Additional research could evaluate whether the additional screening questions distract the triage nurse from his or her primary goal of assessing acuity and contribute to inconsistency in triage assessments. If nurses were liberated from the mandated questions, they could potentially have more time for one-on-one patient care and other aspects of patient care, such as medication administration and lab draws. Although we suspect that reducing the number of required questions would free nurses to spend more time on direct patient care and improve efficiency of ED throughput, additional research will be required to study this hypothesis. Studies evaluating ED screening questions often praise their ability to detect at-risk groups without looking at patient oriented outcomes or cost. Cost-benefit analyses should be considered prior to mandating additional nurse screening questions as even a few seconds spent on a question adds up to a significant amount of time. There is significant potential for future research related to this topic. Further studies are needed to determine cost effectiveness of required ED screenings, including questions included as public health screens. Other potential time saving measures, such as self-completed triage questionnaires on kiosks,trimming cannabis could be researched as well. Dr. Roberts has delivered an excellent review of many medical aspects of cannabis use and the effect of cannabis legalization on emergency medicine in Colorado.
As emergency physician researchers in Colorado, we echo many of his concerns. As he notes, since legalization, we have identified an increase in accidental pediatric exposures, an increase in emergency department visits for hyperemesis ,an increased number of visits attributable to cannabis edibles,a disproportionate increase in adult and adolescent mental health visits related to cannabis, and an increased number of visits for cannabis toxicity .These effects are measurable, and while the direct attribution of these changes to cannabis legalization are limited to observational data that is subject to temporal trends, selection bias, and confounding, we believe the links between these changes and cannabis legalization are plausible, consistent and relevant. While much of the focus in Colorado has been on recreational cannabis, it is important to note that many of the issues identified began before recreational cannabis was available in 2014. In Colorado, medical cannabis was legalized in 2000 and has been widely available since 2009. In Colorado, the qualifying medical conditions for cannabis use include the following: cancer, glaucoma HIV, severe pain, seizures, nausea, muscle spasm, post-traumatic stress disorder , autism spectrum disorder, and cachexia.As of June 2019, almost 84,000 patients have an active medical marijuana registration, 337 less than 18 years of age.As with any therapy, the adverse effects we have identified must be balanced against the potential benefits to patients and society. However, there are few high-quality evidenced based studies to support these recommendations. Without clinical trials the measurement of the positive effects of cannabis remain largely anecdotal. There are additional concerns for reported cannabinoid content and claims on treatment for disease.
The United States Food and Drug Administration has issued numerous warning letters to various cannabidiol manufacturers for false claims in relation to disease diagnosis and treatment.The medical utility of cannabis is further limited by insufficient training provided to medical professionals and trainees, in addition to the reliance of many users on non-medical providers to guide therapeutic choices. For example, many dispensaries will recommend cannabis to pregnant women despite various national guidelines cautioning against this practice.The medical benefits of cannabis should have been evaluated using accepted clinical standards prior to providing legal status as medical treatments. Recreational use has no demonstrated inherent health benefit. While some have suggested that it may increase relaxation and reduce stress, there are no clinical studies to support those claims. One plausible health benefit is the substitution of cannabis for other more dangerous recreational drugs; however, this is also not studied. Unfortunately, in Colorado we see that cannabis is also often combined with alcohol and other drugs and the relative increase in adverse effects may outweigh this potential benefit. Despite the observed increase in cannabis related driving fatalities in Colorado, 55% of cannabis users believed it was safe to drive under the influence of cannabis.There have been mixed results on how marijuana legalization has affected medical and non-medical opioid use and prescribing.The discussion around the impact of cannabis on the healthcare system is not absolute. When we speak to cannabis supporters we often hear the justification that it is safer than alternatives, and there are no real adverse effects. We believe our work has clearly demonstrated that cannabis legalization has measurably impacted the delivery of emergency care in Colorado. However, it is important to put the magnitude of this impact in perspective.
Since 2006, more than 2000 Coloradans have died from opioid overdose, and tobacco use-associated healthcare costs in Colorado are almost 2 billion dollars per year. While it is disingenuous to say that cannabis legalization has not impacted emergency medicine in Colorado, it is important to recognize that there are many greater threats to public health and to provide appropriate focus to each of these conditions. A legitimate discussion around the health effects of cannabis in Colorado requires a fair assessment of the risks and benefits by advocates and critics alike. Continued surveillance on both the positive and negative effects on marijuana legalization, and evidence based research is needed as more states continue to pass medical and recreational marijuana. The long-term effects of increased availability of high-THC-cannabis are still to be determined. It is critical for public health officials, healthcare providers and legislators, in conjunction with advocates and industry representatives, to work toward regulations aimed at minimizing the public health impact of cannabis legalization on society. Musculoskeletal injuries are a major cause of morbidity and mortality across the world that disproportionately affect those in low- and middle-income countries , which often lack trained healthcare providers who can properly treat such conditions. Approximately 90% of the five million annual deaths across the world due to injuries occur in LMICs such as Rwanda.The literature lacks an updated fund of knowledge regarding the prevalence, etiology, and treatment for MSIs in Rwanda to supplement previous studies. The growing number of Rwandan healthcare providers may incorporate this knowledge into educational programs when approaching MSI. Injuries in Rwanda are associated with significant morbidity and mortality.Past studies in Rwanda have shown that most trauma victims are young men.Road traffic accidents , especially those involving motorcycles, were the most common mechanism for adults, while children were frequently injured as pedestrians.Approximately one-quarter of injured patients suffered a fracture.The overall mortality prevalence was 5.5% with approximately half of the hospital deaths occurring in the emergency department .Yet, these mortality figures do not paint a comprehensive picture of the burdens posed by MSIs and fractures in particular.
