Knowledge of Emergency Medicine Residents in Relation to
Transcript Of Knowledge of Emergency Medicine Residents in Relation to
71 Emergency (2014); 2 (2): 71-76
ORIGINAL RESEARCH
Knowledge of Emergency Medicine Residents in Relation to Prevention of Tetanus
Hojjat Derakhshanfar1, Behrooz Hashemi2*, Mohammad Manouchehrifar3, Parvin Kashani1 Mohammad Mehdi Forouzanfar2
1. Department of Emergency Medicine, Imam Hussein Hospital, Shahid Beheshti University of Medical Sciences, Tehran, Iran 2. Department of Emergency Medicine, Shohadaye Tajrish Hospital, Shahid Beheshti University of Medical Sciences, Tehran, Iran 3. Department of Emergency Medicine, Loghman Hakim Hospital, Shahid Beheshti University of Medical Sciences, Tehran, Iran
Abstract
Introduction: Knowledge of emergency medicine residents about the management of patients suspected of having tetanus-favoring wounds is very important due to their responsibility for the treatment of such patients. The aim of the present study was to evaluate this knowledge and making sure of the adequacy of instructions they have received in relation to prevention of tetanus. Methods: A reliable and reproducible questionnaire was used to evaluate knowledge of all the emergency medicine residents in Imam Hussein Hospital in Tehran, Iran, about conditions favoring tetanus (9 questions) and proper interventions in such conditions (12 questions). The questionnaires were completed and scored as poor and good. The Mann-Whitney U test was used to analyze data. Statistical significance was set at P<0.05. Results: In the present study, 73 emergency medicine residents were evaluated (45.2% male). Knowledge of 31 (42.5%) residents in relation to conditions favoring tetanus and 41 (56.2%) residents in correct therapeutic interventions was in good level. The most frequent incorrect answer was related to diabetic ulcers and wounds in patients with sepsis. There was an increase in scores of conditions favoring tetanus (P<0.001) and correct therapeutic interventions (P=0.001) with an increase in educational years. However, age (P=0.64), gender (P=0.31), job experience (P=0.38) and participation in educational courses (P=0.67) had no effect on the knowledge level of emergency medicine residents. Conclusion: According to the findings of the present study, the knowledge of emergency medicine residents about correct management of patients suspected of tetanus was low, which emphasizes the necessity of providing further instructions on prevention of tetanus in wound management. Key words: Tetanus; vaccines; immunoglobulin; emergency medicine; primary prevention
Cite this article as: Derakhshanfar H, Hashemi H, Manouchehrifar M, Kashani K, Forouzanfar MM. Knowledge of emergency medicine residents in relation to prevention of tetanus. Emergency. 2014;2(2):71-6.
TIntroduction:1 etanus is an acute and life-threatening condition which is common in all the age groups and in all the geographic locations. Despite the fact that the condition is an international problem, hot and humid areas, which have a soil rich in organic materials, have the highest prevalence rate. In addition, the risk is higher in intravenous drug abusers, non-vaccinated individuals and immunocompromised patients (1). Tetanusrelated mortality in developing counties is 135 folds higher than that in developed countries (2). The exact prevalence rate of the condition worldwide is not fully known, but based on estimates the incidence is 500,000 to 1,000,000 cases annually with a mortality rate of
*Corresponding Author: Behrouz Hashemi; Farhad Rahmati; Department of Emergency Medicine, Shohadaye Tajrish Hospital, Tajrish Square, Tehran, Iran. Tel/Fax: +982122721155; Email: [email protected] Received: 12 April 2014; Accepted: 10 May 2014
20% to 45%. The majority of new tetanus cases arise in developing countries, with almost 50% of cases occurring in newborns. However, in developed counties, tetanus is rare and mostly occurs in the elderly (3, 4). It should be pointed out that tetanus is the only noncommunicable infections disease which can be prevented by vaccination (5). The most important risk factor for the development of tetanus is lack of immunization; in this context, 72% of tetanus victims have not completed their initial vaccination (6). In taking care of wounds suspected of tetanus and use of prophylaxis for it, a history of patient’s vaccination is very important because in individuals who have received five initial vaccination doses completely no particular intervention is necessary, except for cases in which the wound favours tetanus. However, if the patient’s vaccination history is not available or the vaccination has been incomplete, therapeutic interventions
This open-access article distributed under the terms of the Creative Commons Attribution NonCommercial 3.0 License (CC BY-NC 3.0). Copyright © 2014 Shahid Beheshti University of Medical Sciences. All rights reserved. Downloaded from: www.jemerg.com
72 Derakhshanfar et al
