLT.14.143917

    View details for PubMedID 25883401



    Patient satisfaction has become a quality indicator tracked closely by hospitals and emergency departments (EDs). Unfortunately, the primary factors driving patient satisfaction remain poorly studied. It has been suggested that correct physician identification impacts patient satisfaction in hospitalized patients, however, the limited studies that exist have demonstrated mixed results.In this study, we sought to identify factors associated with improved satisfaction among ED patients, and specifically, to test whether improving physician identification by patients would lead to increased satisfaction.We performed a pre- and postintervention, survey-based study of patients at the end of their ED visits. We compared patient satisfaction scores as well as patients' abilities to correctly identify their physicians over two separate 1-week periods: prior to and after introducing a multimedia presentation of the attending physicians into the waiting room.A total of 486 patients (25% of all ED visits) were enrolled in the study. In the combined study population, overall patient satisfaction was higher among patients who correctly identified their physicians than among those who could not identify their physicians (combined mean satisfaction score of 8.1 vs. 7.2; odds ratio [OR] 1.07). Overall satisfaction was also higher among parents or guardians of pediatric patients than among adult patients (satisfaction score of 8.4 vs. 7.4; OR 1.07), and among patients who experienced a shorter door-to-doctor time (satisfaction score of 8.2 for shorter waiting time vs. 5.6 for longer waiting time; OR 1.15). Ambulance patients showed decreased satisfaction over some satisfaction parameters, including physician courtesy and knowledge. No direct relationship was demonstrated between the study intervention (multimedia presentation) and improved patient satisfaction or physician identification.Improved patient satisfaction was found to be positively correlated with correct physician identification, shorter waiting times, and among the pediatric patient population. Further studies are needed to determine interventions that improve patients' abilities to identify their physicians and lower waiting times.

    View details for DOI 10.1016/j.jemermed.2013.08.036

    View details for PubMedID 24462030



    The American Heart Association (AHA) Advanced Cardiovascular Life Support (ACLS) course is taught worldwide. The ACLS course is designed for consistency, regardless of location; to our knowledge, no previous study has compared the cognitive performance of international ACLS students to those in the United States (US).As international health educational initiatives continue to expand, an assessment of their efficacy is essential. This study assesses the AHA ACLS curriculum in an international setting by comparing performance of a cohort of US and Indian paramedic students.First-year paramedic students at the Emergency Management and Research Institute, Hyderabad, India, and a cohort of first-year paramedic students from the United States comprised the study population. All study participants had successfully completed the standard 2-day ACLS course, taught in English. Each student was given a 40-question standardized AHA multiple-choice examination. Examination performance was calculated and compared for statistical significance.There were 117 Indian paramedic students and 43 US paramedic students enrolled in the study. The average score was 86% (± 11%) for the Indian students and 87% (± 6%) for the US students. The difference between the average examination scores was not statistically significant in an independent means t-test (p=0.508) and a Wilcoxon test (p=0.242).Indian paramedic students demonstrated excellent ACLS cognitive comprehension and performed at a level equivalent to their US counterparts on an AHA ACLS written examination. Based on the study results, the AHA ACLS course proved effective in an international setting despite being taught in a non-native language.

    View details for DOI 10.1016/j.jemermed.2011.05.096

    View details for PubMedID 22244286

  • National Survey of Preventive Health Services in US Emergency Departments Scientific Assembly of the American-College-of-Emergency-Physicians Delgado, M. K., Acosta, C. D., Ginde, A. A., Wang, N. E., Strehlow, M. C., Khandwala, Y. S., Camargo, C. A. MOSBY-ELSEVIER. 2011: 104–8


    We describe the availability of preventive health services in US emergency departments (EDs), as well as ED directors' preferred service and perceptions of barriers to offering preventive services.Using the 2007 National Emergency Department Inventory (NEDI)-USA, we randomly sampled 350 (7%) of 4,874 EDs. We surveyed directors of these EDs to determine the availability of (1) screening and referral programs for alcohol, tobacco, geriatric falls, intimate partner violence, HIV, diabetes, and hypertension; (2) vaccination programs for influenza and pneumococcus; and (3) linkage programs to primary care and health insurance. ED directors were asked to select the service they would most like to implement and to rate 5 potential barriers to offering preventive services.Two hundred seventy-seven EDs (80%) responded across 46 states. Availability of services ranged from 66% for intimate partner violence screening to 19% for HIV screening. ED directors wanted to implement primary care linkage most (17%) and HIV screening least (2%). ED directors "agreed/strongly agreed" that the following are barriers to ED preventive care: cost (74%), increased patient length of stay (64%), lack of follow-up (60%), resource shifting leading to worse patient outcomes (53%), and philosophical opposition (27%).Most US EDs offer preventive services, but availability and ED director preference for type of service vary greatly. The majority of EDs do not routinely offer Centers for Disease Control and Prevention-recommended HIV screening. Most ED directors are not philosophically opposed to offering preventive services but are concerned with added costs, effects on ED operations, and potential lack of follow-up.