MSIs resulting from trauma are frequently under treated, causing difficulty for patients to resume normal work and life activities.This is related both to cost and a shortage of technology and supplies.In addition to a dearth of supplies, achieving health outcome targets without securing the appropriate human resources is difficult.One team in Namibia found that three out of the eight Millennium Development Goals concerning healthcare required appropriate human resources for success.A recent interrupted time-series study found that building Rwanda’s emergency medicine training program resulted in an absolute reduction of overall facilities-based mortality by 4% overall, which was twice as great a decline as the national trend.Such investments are vital to improving health in this region. While Africa contains approximately one-quarter of the world’s burden of diseases, it possesses 4% of its health staff.A recent systematic review found that of 59 LMIC emergency care programs,plant benches very few incorporated specialist emergency care training. The largest share of facilities was staffed either by physicians-in-training or by physicians whose level of training was unspecified. Data showed high patient loads and mortality, specifically in Africa where a substantial proportion of total deaths occurred in EDs.Compared to other LMIC regions, ED mortality is highest in Africa, with a median mortality rate of 3.4% compared to the average of 1.8% across all studied LMICs.A minority of LMIC EDs incorporate specialty-trained emergency physicians into the staffing paradigm, but availability is limited.The high volume and urgency of treatment make emergency care an important area of focus for interventions aimed at reducing mortality in these settings. Within a short period of time, Rwanda has made significant improvements to its healthcare system. Rwanda’s transformation of its health sector since the 1990s has helped to raise life expectancy from 27 years to 63 years of age, and nearly all Rwandans have health insurance.Although there have been significant improvements, Rwanda has just 0.84 health providers per 1000 population, the majority of whom are generalists. This number falls below the minimum 2.3 providers per 1000 population set forth by the World Health Organization. In 2011, the Rwandan Ministry of Health began a seven-year partnership with a U.S. academic consortium to train Rwandan providers to become future educators through medical residencies, creating the Human Resources for Health Program. Among the new medical residencies is the first EMTP in Rwanda.These trainees have introduced new emergency skills, such as triage and resuscitation, along with improvements to local protocols and systems.The training curriculum was in line with the American Board of Emergency Medicine 2013 Model of the Clinical Practice of Emergency Medicine.International faculty practicing EM were hired to implement EM training through the HRH program, a collaboration between academic medical centers in the U.S. and the Rwandan Ministry of Health .Within the EMTP curriculum, specific longitudinal educational trainings on the diagnosis and treatments of MSI and fractures were provided through lectures and workshops. Research studies regarding the epidemiology of injuries and the impact of emergency training on patient outcomes have been conducted, although specific epidemiology regarding fractures and the impact of training on patient outcomes is lacking.The purpose of our research was twofold: 1) to understand the epidemiology of MSI fractures in Rwanda; and 2) to evaluate the progress of the country’s first EM residency program in treating MSI-related injuries by assessing ED mortality rates, length of stay, and complication rates.This was a pre-post study examining the characteristics and outcomes of MSIs before and after implementation of an EMTP at the University Teaching Hospital of Kigali in Kigali, Rwanda. UTH-K is an urban referral and tertiary-care teaching hospital with approximately 560 inpatient beds and 40 ED beds. UTH-K contains a 24-hour Accident and Emergency Department that serves adult patients with acute complaints, as well as pediatric and obstetric trauma patients. Resources at UTH-K include 24-hour surgical coverage, 24-hour access to radiologic services including radiograph, ultrasound, and computed tomography, as well as continuous access to general surgery, orthopedic and neurological specialists.The A&E department is covered by general practice physicians and EM residents. An EM post-graduate diploma program was initiated on November 1, 2013, and most physicians enrolled subsequently participated in the official EM residency, which began in September 2015. Both programs are herein formally referred to as the EMTP. Prior to initiation of these training programs, care was provided exclusively by GPs. Since initiation of EMTP, ED care has been provided jointly by GPs and EM resident-trainees who have oversight by board-certified emergency physicians. All patients who presented at UTH-K during the two data collection periods, from November 2012- October 2013 and August 2015-July 2016, were eligible for inclusion. These preand post-time periods for data collection were chosen to correspond with the absence of an EMTP and implementation of an EMTP, respectively. We identified cases and queried data from institutional records via protocolled methods, as previously described in prior studies.Briefly, using a multi-point composite index generated from an electronic hospital database, we identified all cases during each month of the accruement periods. Subsequently, all cases were coded with a unique identification number and were sampled at random until a sufficient number of records meeting inclusion criteria were identified . We then narrowed the dataset to those with MSI, either with open, closed, or mixed fractures. Next, we applied the following exclusion criteria: incomplete or erroneous evaluation documentation dates from the ED, comprising patients without admission dates, or patients with admission dates that preceded discharge dates. Measured variables included age, sex, mechanism of injury, injury type, hospital vital signs, hospital admissions, surgical interventions, medical treatments, discharge date, and disposition. If more than one anatomical region was indicated as injured, each region was recorded.