are similar to those cases in which the patient is not immune to tetanus. In such cases, human tetanus immune globulin (TIg) and Booster vaccine are the most important therapeutic measures to prevent tetanus (7, 8). Based on the above-mentioned, one of the measures, which is necessary in traumatic patients, is evaluation of their status and a judgment about the need to use TIg and vaccine. The evaluation is carried out in different ways, including clinical judgment, ELISA test and rapid diagnostic procedures (9-11). Limitations in the use of laboratory tests and sometimes low accuracy of these tests (12, 13) have made the physician’s clinical judgment an important factor in decision-making processes. Unfortunately, lack of proper knowledge of physicians in this respect has resulted in indiscriminate and unnecessary use of the vaccine and immune globulin (8, 12). This lack of knowledge has increased patient treatment costs and the economic toll on the country’s health system. On the other hand, if correct prophylactic measures are not taken in situations favouring tetanus, the patient is exposed to a high risk of this lifethreatening disease, which will have tragic consequences. Therefore, the present study was undertaken to evaluate the knowledge of emergency medicine residents and the adequacy of education they have received in relation to prevention of tetanus. Methods: The present cross-sectional study was carried out from April 2012 to October 2012 in Imam Hussein Hospital in Tehran, Iran, a third-level university hospital with 60000 annual admissions. All the emergency medicine residents were evaluated. Exclusion criterion was unwillingness to participate in the study. The minimum sample size at P=0.5 (14), maximum permissible error of 0.05 (d=0.05) at confidence interval of 95% was 61 residents. In order to collect data, a questionnaire was designed, with the aim to evaluate the knowledge of the emergency medicine residents about the diagnosis and management of wounds and conditions suspected of tetanus. The questionnaire was designed using emergency medicine references and textbooks under the supervision of two emergency medicine specialists and one epidemiologist. Then the reliability of the questionnaire was confirmed by calculating Cronbach’s alpha at 0.71. The questionnaire consisted of three sections. The first section consisted of questions on the residents’ demographic data (age, gender, educational status, job experience and participation in educational courses on tetanus). The second section consisted of nine questions, each with three choices (Yes, No, I do not know) in relation to the knowledge of residents about conditions favoring tetanus. These nine questions concerned the odds of developing tetanus due to contaminated
wounds, deep wounds, and wounds more than 12 hours old, wounds in systemic septic patients, diabetic ulcerations, infection of the injection site in drug addicts, wounds inflicted in open areas (streets, parks etc), burns, and finally wounds requiring surgical intervention for debridement. The third section consisted of 12 questions with three choices (always, sometimes, never) on the knowledge of residents about the necessary interventions in cases suspected of tetanus. These questions were as follows: two questions in relation to the necessary interventions concerning the time elapsed since the patient’s complete vaccination (more than 10 years, less than 10 years); administration of a Booster dose in the past; lack of access to patient’s vaccination history; receiving only one dose of tetanus vaccine; and the necessary measures in immunocompromised patients. The questionnaires were handed in to the residents and each resident was given 30 minutes to answer the questions. Scoring of the questions on the residents’ knowledge about conditions favouring tetanus was carried out by giving one positive score to each correct answer and one negative score to each incorrect answer. The answer “I do not know” received no score (a score of zero). In scoring questions on correct measures during encounter with conditions favouring tetanus, too, each correct answer received a positive score and each incorrect answer received a negative score. Therefore, the subjects could receive a total score of -9 to 9 in the section on knowledge about conditions favouring tetanus and a total score of -12 to 12 in the section on correct intervention. A minimum score of 5 (5≥) in the section on conditions favouring tetanus and at least 6 (6≥) in the section on correct intervention were considered good knowledge level; scores less than these values were considered poor knowledge level. Data collected from the questionnaires were entered into SPSS 21 software and then STATA 11.0 software was used for descriptive and analytical evaluation of data. Man-Whitney U test was used to evaluate the relationship between the scores and the demographic data. Statistical significance was set at p<0.05. Results: In the present study, 73 emergency residents were evaluated (male: 45.2%). Mean and standard deviation of ages of the subjects was 33.3±4.5 years. Of 37 residents in the present study 29 (39.7%), 23 (31.5%) and 21 (28.8%) were first-, second- and third-year residents, respectively. The majority of the subjects (52.1%) had job experiences of more than two years, before initiation of residency. Of all the residents under study, only 7 residents (9.6%) had participated in courses on tetanus and vaccination against tetanus (Table 1). Knowledge of 31 (42.5%) residents about the conditions favoring tetanus was at a good level (mean ±
This open-access article distributed under the terms of the Creative Commons Attribution NonCommercial 3.0 License (CC BY-NC 3.0). Copyright © 2014 Shahid Beheshti University of Medical Sciences. All rights reserved. Downloaded from: www.jemerg.com
73 Emergency (2014); 2 (2): 71-76