    View details for DOI 10.1016/j.annemergmed.2010.07.015

    View details for Web of Science ID 000287464900007

    View details for PubMedID 20889237

    View details for PubMedCentralID PMC3538034

  • Evaluating the efficacy of simulators and multimedia for refreshing ACLS skills in India RESUSCITATION Delasobera, B. E., Goodwin, T. L., Strehlow, M., Gilbert, G., D'Souza, P., Alok, A., Raje, P., Mahadevan, S. V. 2010; 81 (2): 217-223


    Data on the efficacy of the simulation and multimedia teaching modalities is limited, particularly in developing nations. This study evaluates the effectiveness of simulator and multimedia educational tools in India.Advanced Cardiac Life Support (ACLS) certified paramedic students in India were randomized to either Simulation, Multimedia, or Reading for a 3-h ACLS refresher course. Simulation students received a lecture and 10 simulator cases. The Multimedia group viewed the American Heart Association (AHA) ACLS video and played a computer game. The Reading group independently read with an instructor present. Students were tested prior to (pre-test), immediately after (post-test), and 3 weeks after (short-term retention test), their intervention. During each testing stage subjects completed a cognitive, multiple-choice test and two cardiac arrest scenarios. Changes in exam performance were analyzed for significance. A survey was conducted asking students' perceptions of their assigned modality.One hundred and seventeen students were randomized to Simulation (n=39), Multimedia (n=38), and Reading (n=40). Simulation demonstrated greater improvement managing cardiac arrest scenarios compared to both Multimedia and Reading on the post-test (9% versus 5% and 2%, respectively, p<0.05) and Reading on the short-term retention test (6% versus -1%, p<0.05). Multimedia showed significant improvement on cognitive, short-term retention testing compared to Simulation and Reading (5% versus 0% and 0%, respectively, p<0.05). On the survey, 95% of Simulation and 84% of Multimedia indicated they enjoyed their modality.Simulation and multimedia educational tools were effective and may provide significant additive benefit compared to reading alone. Indian students enjoyed learning via these modalities.

    View details for DOI 10.1016/j.resuscitation.2009.10.013

    View details for Web of Science ID 000274982500014

    View details for PubMedID 19926385

  • Early Identification of Shock in Critically Ill Patients EMERGENCY MEDICINE CLINICS OF NORTH AMERICA Strehlow, M. C. 2010; 28 (1): 57-?


    Emergency providers must be experts in the resuscitation and stabilization of critically ill patients, and the rapid recognition of shock is crucial to allow aggressive targeted intervention and reduce morbidity and mortality. This article reviews the physiologic definition of shock, the importance of early intervention, and the clinical and diagnostic signs that emergency department providers can use to identify patients in shock.

    View details for DOI 10.1016/j.emc.2009.09.006

    View details for Web of Science ID 000278319500005

    View details for PubMedID 19945598

  • A better way to estimate adult patients' weights AMERICAN JOURNAL OF EMERGENCY MEDICINE Lin, B. W., Yoshida, D., Quinn, J., Strehlow, M. 2009; 27 (9): 1060-1064


    In the emergency department (ED), adult patients' weights are often crudely estimated before lifesaving interventions. In this study, we evaluate the reliability and accuracy of a method to rapidly calculate patients' weight using readily obtainable anthropometric measurements. We compare this method to visual estimates, patient self-report, and measured weight.A convenience sample of adult ED patients in an academic medical center were prospectively enrolled. Midarm circumference and knee height were measured. These values were input in to equations to calculate patients' weights. A physician and nurse were then independently asked to estimate the patients' weights. Each patient was asked to report his/her own weight before being weighed. Calculated weights using the above equations, visual estimates, and patient reports were compared with actual weights by determining the percentage accurate within 10%. The intraclass correlation coefficient was used to determine the reliability of the estimates with respect to actual weights.Weight was determined within 10% accuracy of actual weight in 69% (95% confidence interval, 63-75) of calculated estimates, 54% (48-61) of physician estimates, 51% (44-57) of nurse estimates, and 86% (81-90) of patient estimates. The weight estimation tool calculated weights more accurately in males (74%, 65-82) than females (65%, 56-73). An analysis of errors revealed that when estimates were inaccurate, approximately half were overestimates and half were underestimates. The correlation coefficient between the calculated estimates and actual weights was 0.89. The correlation coefficient of actual weights with respect to physician estimates, nurse estimates, and doctor's estimates were 0.85, 0.78, and 0.95, respectively.This technique using readily obtainable measurements estimates weight more accurately than ED providers. The technique correlates well with actual patient weights. When available, patient estimates of their own weight are most accurate.

