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Abstract Background The conflict in eastern Democratic Republic of the Congo (DRC) is the deadliest since World War II. Over a decade of fighting amongst an array of armed groups has resulted in extensive human rights abuses, particularly the widespread use of sexual violence against women. Methods Using a mixed-methods approach, we surveyed a non-random sample of 255 women attending a referral hospital and two local non-governmental organizations to characterize their experiences of sexual and gender-based violence (SGBV). We then conducted focus groups of 48 women survivors of SGBV to elaborate on survey findings. Quantitative and qualitative data underwent thematic and statistical analysis respectively. Findings Of the women surveyed, 193 (75.7%) experienced rape. Twenty-nine percent of raped women were rejected by their families and 6% by their communities. Thirteen percent of women had a child from rape. Widowhood, husband abandonment, gang rape, and having a child from rape were significant risk factors for social rejection. Mixed methods findings show rape survivors were seen as "contaminated" with HIV, contributing to their isolation and over 95% could not access prophylactic care in time. Receiving support from their husbands after rape was protective against survivors' feelings of shame and social isolation. Interpretation Rape results not only in physical and psychological trauma, but can destroy family and community structures. Women face significant obstacles in seeking services after rape. Interventions offering long-term solutions for hyper-vulnerable women are vital, but lacking; reintegration programs on SGBV for women, men, and communities are also needed.

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Recent political and demographic factors have exposed the vulnerability of the youth in the Middle East and North Africa (MENA) region. This study aimed to elucidate the current needs, activities, stakeholders and solutions related to at-risk youth and young adults in the MENA region. A systematic literature review was conducted of the peer-reviewed and grey literature. This was complemented by an in-region landscape analysis involving key-informant interviews and focus group discussions. After extensive screening of 1160 unique articles, 275 articles were considered relevant to this study. Of these 275, 145 (52.7%) were related to health (64.8% of these related to mental health), 101 (36.7%) to livelihood, 87 (31.6%) to violence prevention and 68 (24.7%) to education. Important themes and challenges identified in the literature and discussions included the MENA region's growing youth bulge; youth unemployment; critical gender gaps; and the impact of conflict on livelihoods, education and health, especially mental health.

Humanitarian medical assistance and intervention during the civil war in Bosnia and Croatia was felt by national health workers to be relatively ineffective (2.8 on a 5-point Likert scale), compared to other forms of humanitarian assistance such as medical supplies (4.4/5) and non-medical materials (3.9/5). Bosnian physicians treating civilians noted that the most helpful types of personnel were surgeons and emergency physicians. This study suggests that assessment of personnel needs at the recipient level, in addition to standard relief assessments, is required early in models of complex emergencies. This study supports existing epidemiological models of complex emergencies, especially when high trauma-related mortality and morbidity are likely to occur.

Objectives: To present suggestions on planning for development of emergency medicine (EM) and out-of-hospital care in countries that are in an early phase of this process, and to provide basic background information for planners not already familiar with EM., Methods: The techniques and programs used by the authors and others in assisting in EM development in other countries to date are described., Conclusions: Some aspects of EM system development have applicability to most countries, but other aspects must be decided by planners based on country-specific factors. Because of the very recent initiation of many EM system development efforts in other countries, to the authors' knowledge there have not yet been extensive evaluative reports of the efficacy of these efforts. Further studies are needed on the relative effectiveness and cost-benefit of different EM development efforts.

This article presents information on considerations involved in setting up and conducting fellowship training programs in emergency medicine (EM) for physicians from other countries. General goals for these programs are to assist in providing physicians from other countries with the knowledge and skills needed to further develop EM in their home countries. The authors report their opinions, based on their cumulative extensive experiences, on the necessary and optional structural elements to consider for international EM fellowship programs. Because of U.S. medical licensing restrictions, much of the proposed programs' content would be "observational" rather than involving direct "hands-on" clinical EM training. Due to the very recent initiation of these programs in the United States, there has not yet been reported any scientific evaluation of their structure or efficacy. International EM fellowship programs involving mainly observational EM experience can serve as one method to assist in EM development in other countries. Future studies should assess the impact and efficacy of these programs.