SD = 3.2 ± 2.4). The most frequent incorrect answer was related to diabetic ulcers. Despite the fact that such ulcers are not susceptible to tetanus, 46 residents (63%) believed it was; in contrast, 8 residents (11%) had no knowledge on the subject (“I do not know”). After diabetic ulcers, the most frequent incorrect answer was related to ulcers in patients with sepsis. Although this ulcer is susceptible to tetanus, 3 residents (31.5%) believed it was not and 10 residents (5.5%) had no knowledge on the subject (“I do not know”). Table 2 presents the frequencies of residents’ responses to each question separately. In addition, knowledge of only 41 (56.2%) residents about correct therapeutic measures was at a good level (mean ± SD = 6.1 ± 2.7). The most frequent mistake of residents was related to injection of TIg in patients who have received complete vaccination. Fifty-eight residents (79%) had given incorrect answer to the first question (elapsing of more than 10 years since complete vaccination) and 97 (50.7%) residents had given incorrect answer to the next question (elapsing of less than 10 years since complete vaccination). Forty-three (58.9%) residents provided incorrect answers to question regarding necessity of TIg and 38 (52%) necessity of vaccine in immune compromised patients (Table 3). The only factor affecting the knowledge of residents about conditions favoring tetanus was the educational level of the residents (P<0.001), i.e. the residents’ knowledge increased with an increase in educational level. Of first-, second- and third-year residents, 13.8%, 39.1% and 90.5% had good knowledge, respectively. However, other factors did not influence their knowledge about the conditions favoring tetanus. Table 4 presents the relationship between these variables and the residents’ knowledge level. In addition, educational level affected knowledge about correct therapeutic measures (P=0.001). Good knowledge level was higher (85.7%) in third-year residents than that in first-year (31.0%) and second-year (52.5%) residents (P=<0.001). However, age (P=0.64), gender (P=0.31), job experience (P=0.38) and participation in educational courses (P=0.67) had no effect on the knowledge level of emergency medicine residents (Table 5). Discussion: The results of the study showed that the knowledge of emergency medicine residents about the diagnosis of conditions favoring tetanus and correct measures in such cases was poor. The most important factor affecting this knowledge was educational years during residency, i.e. the third-year residents had higher knowledge compared to first- and second-year residents. The most common error of the residents in the diagnosis of conditions favoring tetanus was deeming diabetic foot ulcerations (63.0%), a factor leading to
Table 1: Baseline characteristics of residents
Variable
Frequency (%)
Gender
male
33(45.2%)
female
40(54.8%)
Educational status
first year
29(39.7%)
second year
31(31.5%)
third year
21(28.8%)
Job experience
less than a year
13(17.8%)
1-2 years
22(30.1%)
more than 2 years
38(52.1%)
Participation in educational courses
no
66(9.6%)
yes
7(90.4%)
tetanus. On the other hand, the most common error in relation to therapeutic intervention for suspected ulcers was administration of TIg in patients who have been completely vaccinated. In addition, 52.9% and 52% of residents were not aware about the necessity of administering TIg and vaccine in immunocompromised patients, respectively. The results of the present study showed the necessity of providing further instructions for emergency medicine residents on the diagnosis and management of suspected tetanus cases. Dabas et al showed that the knowledge of physicians in relation to the vaccination of adults was low and only 48.3% of physicians knew the correct indications and cases of tetanus vaccine (15). A study by Brand et al, too, showed that 23% of cases suspected of tetanus were not treated correctly, with 6% of inadequate administration and 17% of excessive prophylactic measures against tetanus (16). A study by Adeboye and Sangowawa in Britain, in which 40 emergency unit personnel, consisting of physicians and nurses were evaluated, showed that only 17 personnel (42.5%) were aware of new prophylactic guidelines against tetanus (17). A study by Chowdhury et al showed that the majority of interns did not have sufficient knowledge about conditions favoring tetanus and proper therapeutic measures (18). A study by Talan et al showed the inadequacy of the therapeutic measures in 35% of cases suspected of tetanus (19). As discussed above, awareness about conditions favoring tetanus and techniques used to tackle them have been at an unfavorable level in the majority of studies; based on these studies the prevalence of diagnostic and therapeutic errors in this disease condition is much higher than that in other clinical problems (12, 15, 1719). These funding show a great disparity between
This open-access article distributed under the terms of the Creative Commons Attribution NonCommercial 3.0 License (CC BY-NC 3.0). Copyright © 2014 Shahid Beheshti University of Medical Sciences. All rights reserved. Downloaded from: www.jemerg.com
74 Derakhshanfar et al
Table 2: Answers given by the residents to questions on conditions favoring tetanus
Questions
Is the wound susceptible to tetanus? (%)
Yes
No
I do not know
Deep wound
57 (78.1)
13 (17.8)
3 (4.1)
Contaminated wound
72 (8.6)
1 (1.4)
0 (0.0)
Wound older than 12 hours
47 (64.4)
22 (30.1)
4 (5.5)
Wound in sepsis patients
40 (54.8)
23 (31.5)
10 (5.5)
Diabetic ulcer
46 (63.0)
19 (26.0)
8 (11.0)
Infection of injection site in drug addicts
55 (75.3)
11 (15.1)
7 (9.6)
Wounds produced in open environments 53 (72.6)
18 (24.7)
2 (2.7)
Burns
68(93.2)
4 (5.5)
1 (1.4)
Wounds requiring debridement
50 (68.5)
17 (23.3)
6 (8.2)
Classification
susceptible susceptible susceptible susceptible not susceptible susceptible not susceptible susceptible susceptible
Table 3: Responses of residents in relation to correct measures in wounds favoring tetanus
Questions on knowledge about correct measures
Always
Sometimes
Never
10 years elapsed after complete vaccination
TIg
34 (46.6)
24(32.9)
15 (20.5)
Vaccine
67 (91.8)
6 (8.2)
0 (0.0)
<10 years elapsed after complete vaccination
TIg
9 (12.3)
28 (38.4)
36 (49.3)
Vaccine
28 (38.4)
37 (50.7)
8 (10.9)
Complete vaccination plus a Booster dose