    View details for DOI 10.1016/j.ajem.2008.08.018

    View details for Web of Science ID 000272403400006

    View details for PubMedID 19931751

  • Internationalizing the Broselow tape: How reliable is weight estimation in Indian children Conference of the Western-Society-for-Academic-Emergency-Medicine Ramarajan, N., Krishnamoorthi, R., Strehlow, M., Quinn, J., Mahadevan, S. V. WILEY-BLACKWELL PUBLISHING, INC. 2008: 431–36


    The Broselow pediatric emergency weight estimation tape is an accurate method of estimating children's weights based on height-weight correlations and determining standardized medication dosages and equipment sizes using color-coded zones. The study objective was to determine the accuracy of the Broselow tape in the Indian pediatric population.The authors conducted a 6-week prospective cross-sectional study of 548 children at a government pediatric hospital in Chennai, India, in three weight-based groups: < 10 kg (n = 175), 10-18 kg (n = 197), and > 18 kg (n = 176). Measured weight was compared to Broselow-predicted weight, and the percentage difference was calculated. Accuracy was defined as agreement on Broselow color-coded zones, as well as agreement within 10% between the measured and Broselow-predicted weights. A cross-validated correction factor was also derived.The mean percentage differences were -2.4, -11.3, and -12.9% for each weight-based group. The Broselow color-coded zone agreement was 70.8% in children weighing less than 10 kg, but only 56.3% in the 10- to 18-kg group and 37.5% in the > 18-kg group. Agreement within 10% was 52.6% for the < 10-kg group, but only 44.7% for the 10- to 18-kg group and 33.5% for the > 18-kg group. Application of a 10% weight-correction factor improved the percentages to 77.1% for the 10- to 18-kg group and 63.0% for the >18-kg group.The Broselow tape overestimates weight by more than 10% in Indian children > 10 kg. Weight overestimation increases the risk of medical errors due to incorrect dosing or equipment selection. Applying a 10% weight-correction factor may be advisable.

    View details for DOI 10.1111/j.1553-2712.2008.00081.x

    View details for PubMedID 18439198

  • Images in emergency medicine - Diagnosis: Serum sickness-like reaction to amoxicillin ANNALS OF EMERGENCY MEDICINE Lin, B., Strehlow, M. 2007; 50 (3): 350-?
  • National study of emergency department visits for sepsis, 1992 to 2001 Scientific Assembly of the American-College-of-Emergency-Physicians Strehlow, M. C., Emond, S. D., Shapiro, N. I., Pelletier, A. J., Camargo, C. A. MOSBY-ELSEVIER. 2006: 326–31


    Epidemiologic data on emergency department (ED) patients with sepsis are limited. Inpatient discharge records from 1979 to 2000 show that hospitalizations for sepsis are increasing. We examine the epidemiology of sepsis in US EDs and the hypothesis that sepsis visits are increasing.The National Hospital Ambulatory Medical Care Survey data (1992 to 2001) provided nationally representative estimates of frequency and disposition in adult ED visits for sepsis. Sepsis visits were identified using International Classification of Diseases, Ninth Revision, Clinical Modification codes; severe sepsis was defined as sepsis in conjunction with organ failure.Of 712 million adult visits during the 10-year period, approximately 2.8 million (0.40%, 95% confidence interval [CI] 0.33% to 0.46%) were related to sepsis. We found no significant increase in overall ED visits for sepsis from 1992 to 2001 (P for trend=.09). ED patients with sepsis were more likely to be elderly, non-Hispanic, and publicly insured and to arrive by ambulance compared with nonsepsis patients (all P<.01). The overall admission rate was 87% (95% CI 82% to 92%), with only 12% (95% CI 8% to 16%) of patients admitted to the ICU. The most frequent codiagnoses were pneumonia (13%), urinary tract infection (13%), and dehydration (11%). Severe sepsis accounted for 8% (95% CI 5% to 11%) of sepsis visits, for an annual incidence of 0.01%; 98% of patients with severe sepsis were admitted.In contrast to data from hospital discharges, ED visits for sepsis demonstrated no increase. Most ED visits for sepsis resulted in admission to non-critical care units.

    View details for DOI 10.1016/j.annemergmed.2006.05.003

    View details for Web of Science ID 000240256400016

    View details for PubMedID 16934654

  • A false negative pregnancy test in a patient with a hydatidiform molar pregnancy NEW ENGLAND JOURNAL OF MEDICINE Tabas, J. A., Strehlow, M., Isaacs, E. 2003; 349 (22): 2172-2173

    View details for DOI 10.1056/NEJM200311273492221

    View details for Web of Science ID 000186779700033

    View details for PubMedID 14645652