Objective: To describe and evaluate a training program to teach civilian prehospital care to military medics in the Sudan People's Liberation Army (SPLA)., Methods: Forty-one SPLA military personnel with variable prior medical experience participated in the course. Pre- and postintervention tests were used to evaluate participant knowledge and skill level, and test results were compared using paired t-tests., Results: An intensive 40-hour course consisting of didactic teaching sessions, small-group discussions, and practical skill stations was completed during November 1997. Thirty-seven participants successfully completed the program. Four medics with significant prior experience were trained as teaching assistants. The pretest scores for the other 33 participants ranged from 25.0% to 75.0% (SD 12.4). The posttest scores ranged from 25.0% to 87.5% (SD 15.2), with a mean improvement in test scores of 35.0% (p < 0.0005). The most striking improvements were noted in the knowledge of subjects related to wound care, hemorrhage, and head trauma., Conclusions: A field medic training program in Southern Sudan was conducted utilizing an interactive training curriculum. This program may serve as an educational model to teach prehospital care principles in other areas of international conflict.

Objectives: To describe the perceived effectiveness of using the Total Quality Management (TQM) approach to quality improvement in both academic and nonacademic EDs, and to discuss some important barriers to effectiveness of TQM programs., Method: A mail survey of 100 EDs was conducted with telephone follow-up. Hospitals were randomly selected from three subgroups: university teaching hospitals, nonuniversity teaching hospitals, and private nonteaching hospitals. ED physician directors or nonphysician administrators with knowledge of departmental quality improvement initiatives were surveyed., Results: The overall response rate was 60%. Of the respondents, 54 (90.0%) used TQM techniques as part of their quality improvement initiatives. TQM techniques were used more frequently and for a longer duration in academic programs. ED staff participation in TQM projects was relatively low; less than 25% in the majority (79.6%) of all EDs. TQM initiatives were ranked least effective in university settings, of which 11 of 13 (84.6%) rated their TQM programs as ineffective or having no effect. More mature programs (>5 years old) had a significantly higher ranking for effectiveness than those programs less than 2 years old., Conclusions: Total Quality Management is being utilized in a large number of EDs. TQM initiative is perceived as having little or no positive effect. This is particularly the case in academic EDs.

Many developing countries are experiencing a greater need for prehospital systems because of urbanization and changing population demographics, leading to greater death rates from trauma and cardiac illnesses. While emergency medical services (EMS) systems may take a variety of forms, they usually contain some system components similar to those found in the United States. In evaluating EMS abroad, it may be useful to compare the developing system type to one of five models of EMS delivery: hospital-based, municipal, private, volunteer, and complex. Using community-based services and available health providers can enable a developing system to function within a primary health network without overtaxing scarce resources. Developing such an approach can lead to creative and effective solutions for prehospital care in developing countries.

Interest in international emergency medicine (EM) has grown steadily over the last ten years. This growth has been fueled by increased demand for emergency services abroad and the proliferation of emergency physicians (EPs) working in international relief and development. As a response, several academic EM programs have developed international EM fellowships for the purpose of providing formal training to EPs interested in international health. Although there have been preliminary articles describing fellowship curricula, to the authors' knowledge no recommendations have been proposed by national consensus that suggest emphasis or required components of a fellowship program. Therefore, a group of EPs interested in fellowship training convened for the purpose of developing goals and objectives for a postgraduate training program in international EM. To that end, this article proposes guidelines for a fellowship training program for international EM.

Russia has undergone sweeping political and social reforms within the past 5 years. The economic and social reforms heralded by the "new openness" of perestroika have led to a restructuring of medicine as well. Changes include the emergence of "for profit" organizations and acute care facilities, the introduction of private health insurance, modifications in the medical education system, and realignment of health priorities with a new trend toward primary care.

Emergency medicine in Hong Kong is a relatively new specialty. Substantial progress toward recognition of emergency medicine in the territory has occurred during the past 2 years, and the Hong Kong College of Emergency Medicine is now formally recognized by the Royal College of Surgeons in the United Kingdom. With the transfer of the territory to chinese rule, the emergency medical system in Hong Kong may serve as a model for the development of emergency medicine in mainland China.

