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Item Availability of mobile phones for discharge follow-up of pediatric Emergency Department patients in western Kenya(PeerJ, 2015-03) House, Darlene R.; Cheptinga, Philip; Rusyniak, Daniel E.; Department of Emergency Medicine, IU School of MedicineObjective. Mobile phones have been successfully used for Emergency Department (ED) patient follow-up in developed countries. Mobile phones are widely available in developing countries and may offer a similar potential for follow-up and continued care of ED patients in low and middle-income countries. The goal of this study was to determine the percentage of families with mobile phones presenting to a pediatric ED in western Kenya and rate of response to a follow-up phone call after discharge. Methods. A prospective, cross-sectional observational study of children presenting to the emergency department of a government referral hospital in Eldoret, Kenya was performed. Documentation of mobile phone access, including phone number, was recorded. If families had access, consent was obtained and families were contacted 7 days after discharge for follow-up. Results. Of 788 families, 704 (89.3%) had mobile phone access. Of those families discharged from the ED, successful follow-up was made in 83.6% of cases. Conclusions. Mobile phones are an available technology for follow-up of patients discharged from a pediatric emergency department in resource-limited western Kenya.Item Bedside lung ultrasound for the diagnosis of pneumonia in children presenting to an emergency department in a resource-limited setting(BMC, 2023-01-09) Amatya, Yogendra; Russell, Frances M.; Rijal, Suraj; Adhikari, Sunil; Nti, Benjamin; House, Darlene R.; Emergency Medicine, School of MedicineBackground: Lung ultrasound (LUS) is an effective tool for diagnosing pneumonia; however, this has not been well studied in resource-limited settings where pneumonia is the leading cause of death in children under 5 years of age. Objective: The objective of this study was to evaluate the diagnostic accuracy of bedside LUS for diagnosis of pneumonia in children presenting to an emergency department (ED) in a resource-limited setting. Methods: This was a prospective cross-sectional study of children presenting to an ED with respiratory complaints conducted in Nepal. We included all children under 5 years of age with cough, fever, or difficulty breathing who received a chest radiograph. A bedside LUS was performed and interpreted by the treating clinician on all children prior to chest radiograph. The criterion standard was radiographic pneumonia, diagnosed by a panel of radiologists using the Chest Radiography in Epidemiological Studies methodology. The primary outcome was sensitivity and specificity of LUS for the diagnosis of pneumonia. All LUS images were later reviewed and interpreted by a blinded expert sonographer. Results: Three hundred and sixty-six children were enrolled in the study. The median age was 16.5 months (IQR 22) and 57.3% were male. Eighty-four patients (23%) were diagnosed with pneumonia by chest X-ray. Sensitivity, specificity, positive and negative likelihood ratios for clinician's LUS interpretation was 89.3% (95% CI 81-95), 86.1% (95%CI 82-90), 6.4, and 0.12 respectively. LUS demonstrated good diagnostic accuracy for pneumonia with an area under the curve of 0.88 (95% CI 0.83-0.92). Interrater agreement between clinician and expert ultrasound interpretation was excellent (k = 0.85). Conclusion: Bedside LUS when used by ED clinicians had good accuracy for diagnosis of pneumonia in children in a resource-limited setting.Item Establishing a Low-Resource Simulation Emergency Medicine Curriculum in Nepal(Association of American Medical Colleges, 2020-07-15) Wang, Alfred; Saltarelli, Nicholas; Cooper, Dylan; Amatya, Yogendra; House, Darlene R.; Emergency Medicine, School of MedicineIntroduction High-fidelity medical simulation is widely used in emergency medicine training because it mirrors the fast-paced environment of the emergency department (ED). However, simulation is not common in emergency medicine training programs in lower-resourced countries as cost, availability of resources, and faculty experience are potential limitations. We initiated a simulation curriculum in a low-resource environment. Methods We created a simulation lab for medical officers and students on their emergency medicine rotation at a teaching hospital in Patan, Nepal, with 48,000 ED patient visits per year. We set up a simulation lab consisting of a room with one manikin, an intubation trainer, and a projector displaying a simulation cardiac monitor. In this environment, we ran a total of eight cases over 4 simulation days. Debriefing was done at the end of each case. At the end of the curriculum, an electronic survey was delivered to the medical officers to seek improvement for future cases. Results All eight cases were well