Background
Emergency medical services (EMS) are paramount to boosting health indices in lower-middle income countries (LMICs); however, lack of uniform data collection and analysis hinders system ...improvement efforts. In the present study, we describe patterns of EMS utilization in the Republic of Armenia and provide key insight into the quality of digital data collection methods.
Results
For calls logged in the capital city, Yerevan, the majority had at least one missing field. The predominant complaint was high blood pressure among adults (34.4%) and fever among pediatrics (65.9%). A majority of patients were female (57.6%), adults (90.2%), and not transported to a hospital (85.0%). In the rural provinces, the data was largely intact. The predominant complaints were unspecified acute condition (27.4%) and high blood pressure (26.2%) among adults, and fever (43.9%) and unspecified acute condition (22.1%) among pediatrics. A majority of patients were female (57.1%), adults (94.2%), and not transported to a hospital (78.9%).
Conclusions
Our study reveals that the majority of calls to the EMS system are for concerns not needing in-hospital treatment and for acute exacerbation of chronic conditions. Our study also provides a critical foundation for the improvement of EMS systems in Armenia and in other nations in transition. The Locator software has the potential to be a valuable tool to the MoH if it is improved for surveillance purposes, and future synchronization of digital systems would provide easy access to critical information on population health needs and the effectiveness of public health interventions.
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IZUM, KILJ, NUK, OILJ, PILJ, PNG, SAZU, UL, UM, UPUK, VSZLJ
Background
Emergency pediatric care curriculum (EPCC) was developed to address the need for pediatric rapid assessment and resuscitation skills among out-of-hospital emergency providers in Armenia. ...This study was designed to evaluate the effectiveness of EPCC in increasing physicians’ knowledge when instruction transitioned to local instructors. We hypothesize that (1) EPCC will have a positive impact on post-test knowledge, (2) this effect will be maintained when local trainers teach the course, and (3) curriculum will satisfy participants.
Methods
This is a quasi-experimental, pre-test/post-test study over a 4-year period from October 2014‑November 2017. Train-the-trainer model was used. Primary outcomes are immediate knowledge acquisition each year and comparison of knowledge acquisition between two cohorts based on North American vs local instructors. Descriptive statistics was used to summarize results. Pre-post change and differences across years were analyzed using repeated measures mixed models.
Results
Test scores improved from pretest mean of 51% (95% CI 49.6 to 53.0%) to post-test mean of 78% (95% CI 77.0 to 79.6%,
p
< 0.001). Average increase from pre- to post-test each year was 27% (95% CI 25.3 to 28.7%). Improvement was sustained when local instructors taught the course (
p
= 0.74). There was no difference in improvement when experience in critical care, EMS, and other specialties were compared (
p
= 0.23). Participants reported satisfaction and wanted the course repeated. In 2017, EPCC was integrated within the Emergency Medicine residency program in Armenia.
Discussion
This program was effective at impacting immediate knowledge as well as participant satisfaction and intentions to change practice. This knowledge acquisition and reported satisfaction remained constant even when the instruction was transitioned to the local instructors after 2 years. Through a partnership between the USA and Armenia, we provided OH-EPs in Armenia with an intensive educational experience to attain knowledge and skills necessary to manage acutely ill or injured children in the out-of-hospital setting.
Conclusions
EPCC resulted in significant improvement in knowledge and was well received by participants. This is a viable and sustainable model to train providers who have otherwise not had formal education in this field.
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IZUM, KILJ, NUK, OILJ, PILJ, PNG, SAZU, UL, UM, UPUK, VSZLJ
Medical education is a critical aspect of healthcare quality and thus requires sufficient investment to meet international standards. The Republic of Armenia, a nation that became independent of the ...Soviet Union in 1991, has not experienced significant advancement of its medical education system as the Western world has. In 2018, the country underwent a revolution to oust systematic corruption and transition to a true democracy, providing an opportunity for future efforts to improve medical education. The Armenian diaspora, which consists of approximately two to three times more individuals than the country’s population, includes healthcare professionals who are motivated and willing to contribute to the advancement of medical education. Assessing the perspectives of stakeholders is a key first step in this endeavor. We conducted a survey of recent medical graduates in Armenia, which revealed self-awareness of deficiencies in clinical, research, and leadership skills, desire to receive further training to improve these skills, and positive attitudes toward diaspora engagement. Thus, it is critical to incorporate a coordinated effort from the diaspora in addition to the local physician workforce, educational institutions, and government to bring about improvements in medical education in Armenia.