Objectives: To describe the rehabilitation of a large referral hospital amid the civil war in Rwanda, and to discuss the effectiveness of a mentor approach in re-establishing the facility's administrative structure., Design: A mentor administrative design was used to re-establish the hospital personnel structure. This approach linked Rwandan health workers with foreign medical consultants. Formal interviews to evaluate the acceptance and effectiveness of the mentor administration model were conducted with foreign and Rwandan administrative staff. Six month retrospective review of hospital demographics (August 1994-January 1995) was compared to 1993 pre-war data (January-December, 1993)., Setting: The Central Hospital of Kigali, a 600 bed facility in Rwanda, East Africa., Participants: Rwandan and foreign administrators, non-government relief organizations (NGOs), United Nations Military forces, and patients presenting to the Central Hospital., Results: The hospital became fully functional in August of 1994. Both foreign and Rwandan administrators surveyed stated that the mentor program was effective but the hospital would ultimately require external financial support for sustainability. A total of 38,042 patients were treated at the hospital during the six month study period. Compared to 1993 pre-war data, there was a substantial increase in both the overall patient volume and the number of traumatic injuries. Despite this, the case fatality ratio during the post-war period was significantly lower., Conclusions: A mentor approach was utilized to re-establish the administrative structure of the Central Hospital of Kigali. The facility was able to successfully function despite a larger patient volume compared to the pre-war period. This collaborative effort between NGOs and Rwandan personnel resulted in the development of a sustainable administrative and medical program. The use of a mentor administration may serve as a model for future rehabilitative efforts abroad.

There are a growing number of emergency physicians (EPs) working in health care abroad. There are, however, no formal training programs for EPs in international health. An International Health Fellowship has been developed to provide training for EPs in public health and international medicine. The fundamental competencies of a fellow completing the International Health Fellowship include assessment of medical need, program development, integration of programs into the existing health care framework, and evaluation of projects. This article outlines the philosophy of a training program in international health, provides an overview of the goals and objectives for such a program, and describes the development of an existing fellowship. The International Health Fellowship will develop leaders in the field of global health by combining clinical expertise, practical field experience, formal public health training, and research and education in international health. Physicians completing a fellowship will be prepared to work within foreign health systems to develop, integrate, and evaluate health care programs on an international scale.

Study Objective: To describe the effectiveness of an emergency medical education program in a postwar developing country., Methods: A prospective, nonrandomized interrupted time-series study was conducted in an emergency department at a national referral hospital in Rwanda immediately after the 1994 civil war. Participants included 11 medical personnel staffing the ED comprising physicians, nurses, and medical assistants. International medical relief workers in the ED identified deficiencies by directly observing routine clinical practices. On the basis of this assessment, formal training programs in trauma resuscitation, airway management, wound care, and blood/fluid precautions were conducted. Subjects were then observed 1 week and 2 months after the educational programs and scored on a standardized data-collection form. Scores before and after intervention were compared with the use of Fisher's exact test to determine program effectiveness., Results: Educational interventions with statistically significantly longer term effects included wound management principles and blood/fluid precautions (before versus after intervention, P < .05). Interventions with the least sustained effect included advanced airway interventions and procedures related to trauma resuscitation., Conclusion: Educational seminars proved to have the greatest sustained effect on those behaviors requiring minimal equipment and noncomplex medical decisionmaking.

Objectives: Since February 1992, the civil war in the former Yugoslavia has left over 140,000 people dead. This study describes the injuries and outcome of patients treated at a provisional war hospital in Bosnia and compares mortality rates with war hospitals from prior armed conflicts., Design: This is a retrospective review of 1,703 trauma patients treated between March 1993 and October 1993 at the Nova Bila War Hospital., Results: In Bosnia, the overall mortality was 10.3% (5.0% dead on arrival and 5.3% inhospital deaths). Head injuries, seen in 19.2% of patients, had a mortality of 23.8%. The odds of sustaining a gunshot wound were 2.8 times greater in Bosnia than in Vietnam (p < 0.05). The odds of sustaining a head injury were 1.1 to 1.6 times greater in Bosnia than in Lebanon and Afghanistan (p < 0.05). The overall mortality odds in Bosnia were 3.1 times greater than in Vietnam (p < 0.001), but were equal to those in Lebanon and Afghanistan., Conclusions: Despite limited personnel and supplies, the inhospital mortality rate was comparable with those found in other war hospitals. The Nova Bila Hospital represents a unique response to the great medical need brought about by the continued fighting in the former Yugoslavia.