received, and learners appreciated the safe learning space and teamwork. Of note, the first simulation case that was run (the airway lab) was more difficult for learners due to lack of experience. Survey feedback included improving the debriefing content and adding further procedural skills training. Discussion Simulation is a valuable experience for learners in any environment. Although resources may be limited abroad, a sustainable simulation lab can be constructed and potItem Estimating the weight of children in Nepal by Broselow, PAWPER XL and Mercy method(Zhejiang University School of Medicine, 2018) Shrestha, Karun; Subedi, Prakriti; Pandey, Oshna; Shakya, Likhita; Chhetri, Kailash; House, Darlene R.; Emergency Medicine, School of MedicineBACKGROUND: Resuscitation of a critically-ill child requires an accurate weight for fluids and medication dosing; however, weighing children on a scale while critically ill is not always practical. The objective of this study is to determine the accuracy of three different weight estimation methods (Broselow, PAWPER XL and Mercy tape) of children presenting to Patan Hospital, Nepal. METHODS: This was a prospective, cross-sectional study that included children presenting to the emergency department and under-fourteen outpatient clinic at Patan Hospital. Measured weight was compared to estimated weight of Broselow, PAWPER XL, and Mercy tapes. The mean percentage error and percentage of estimated weights that were within 10% (PW10) and 20% (PW20) of actual weight were calculated. Acceptable accuracy was determined as a PW10>70% and PW20>95%. A Bland-Altman analysis was done to determine agreement between each weight estimation method and actual weight. RESULTS: The study included 813 children. The mean age was 4.2 years (ranging from 4 days to 14 years) with 60% male. The mean percentage error (MPE) for Broselow, PAWPER XL and Mercy were -1.0% (SD 11.8), 0.7% (10.5) and 4.2% (11.9) respectively. The predicted weight within 10% was highest for the PAWPER XL (71.5%) followed by Broselow (63.2%) and Mercy (58.1%). The predicted weight within 20% of actual weight was 95.2%, 91.5% and 91.3% for PAWPER XL, Broselow and Mercy respectively. CONCLUSION: The PAWPER XL tape was the only method found to be accurate in estimating the weight of Nepalese children.Item Impact of bedside lung ultrasound on physician clinical decision-making in an emergency department in Nepal(BMC, 2020) House, Darlene R.; Amatya, Yogendra; Nti, Benjamin; Russell, Frances M.; Emergency Medicine, School of MedicineBackground Lung ultrasound is an effective tool for the evaluation of undifferentiated dyspnea in the emergency department. Impact of lung ultrasound on clinical decisions for the evaluation of patients with dyspnea in resource-limited settings is not well-known. The objective of this study was to evaluate the impact of lung ultrasound on clinical decision-making for patients presenting with dyspnea to an emergency department in the resource-limited setting of Nepal. Methods A prospective, cross-sectional study of clinicians working in the Patan Hospital Emergency Department was performed. Clinicians performed lung ultrasounds on patients presenting with dyspnea and submitted ultrasounds with their pre-test diagnosis, lung ultrasound interpretation, post-test diagnosis, and any change in management. Results Twenty-two clinicians participated in the study, completing 280 lung ultrasounds. Diagnosis changed in 124 (44.3%) of patients with dyspnea. Clinicians reported a change in management based on the lung ultrasound in 150 cases (53.6%). Of the changes in management, the majority involved treatment (83.3%) followed by disposition (13.3%) and new consults (2.7%). Conclusions In an emergency department in Nepal, bedside lung ultrasound had a significant impact on physician clinical decision-making, especially on patient diagnosis and treatment.Item In Patients With ST-Segment Elevation Myocardial Infarction, Which Fibrinolytic Agent Is the Safest and Most Effective?(Elsevier, 2018) Shrestha, Ashis; House, Darlene R.; Welch, Julie L.; Emergency Medicine, School of MedicineItem Lower extremity weakness: A rare case of extrapulmonary tuberculosis(Elsevier, 2019-01) Rijal, Suraj; Adhikari, Sunil; House, Darlene R.; Emergency Medicine, School of MedicineItem Lung ultrasound training and evaluation for proficiency among physicians in a low-resource setting(Springer, 2021-06-30) House, Darlene R.; Amatya, Yogendra; Nti, Benjamin; Russell, Frances M.; Emergency Medicine, School of MedicineBackground: Lung ultrasound (LUS) is helpful for the evaluation of patients with dyspnea in the emergency department (ED). However, it remains unclear how much training and how many LUS examinations are needed for ED physicians to obtain proficiency. The objective of this study was to determine the threshold number of LUS physicians need to perform to achieve proficiency for interpreting LUS