TIg
3 (4.1)
20 (27.4)
50 (68.5)
Vaccine
9 (12.3)
31 (42.5)
33 (45.2)
No vaccination history is available
TIg
57 (78.1)
12 (16.4)
4 (5.5)
Vaccine
70 (95.9)
3 (4.1)
0 (0.0)
One vaccination dose received
TIg
40 (54.8)
24 (32.9)
9 (12.3)
Booster
58 (79.5)
10 (13.7)
5 (6.8)
Immunocompromised
TIg
30 (41.1)
34 (46.6)
9 (12.3)
Booster
35 (48.0)
30 (41.1)
8 (10.9)
*TIg: Tetanus immune globulin
Classification
never always
never sometimes
never sometimes
always always
always always
always always
these guidelines and what actual happens in the clinic. Therefore, due to the low knowledge of residents in the present study and other similar studies, measures should be taken to define and prepare guidelines to promote awareness of physicians about prevention of tetanus. Medical education groups, especially emergency medicine group, should play a key role in this respect because emergency medicine specialists, during their education and after graduation, are the first physicians who carry out therapeutic interventions (20, 21). In addition, the high prevalence of accidents and other cases of traumas in our country (22, 23) on one hand and the need to provide correct care for such traumas on the other hand show the great importance of proper and up-to-date knowledge of physicians in relation to the management of wounds. In the present study, irrespective of educational years, what attracts attention is the low scores of residents in the diagnosis and management of wounds favoring tet-
anus. As discussed in the results section, the means and standard deviations of the residents’ scores in the present study in relation to conditions favoring tetanus and correct therapeutic procedures were 3.2±2.4 and 6.1±2.7, respectively. Based on these data, since the maximum attainable scores in these two sections were 9 and 12, respectively, unfortunately the scores gained by the residents were very low. These findings reflect the shortcomings of the educational system, which might be attributed to deficiencies of the educational structures, inappropriate educational environments, lack of attention of the educational system to the needs of the community and the students and finally presentation of a large volume of educational materials in a short time. Therefore, different reasons have led to the inadequacy of the instructions provided, which include the inadequacy of the educational structure and system, inappropriate teaching environment and a lack of consistency between the educational programs and the
This open-access article distributed under the terms of the Creative Commons Attribution NonCommercial 3.0 License (CC BY-NC 3.0). Copyright © 2014 Shahid Beheshti University of Medical Sciences. All rights reserved. Downloaded from: www.jemerg.com
75 Emergency (2014); 2 (2): 71-76
Table 4: The relationship between knowledge about tetanus risk factors and demographic factors
Variable
Poor knowledge
Good knowledge
P
n
%
n
%
Gender
male female
77 2117..25 2363 7882..85 0.69
Educational status
first year
25
86.2
4
13.8
second year
14
60.9
9
39.1
<0.0001
third year
2
9.5
19
90.5
Job experience
less than a year
3
23.1
10
76.9
1-2 years
2
9.1
20
90.9
0.38
> 2 years
9
23.7
29
76.3
Participation in educational courses
nyeos 122 1288..26 554 8711..84 0.61
Table 5: Relationship between knowledge about correct
Variable
Poor knowledge
n
%
Gender
male
10
30.3
female
8
20.0
Educational status
first year
20
69.0
second year
11
47.8
third year
3
14.3
Job experience
less than a year
4
30.8
1-2 years
4
18.2
> 2 years
10
26.3
Participation in educational courses
no
17
25.8
yes
1
14.3
therapeutic measure and demographic
Good knowledge
n
%
23
69.7
32
80.0
9
31.0
12
52.2
18
85.7
9
69.2
18
81.85
28
73.7
49
74.2
6
85.75
factors P
0.31
0.001 0.38 0.67
needs of the community and the students. Therefore, the existing educational system should be thoroughly revised. One of the limitations of the present study was the absence of an educational intervention. If an educational intervention had been available, it wound have been possible to evaluate the effect of education on improving the knowledge of residents. On the other hand, the resident’s awareness of the fact that he or she was under evaluation might have resulted in bias, affecting the results of the study, showing an increase in knowledge of residents in a false manner. However, since the mean knowledge level of the residents was low, the authors believe that the results are valid and reliable largely. Nevertheless, it is suggested that in future studies, the emergency medicine residents’ knowledge be evaluated
in a double-blind manner next to the patient bed and then an educational program be designed and the residents’ knowledge be evaluated again so that the effect of education on promoting knowledge can be evaluated. Conclusion: According to the findings of the present study, the knowledge of emergency medicine residents about correct management of patients suspected of tetanus was low, which emphasizes the necessity of providing further instructions on prevention of tetanus in wound management. Acknowledgments:
The authors appreciate the insightful cooperation of Medical Sciences and the staffs of the Emergency Department of Imam Hussein Hospital in Tehran, Iran. Conflict of interest:
This open-access article distributed under the terms of the Creative Commons Attribution NonCommercial 3.0 License (CC BY-NC 3.0). Copyright © 2014 Shahid Beheshti University of Medical Sciences. All rights reserved. Downloaded from: www.jemerg.com
76 Derakhshanfar et al
None Funding support: None Authors’ contributions: All authors passed four criteria for authorship contribu-
tion based on recommendations of the International
Committee of Medical Journal Editors.