Virtual interviews (VI) are now a permanent part of pediatric emergency medicine (PEM) recruitment, especially given the cost and equity advantages. Yet inability to visit programs in person can ...impact decision-making, leading applicants to apply to more programs. Moreover, the cost advantages of VI may encourage applicants to apply to programs farther away than they might otherwise have been willing or able to travel. This could create unnecessary strain on programs. We conducted this study to determine whether PEM fellowship applicants would apply to a larger number of programs and in different geographic patterns with VI (2020 and 2021) as compared to in-person interviews (2018 and 2019).
We conducted an anonymous national survey of all PEM fellows comparing two cohorts: current fellows who interviewed inperson (applied in 2018/2019) and fellows who underwent VIs in 2020/2021 (current fellows and those recently matched in 2021). The study took place in March-April 2022. Questions focused on geographic considerations during interviews and the match. We used descriptive statistics, chi-square and
-tests for analysis.
Overall response rate was 42% (231/550); 32% (n = 74) interviewed in person and 68% (n = 157) virtually. Fellows applied to a median of 4/6 geographic regions (interquartile range 2, 5). Most applied for fellowship both in the same region as residency (216, 93%) and outside (192, 83%). Only the Pacific region saw a statistically significant increase in applicants during VI (59.9% vs 43.2%,
= 0.02). There was no statistical difference in the number of programs applied to during in-person vs VI (mean difference (95% confidence interval 0.72, -2.8 - 4.2). A majority matched in their preferred state both during VI (60.4%) and in-person interviews (65.7%). The difference was not statistically significant (
= 0.45).
While more PEM fellowship applicants applied outside the geographic area where their residency was and to the Pacific region, there was no overall increase in the number of programs or geographic areas PEM applicants applied to during VI as compared to in-person interview seasons. As this was the first two years of VI, ongoing data collection will further identify trends and the impactof VI.
Background: Armenia has trained physicians to practice family medicine (FM) for over 20 years. The pediatric population comprises a significant proportion of patients seen by FM practices, yet to ...date, there have been no studies assessing the knowledge and self-efficacy of FM physicians regarding pediatric care. As the first step is needs assessment to improve the quality of care, this study aims to assess the self-efficacy and knowledge of FM physicians regarding the care of pediatric patients. Materials and Methods: We distributed a survey to attendees at an FM conference in Lori Province, Armenia. The survey instrument assessed demographics and experience, self-efficacy in providing pediatric care, and pediatric knowledge via questions adapted from the American Board of Family Medicine (ABFM). Results: Eighty-seven percent of participants were female. Roughly half (45%) had trained through an FM residency program, while the remainder had retrained to become FM physicians following a residency in another field. Almost all (97%) practiced outside of the capital city, Yerevan. About half believed that their didactic (51%) and clinical education (48%) prepared them either "extremely" or "very" well. Overall, there was no clear relationship between participants' reported self-efficacy in a given area of pediatrics and their score in that area on the knowledge portion of the survey. Conclusions: Our findings reveal opportunities for improvement in knowledge related to pediatric care in FM physicians in Armenia, as well as a lack of relationship between reported self-efficacy and knowledge. Thus, future programs should not rely solely on self-reported gaps to identify or prioritize areas of focus. Further study is recommended in other specialties in Armenia and internationally to improve future programs.
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DOBA, IZUM, KILJ, NUK, PILJ, PNG, SAZU, UILJ, UKNU, UL, UM, UPUK
Rickets due to vitamin D deficiency, typically presenting as bowed legs in toddlers, is uncommon in the modern era. We describe the case of a nine-year-old girl with autism and developmental delay ...who was evaluated for chronic intermittent extremity pain for more than one year prior to referral to the emergency department for hypocalcemia and increased alkaline phosphatase, which eventually led to the diagnosis of rickets confirmed by radiographic and laboratory findings. This report highlights the importance of the patient's history of developmental delay and autism in the evaluation and approach to limb pain, and discusses the appropriate diagnostic approach.