on ED patients with dyspnea. Methods: A prospective study was performed at Patan Hospital in Nepal, evaluating proficiency of physicians novice to LUS. After eight hours of didactics and hands-on training, physicians independently performed and interpreted ultrasounds on patients presenting to the ED with dyspnea. An expert sonographer blinded to patient data and LUS interpretation reviewed images and provided an expert interpretation. Interobserver agreement was performed between the study physician and expert physician interpretation. Cumulative sum analysis was used to determine the number of scans required to attain an acceptable level of training. Results: Nineteen physicians were included in the study, submitting 330 LUS examinations with 3288 lung zones. Eighteen physicians (95%) reached proficiency. Physicians reached proficiency for interpreting LUS accurately when compared to an expert after 4.4 (SD 2.2) LUS studies for individual zone interpretation and 4.8 (SD 2.3) studies for overall interpretation, respectively. Conclusions: Following 1 day of training, the majority of physicians novice to LUS achieved proficiency with interpretation of lung ultrasound after less than five ultrasound examinations performed independently.Item Qualitative study of healthcare providers’ current practice patterns and barriers to successful rehydration for pediatric diarrheal illnesses in Kenya(PeerJ, 2017-10-06) House, Darlene R.; Cheptinga, Philip; Rusyniak, Daniel E.; Vreeman, Rachel C.; Pediatrics, School of MedicineBackground For children worldwide, diarrhea is the second leading cause of death. These deaths are preventable by fluid resuscitation. Nasogastric tubes (NGs) have been shown to be equivalent to intravenous fluids for rehydration and recommended by the World Health Organization (WHO) for use in severe dehydration. Despite this, NGs are rarely used for rehydration in Kenya. Our objective was to evaluate clinicians’ adherence to rehydration guidelines and to identify barriers to the use of NGs for resuscitating dehydrated children. Methods A case-based structured survey was administered to pediatric care providers in western Kenya to determine their choices for alternative rehydration therapies when oral rehydration and intravenous fluids fail. Providers then participated in a qualitative, semi-structured interview to identify barriers to using nasogastric tubes for rehydration. Analysis included manual, progressive coding of interview transcripts to identify emerging central themes. Results Of 44 participants, only four (9%) followed WHO guidelines that recommend quickly switching to NG for rehydration in their case responses. Participants identified that placing intravenous lines in dehydrated children is a challenge. However, when discussing NG use, many believed NGs are not effective for rehydration. Other participants’ concerns surrounded knowledge and training regarding guidelines as well as not having NGs available. Discussion Healthcare providers in western Kenya do not report using NGs for rehydration in accordance with WHO guidelines for diarrheal illness with severe dehydration. Barriers to the use of NG tubes were lack of knowledge and availability. Education and implementation of guidelines using NG tubes for rehydration may improve outcomes of children suffering from diarrheal illness with severe dehydration.Item To research (or not) that is the question: ethical issues in research when medical care is disrupted by political action: a case study from Eldoret, Kenya(BMJ, 2016-01) House, Darlene R.; Marete, Irene; Meslin, Eric M.; Department of Emergency Medicine, IU School of MedicineWhile considerable attention has been focused on understanding the myriad of ethical analysis in international research in low and middle income countries, new issues always arise that have not been anticipated in guidelines or studied extensively. The disruption of medical care arising as a direct result of political actions, including strikes, postelection violence and related activities, is one such issue that leaves physician-researchers struggling to manage often conflicting professional responsibilities. This paper discusses the ethical conflicts that arise for physician-researchers, particularly when disruption threatens the completion of a study or completion is possible but at the expense of not addressing unmet medical needs of patients. We review three pragmatic strategies and the ethical issues arising from each: not starting research, stopping research that has already started, and continuing research already initiated. We argue that during episodes of medical care disruption, research that has been started can be continued only if the ethical standards imposed at the beginning of the study can continue to be met; however, studies that have been approved but not yet started should not begin until the disruption has ended and ethical standards can again be assured.