References: 1. Wassilak SG, Kretsinger K. Tetanus. Bacterial Infections of Humans: Springer; 2009. p. 813-32. 2. Parveen G, Hussain S, Malik F, et al. Seroepidemiological surveillance of antitetanus antibodies in Pakistani childbearing women: A population based survey. Afr J Pharm Pharacol. 2012;6(36):2621-8. 3. Hüllstrung HD, Mäusezahl D, Feuz M, Herzog C, Conzelmann M, Zimmerli W. Tetanus immunisation in geriatric patients with accidental wounds: how much is needed. Swiss Med Wkly. 2003;133(15-16):227-32. 4. Kapoor AN, Tharyan P, Kant L, Balraj V, Shemilt I. Combined DTP-HBV vaccine versus separately administered DTP and HBV vaccines for primary prevention of diphtheria, tetanus, pertussis, and hepatitis B. Cochrane Lib. 2010;6(1):7-65. 5. Althouse BM, Bergstrom TC, Bergstrom CT. A public choice framework for controlling transmissible and evolving diseases. Proc Natl Acad Sci. 2010;107(suppl 1):1696-701. 6. Afshar M, Raju M, Ansell D, Bleck TP. Narrative review: tetanus—a health threat after natural disasters in developing countries. Ann Intern Med. 2011;154(5):329-35. 7. Miyagi K, Shah AK. Tetanus prophylaxis in the management of patients with acute wounds. J Plast Reconstr Aesthet Surg. 2011;64(10):e267-9. 8. Scott T. Point-of-care tetanus immunoassay: An audit of unscheduled tetanus prophylaxis. Int J Orth Trauma Nurs. 2012;16(2):97-103. 9. Hatamabadi HR, Abdalvand A, Safari S, et al. Tetanus Quick Stick as an applicable and cost-effective test in assessment of immunity status. Am J Emerg Med. 2011;29(7):717-20. 10. McVicar J. Should we test for tetanus immunity in all emergency department patients with wounds? Emerg Med J. 2013;30(3):177-9. 11. Örtqvist Å, Blennow M, Carlsson RM, et al. Vaccination of children–a systematic review. Acta Paediatr. 2010;99 (s461):1-192.
12. Gall SA. Prevention of pertussis, tetanus, and diphtheria among pregnant, postpartum women, and infants. Clin Obstet Gynecol. 2012;55(2):498. 13. Reid PM, Brown D, Coni N, Sama A, Waters M. Tetanus immunisation in the elderly population. J Accid Emerg Med. 1996;13(3):184-5. 14. Heydari G, Yousefifard M, Hosseini M, Ramezankhani A, Masjedi M. Comparison of Cigarette Smoking, Knowledge, Attitude and Prediction of Smoking for the Next Five Years and Their Association between Students, Teachers and Clergymen. Int J Prev Med. 2013;4(5):557-64. 15. Dabas P, Agarwal C, Kumar R, Taneja D, Ingle G, Saha R. Knowledge of general public and health professionals about tetanus immunization. Indian J Pediatr. 2005;72(12):1035-7. 16. Brand DA, Acampora D, Gottlieb LD, Glancy KE, Frazier WH. Adequacy of antitetanus prophylaxis in six hospital emergency rooms. N Engl J Med. 2007;309(11):636-9. 17. Adeboye K, Sangowawa O. Tetanus prophylaxis in the A&E department. J R Soc Med. 2002;95(3):113. 18. Chowdhury R, Mukherjee A, Lahiri SK. A Study on the Knowledge of Tetanus Immunization Among Internees in A Government Medical College of Kolkata. Nat J Community Med. 2011;2(3):432-9. 19. Talan DA, Abrahamian FM, Moran GJ, et al. Tetanus immunity and physician compliance with tetanus prophylaxis practices among emergency department patients presenting with wounds. Ann Emerg Med. 2004;43(3):305-14. 20. King RA, Liu KY, Talley BE, Ginde AA. Availability and Potential Impact of International Rotations in Emergency Medicine Residency Programs. J Emerg Med. 2013;44(2):499– 504. 21. Smith-Coggins R, Carius ML, Collier RE, et al. Report on Residency Training Information (2011-2012), American Board of Emergency Medicine. Ann Emerg Med. 2012;59(5):416-24. 22. Bakhtiyari M, Mehmandar MR, Mirbagheri B, Hariri GR, Delpisheh A, Soori H. An epidemiological survey on road traffic crashes in Iran: application of the two logistic regression models. Int J Inj Contr Saf Promot. 2013 (ahead-ofprint):1-7. 23. Heydari ST, Hoseinzadeh A, Sarikhani Y, et al. Time analysis of fatal traffic accidents in Fars Province of Iran. Chin J Traumatol. 2013;16(2):84-8.
This open-access article distributed under the terms of the Creative Commons Attribution NonCommercial 3.0 License (CC BY-NC 3.0). Copyright © 2014 Shahid Beheshti University of Medical Sciences. All rights reserved. Downloaded from: www.jemerg.com
ORIGINAL RESEARCH
Knowledge of Emergency Medicine Residents in Relation to Prevention of Tetanus
Hojjat Derakhshanfar1, Behrooz Hashemi2*, Mohammad Manouchehrifar3, Parvin Kashani1 Mohammad Mehdi Forouzanfar2
1. Department of Emergency Medicine, Imam Hussein Hospital, Shahid Beheshti University of Medical Sciences, Tehran, Iran 2. Department of Emergency Medicine, Shohadaye Tajrish Hospital, Shahid Beheshti University of Medical Sciences, Tehran, Iran 3. Department of Emergency Medicine, Loghman Hakim Hospital, Shahid Beheshti University of Medical Sciences, Tehran, Iran
Abstract
Introduction: Knowledge of emergency medicine residents about the management of patients suspected of having tetanus-favoring wounds is very important due to their responsibility for the treatment of such patients. The aim of the present study was to evaluate this knowledge and making sure of the adequacy of instructions they have received in relation to prevention of tetanus. Methods: A reliable and reproducible questionnaire was used to evaluate knowledge of all the emergency medicine residents in Imam Hussein Hospital in Tehran, Iran, about conditions favoring tetanus (9 questions) and proper interventions in such conditions (12 questions). The questionnaires were completed and scored as poor and good. The Mann-Whitney U test was used to analyze data. Statistical significance was set at P<0.05. Results: In the present study, 73 emergency medicine residents were evaluated (45.2% male). Knowledge of 31 (42.5%) residents in relation to conditions favoring tetanus and 41 (56.2%) residents in correct therapeutic interventions was in good level. The most frequent incorrect answer was related to diabetic ulcers and wounds in patients with sepsis. There was an increase in scores of conditions favoring tetanus (P<0.001) and correct therapeutic interventions (P=0.001) with an increase in educational years. However, age (P=0.64), gender (P=0.31), job experience (P=0.38) and participation in educational courses (P=0.67) had no effect on the knowledge level of emergency medicine residents. Conclusion: According to the findings of the present study, the knowledge of emergency medicine residents about correct management of patients suspected of tetanus was low, which emphasizes the necessity of providing further instructions on prevention of tetanus in wound management. Key words: Tetanus; vaccines; immunoglobulin; emergency medicine; primary prevention
Cite this article as: Derakhshanfar H, Hashemi H, Manouchehrifar M, Kashani K, Forouzanfar MM. Knowledge of emergency medicine residents in relation to prevention of tetanus. Emergency. 2014;2(2):71-6.