Hypothesis: Pediatric mortality is predicted by age, presence of head trauma, head trauma with a low Glasgow Coma Scale (GCS) score, a low Pediatric Trauma Score (PTS), and transport directly to a pediatric trauma center., Population: Studied were 1,429 patients younger than 16 years old admitted to or declared dead on arrival (DOA) in a pediatric trauma center from January through October, 1988. The trauma system, which served 3-million persons, included six pediatric trauma centers., Methods: Data were obtained by a retrospective review of summary statistics provided to the Chicago Department of Health by the pediatric trauma centers., Results: Overall mortality was 4.8% (68 of 1429); 32 of the patients who died (47.1%) were DOA. The in-hospital mortality rate was 2.6%. Head injury was the principal diagnosis in 46.2% of admissions and was a factor in 72.2% of hospital deaths. The mortality rate was 20.3% in children with a GCS < or = 10 and 0.4% when the GCS was > 10 (odds ratio [OR] = 67.0, 95% CI = 15.0-417.4). When the PTS was < or = 5, mortality was 25.6%; with a PTS > 5, the mortality was 0.2% (OR = 420.7, 95% CI = 99.3-2,520). Although transfers to a pediatric trauma center accounted for 73.6% of admissions, direct field triage to a pediatric trauma center was associated with a 3.2 times greater mortality risk (95% CI = 1.58-6.59). Mortality rates were equal for all age groups. Pediatric trauma center volume did not influence mortality rates., Conclusions: Head injury and death occur in all age groups, suggesting the need for broad prevention strategies. Specific GCS and PTS values that predict mortality can be used in emergency medical services (EMS) triage protocols. Although the high proportion of transfers mandates systemwide transfer protocols, the lower mortality in these patients suggests appropriate EMS field triage. These factors should be considered as states develop pediatric trauma systems.

Introduction: The civil war in Somalia has destroyed the medical system and left hundreds of thousands of people without access to medical care. Samaritan's Purse and World Medical Missions, two relief organizations, developed mobile medical teams to provide health care to urban and rural Somalia. Gastroenteritis with severe dehydration was encountered frequently, and difficult intravenous (i.v.) access presented a challenging dilemma for patients who were unable to tolerate oral or nasogastric fluid administration., Hypothesis: Intraperitoneal (i.p.) fluid infusion may be used to treat dehydration in patients with poor venous access and ongoing fluid losses., Methods: Two mobile medical teams treated patients from 1 January to 1 April 1993. Intraperitoneal fluid infusions were given to 16 patients with severe dehydration in whom i.v. access was unobtainable. Children received approximately 80 ml/kg of 0.45% normal saline, and adults received 40 ml/kg of 0.9% normal saline. Patients were reexamined at one and seven days., Results: A total of 25,659 patients were seen in the mobile medical clinics during a 3-month period. Dehydration was diagnosed in 1,833 (7.1%) patients, and 1,203 (4.7%) patients were found to be malnourished. Sixteen patients were treated with i.p. fluid infusions, 14 patients (87.5%) survived, and two patients (12.5%) died, both within 24 hours. In one patient (6.3%), subcutaneous infiltration occurred without subsequent adverse effects., Conclusion: This case series found that in the mobile clinic setting in Somalia, i.p. fluid administration improved the hydration status in patients with significant dehydration. Although i.v. infusion remains the treatment of choice when oral or nasogastric fluid administration is not possible, i.p. infusion is easily performed and may be an important alternative in disaster settings.

This case series illustrates the use of a suction catheter to guide the passage of an endotracheal (ET) tube through the glottis, a technique modification which can be used when standard nasotracheal intubation is unsuccessful. The technique is appropriate for patients in whom airway management is urgent, but not emergent. Catheter-assisted nasotracheal intubation is useful when intubation is difficult because of excessive patient resistance to movement of the ET tube within the oropharynx. The clinical use of this technique is described for the following scenarios: overdose with obtundation, multiple trauma with agitation, and respiratory failure from pneumonia and pulmonary edema.