Increasing access to safe, timely, and affordable acute care in low- and middle-income countries is a worldwide priority. Longitudinal curricula on systems of acute care have not been previously ...described.
The authors aimed to develop a novel four-year longitudinal curriculum for medical students addressing systems development across multiple acute care specialties.
The authors followed Kern's six-step framework for curriculum design. After review of literature, a group of medical students and school of medicine faculty conducted a targeted needs assessment. Foundational goals and objectives were adapted from the 39 interprofessional global health competencies by the Consortium of Universities for Global Health. Educational strategies include didactic sessions, workshops, journal clubs, preceptorships, and community outreach. Clinical years include specialty-specific emphases, guided junior-level discussions, and a capstone project. Yearly SWOT and Kirkpatrick model analyses served as program evaluation.
The Curriculum Council approved the program in July 2019. During the first cycle, the program matriculated 30 students from classes of 2023 (14) and 2022 (16). The first year produced 11 interactive sessions, 6 journal clubs, and 10 seminars led by 31 faculty and guest speakers; 29/30 students completed requirements; 87 evaluations reflected 4.57/5 content satisfaction and 4.73/5 instructor satisfaction. The 2023 cohort reported improved understanding of session objectives (3.13/5 vs. 3.82/5, p = 0.03). Free-text feedback led to implementation of pre-reading standardization and activity outlines.
The Program was well-received and successfully implemented. It meets the needs of graduating medical students interested in leading global health work. This novel student-faculty collaborative model could be applied at other institutions seeking to provide students with a foundation in global acute care.
A pediatric patient with hypoxia or cyanosis can frighten even the most seasoned emergency providers. Patients with these symptoms require immediate evaluation and intervention to stabilize their ...condition. While the differential can be broad, specific attention must be paid to cardiopulmonary etiologies. Tetralogy of Fallot is the most common cyanotic congenital heart abnormality, and routine screening surprisingly misses a significant amount of these cases. This case serves as an example of a missed diagnosis by screening efforts and reaffirms the resuscitation algorithm of a hypoxic pediatric patient that all emergency providers should be familiar with.
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FZAB, GIS, IJS, IZUM, KILJ, NLZOH, NUK, OILJ, PILJ, PNG, SAZU, SBCE, SBMB, UL, UM, UPUK
Background
Out-of-hospital emergency care is at an early stage of development in Armenia, with the current emergency medical services (EMS) system having emergency physicians (EPs) work on ambulances ...along with nurses. While efforts are underway by the Ministry of Health and other organizations to reform the EMS system, little data exists on the status of pediatric emergency care (PEC) in the country. We designed this study to evaluate the knowledge and attitudes of out-of-hospital emergency physicians in pediatric rapid assessment and resuscitation, and identify areas for PEC improvement.
Methods
We distributed an anonymous, self-administered Knowledge and Attitudes survey to a convenience sample of out-of-hospital EPs in the capital, Yerevan, from August to September 2012.
Results
With a response rate of 80%, the majority (89.7%) of respondents failed a 10-question knowledge test (with a pre-defined passing score of ≥7) with a mean score of 4.17 ± 1.99 SD. Answers regarding the relationship between pediatric cardiac arrest and respiratory issues, compression-to-ventilation ratio in neonates, definition of hypotension, and recognition of shock were most frequently incorrect. None of the participants had attended pediatric-specific continuing medical education (CME) activities within the preceding 5 years. χ
2
analysis demonstrated no statistically significant association between physician age, length of EMS experience, type of ambulance (general vs. resuscitation/critical care), or CME attendance and pass/fail status. The majority of participants agreed that PEC education in Armenia needs improvement (98%), that there is a need for pediatric-specific CME (98%), and that national out-of-hospital PEC guidelines would increase PEC safety, efficiency, and effectiveness (96%).
Conclusions
Out-of-hospital emergency physicians in Yerevan, Armenia are deficient in pediatric-specific emergency assessment and resuscitation knowledge and training, but express a clear desire for improvement. There is a need to support additional PEC training and CME within the EMS system in Armenia.
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IZUM, KILJ, NUK, OILJ, PILJ, PNG, SAZU, UL, UM, UPUK, VSZLJ
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