TIntroduction:1 etanus is an acute and life-threatening condition which is common in all the age groups and in all the geographic locations. Despite the fact that the condition is an international problem, hot and humid areas, which have a soil rich in organic materials, have the highest prevalence rate. In addition, the risk is higher in intravenous drug abusers, non-vaccinated individuals and immunocompromised patients (1). Tetanusrelated mortality in developing counties is 135 folds higher than that in developed countries (2). The exact prevalence rate of the condition worldwide is not fully known, but based on estimates the incidence is 500,000 to 1,000,000 cases annually with a mortality rate of
*Corresponding Author: Behrouz Hashemi; Farhad Rahmati; Department of Emergency Medicine, Shohadaye Tajrish Hospital, Tajrish Square, Tehran, Iran. Tel/Fax: +982122721155; Email: [email protected] Received: 12 April 2014; Accepted: 10 May 2014
20% to 45%. The majority of new tetanus cases arise in developing countries, with almost 50% of cases occurring in newborns. However, in developed counties, tetanus is rare and mostly occurs in the elderly (3, 4). It should be pointed out that tetanus is the only noncommunicable infections disease which can be prevented by vaccination (5). The most important risk factor for the development of tetanus is lack of immunization; in this context, 72% of tetanus victims have not completed their initial vaccination (6). In taking care of wounds suspected of tetanus and use of prophylaxis for it, a history of patient’s vaccination is very important because in individuals who have received five initial vaccination doses completely no particular intervention is necessary, except for cases in which the wound favours tetanus. However, if the patient’s vaccination history is not available or the vaccination has been incomplete, therapeutic interventions
This open-access article distributed under the terms of the Creative Commons Attribution NonCommercial 3.0 License (CC BY-NC 3.0). Copyright © 2014 Shahid Beheshti University of Medical Sciences. All rights reserved. Downloaded from: www.jemerg.com
72 Derakhshanfar et al
are similar to those cases in which the patient is not immune to tetanus. In such cases, human tetanus immune globulin (TIg) and Booster vaccine are the most important therapeutic measures to prevent tetanus (7, 8). Based on the above-mentioned, one of the measures, which is necessary in traumatic patients, is evaluation of their status and a judgment about the need to use TIg and vaccine. The evaluation is carried out in different ways, including clinical judgment, ELISA test and rapid diagnostic procedures (9-11). Limitations in the use of laboratory tests and sometimes low accuracy of these tests (12, 13) have made the physician’s clinical judgment an important factor in decision-making processes. Unfortunately, lack of proper knowledge of physicians in this respect has resulted in indiscriminate and unnecessary use of the vaccine and immune globulin (8, 12). This lack of knowledge has increased patient treatment costs and the economic toll on the country’s health system. On the other hand, if correct prophylactic measures are not taken in situations favouring tetanus, the patient is exposed to a high risk of this lifethreatening disease, which will have tragic consequences. Therefore, the present study was undertaken to evaluate the knowledge of emergency medicine residents and the adequacy of education they have received in relation to prevention of tetanus. Methods: The present cross-sectional study was carried out from April 2012 to October 2012 in Imam Hussein Hospital in Tehran, Iran, a third-level university hospital with 60000 annual admissions. All the emergency medicine residents were evaluated. Exclusion criterion was unwillingness to participate in the study. The minimum sample size at P=0.5 (14), maximum permissible error of 0.05 (d=0.05) at confidence interval of 95% was 61 residents. In order to collect data, a questionnaire was designed, with the aim to evaluate the knowledge of the emergency medicine residents about the diagnosis and management of wounds and conditions suspected of tetanus. The questionnaire was designed using emergency medicine references and textbooks under the supervision of two emergency medicine specialists and one epidemiologist. Then the reliability of the questionnaire was confirmed by calculating Cronbach’s alpha at 0.71. The questionnaire consisted of three sections. The first section consisted of questions on the residents’ demographic data (age, gender, educational status, job experience and participation in educational courses on tetanus). The second section consisted of nine questions, each with three choices (Yes, No, I do not know) in relation to the knowledge of residents about conditions favoring tetanus. These nine questions concerned the odds of developing tetanus due to contaminated
wounds, deep wounds, and wounds more than 12 hours old, wounds in systemic septic patients, diabetic ulcerations, infection of the injection site in drug addicts, wounds inflicted in open areas (streets, parks etc), burns, and finally wounds requiring surgical intervention for debridement. The third section consisted of 12 questions with three choices (always, sometimes, never) on the knowledge of residents about the necessary interventions in cases suspected of tetanus. These questions were as follows: two questions in relation to the necessary interventions concerning the time elapsed since the patient’s complete vaccination (more than 10 years, less than 10 years); administration of a Booster dose in the past; lack of access to patient’s vaccination history; receiving only one dose of tetanus vaccine; and the necessary measures in immunocompromised patients. The questionnaires were handed in to the residents and each resident was given 30 minutes to answer the questions. Scoring of the questions on the residents’ knowledge about conditions favouring tetanus was carried out by giving one positive score to each correct answer and one negative score to each incorrect answer. The answer “I do not know” received no score (a score of zero). In scoring questions on correct measures during encounter with conditions favouring tetanus, too, each correct answer received a positive score and each incorrect answer received a negative score. Therefore, the subjects could receive a total score of -9 to 9 in the section on knowledge about conditions favouring tetanus and a total score of -12 to 12 in the section on correct intervention. A minimum score of 5 (5≥) in the section on conditions favouring tetanus and at least 6 (6≥) in the section on correct intervention were considered good knowledge level; scores less than these values were considered poor knowledge level. Data collected from the questionnaires were entered into SPSS 21 software and then STATA 11.0 software was used for descriptive and analytical evaluation of data. Man-Whitney U test was used to evaluate the relationship between the scores and the demographic data. Statistical significance was set at p<0.05. Results: In the present study, 73 emergency residents were evaluated (male: 45.2%). Mean and standard deviation of ages of the subjects was 33.3±4.5 years. Of 37 residents in the present study 29 (39.7%), 23 (31.5%) and 21 (28.8%) were first-, second- and third-year residents, respectively. The majority of the subjects (52.1%) had job experiences of more than two years, before initiation of residency. Of all the residents under study, only 7 residents (9.6%) had participated in courses on tetanus and vaccination against tetanus (Table 1). Knowledge of 31 (42.5%) residents about the conditions favoring tetanus was at a good level (mean ±
This open-access article distributed under the terms of the Creative Commons Attribution NonCommercial 3.0 License (CC BY-NC 3.0). Copyright © 2014 Shahid Beheshti University of Medical Sciences. All rights reserved. Downloaded from: www.jemerg.com
73 Emergency (2014); 2 (2): 71-76
SD = 3.2 ± 2.4). The most frequent incorrect answer was related to diabetic ulcers. Despite the fact that such ulcers are not susceptible to tetanus, 46 residents (63%) believed it was; in contrast, 8 residents (11%) had no knowledge on the subject (“I do not know”). After diabetic ulcers, the most frequent incorrect answer was related to ulcers in patients with sepsis. Although this ulcer is susceptible to tetanus, 3 residents (31.5%) believed it was not and 10 residents (5.5%) had no knowledge on the subject (“I do not know”). Table 2 presents the frequencies of residents’ responses to each question separately. In addition, knowledge of only 41 (56.2%) residents about correct therapeutic measures was at a good level (mean ± SD = 6.1 ± 2.7). The most frequent mistake of residents was related to injection of TIg in patients who have received complete vaccination. Fifty-eight residents (79%) had given incorrect answer to the first question (elapsing of more than 10 years since complete vaccination) and 97 (50.7%) residents had given incorrect answer to the next question (elapsing of less than 10 years since complete vaccination). Forty-three (58.9%) residents provided incorrect answers to question regarding necessity of TIg and 38 (52%) necessity of vaccine in immune compromised patients (Table 3). The only factor affecting the knowledge of residents about conditions favoring tetanus was the educational level of the residents (P<0.001), i.e. the residents’ knowledge increased with an increase in educational level. Of first-, second- and third-year residents, 13.8%, 39.1% and 90.5% had good knowledge, respectively. However, other factors did not influence their knowledge about the conditions favoring tetanus. Table 4 presents the relationship between these variables and the residents’ knowledge level. In addition, educational level affected knowledge about correct therapeutic measures (P=0.001). Good knowledge level was higher (85.7%) in third-year residents than that in first-year (31.0%) and second-year (52.5%) residents (P=<0.001). However, age (P=0.64), gender (P=0.31), job experience (P=0.38) and participation in educational courses (P=0.67) had no effect on the knowledge level of emergency medicine residents (Table 5). Discussion: The results of the study showed that the knowledge of emergency medicine residents about the diagnosis of conditions favoring tetanus and correct measures in such cases was poor. The most important factor affecting this knowledge was educational years during residency, i.e. the third-year residents had higher knowledge compared to first- and second-year residents. The most common error of the residents in the diagnosis of conditions favoring tetanus was deeming diabetic foot ulcerations (63.0%), a factor leading to
Table 1: Baseline characteristics of residents
Variable
Frequency (%)
Gender
male
33(45.2%)
female
40(54.8%)
Educational status
first year
29(39.7%)
second year
31(31.5%)
third year
21(28.8%)
Job experience
less than a year
13(17.8%)
1-2 years
22(30.1%)
more than 2 years
38(52.1%)
Participation in educational courses
no
66(9.6%)
yes
7(90.4%)
tetanus. On the other hand, the most common error in relation to therapeutic intervention for suspected ulcers was administration of TIg in patients who have been completely vaccinated. In addition, 52.9% and 52% of residents were not aware about the necessity of administering TIg and vaccine in immunocompromised patients, respectively. The results of the present study showed the necessity of providing further instructions for emergency medicine residents on the diagnosis and management of suspected tetanus cases. Dabas et al showed that the knowledge of physicians in relation to the vaccination of adults was low and only 48.3% of physicians knew the correct indications and cases of tetanus vaccine (15). A study by Brand et al, too, showed that 23% of cases suspected of tetanus were not treated correctly, with 6% of inadequate administration and 17% of excessive prophylactic measures against tetanus (16). A study by Adeboye and Sangowawa in Britain, in which 40 emergency unit personnel, consisting of physicians and nurses were evaluated, showed that only 17 personnel (42.5%) were aware of new prophylactic guidelines against tetanus (17). A study by Chowdhury et al showed that the majority of interns did not have sufficient knowledge about conditions favoring tetanus and proper therapeutic measures (18). A study by Talan et al showed the inadequacy of the therapeutic measures in 35% of cases suspected of tetanus (19). As discussed above, awareness about conditions favoring tetanus and techniques used to tackle them have been at an unfavorable level in the majority of studies; based on these studies the prevalence of diagnostic and therapeutic errors in this disease condition is much higher than that in other clinical problems (12, 15, 1719). These funding show a great disparity between
This open-access article distributed under the terms of the Creative Commons Attribution NonCommercial 3.0 License (CC BY-NC 3.0). Copyright © 2014 Shahid Beheshti University of Medical Sciences. All rights reserved. Downloaded from: www.jemerg.com
74 Derakhshanfar et al
Table 2: Answers given by the residents to questions on conditions favoring tetanus
Questions
Is the wound susceptible to tetanus? (%)
Yes
No
I do not know
Deep wound
57 (78.1)
13 (17.8)
3 (4.1)
Contaminated wound
72 (8.6)
1 (1.4)
0 (0.0)
Wound older than 12 hours
47 (64.4)
22 (30.1)
4 (5.5)
Wound in sepsis patients
40 (54.8)
23 (31.5)
10 (5.5)
Diabetic ulcer
46 (63.0)
19 (26.0)
8 (11.0)
Infection of injection site in drug addicts
55 (75.3)
11 (15.1)
7 (9.6)
Wounds produced in open environments 53 (72.6)
18 (24.7)
2 (2.7)
Burns
68(93.2)
4 (5.5)
1 (1.4)
Wounds requiring debridement
50 (68.5)
17 (23.3)
6 (8.2)
Classification
susceptible susceptible susceptible susceptible not susceptible susceptible not susceptible susceptible susceptible
Table 3: Responses of residents in relation to correct measures in wounds favoring tetanus
Questions on knowledge about correct measures
Always
Sometimes
Never
10 years elapsed after complete vaccination
TIg
34 (46.6)
24(32.9)
15 (20.5)
Vaccine
67 (91.8)
6 (8.2)
0 (0.0)
<10 years elapsed after complete vaccination
TIg
9 (12.3)
28 (38.4)
36 (49.3)
Vaccine
28 (38.4)
37 (50.7)
8 (10.9)
Complete vaccination plus a Booster dose
TIg
3 (4.1)
20 (27.4)
50 (68.5)
Vaccine
9 (12.3)
31 (42.5)
33 (45.2)
No vaccination history is available
TIg
57 (78.1)
12 (16.4)
4 (5.5)
Vaccine
70 (95.9)
3 (4.1)
0 (0.0)
One vaccination dose received
TIg
40 (54.8)
24 (32.9)
9 (12.3)
Booster
58 (79.5)
10 (13.7)
5 (6.8)
Immunocompromised
TIg
30 (41.1)
34 (46.6)
9 (12.3)
Booster
35 (48.0)
30 (41.1)
8 (10.9)
*TIg: Tetanus immune globulin
Classification
never always
never sometimes
never sometimes
always always
always always
always always
these guidelines and what actual happens in the clinic. Therefore, due to the low knowledge of residents in the present study and other similar studies, measures should be taken to define and prepare guidelines to promote awareness of physicians about prevention of tetanus. Medical education groups, especially emergency medicine group, should play a key role in this respect because emergency medicine specialists, during their education and after graduation, are the first physicians who carry out therapeutic interventions (20, 21). In addition, the high prevalence of accidents and other cases of traumas in our country (22, 23) on one hand and the need to provide correct care for such traumas on the other hand show the great importance of proper and up-to-date knowledge of physicians in relation to the management of wounds. In the present study, irrespective of educational years, what attracts attention is the low scores of residents in the diagnosis and management of wounds favoring tet-
anus. As discussed in the results section, the means and standard deviations of the residents’ scores in the present study in relation to conditions favoring tetanus and correct therapeutic procedures were 3.2±2.4 and 6.1±2.7, respectively. Based on these data, since the maximum attainable scores in these two sections were 9 and 12, respectively, unfortunately the scores gained by the residents were very low. These findings reflect the shortcomings of the educational system, which might be attributed to deficiencies of the educational structures, inappropriate educational environments, lack of attention of the educational system to the needs of the community and the students and finally presentation of a large volume of educational materials in a short time. Therefore, different reasons have led to the inadequacy of the instructions provided, which include the inadequacy of the educational structure and system, inappropriate teaching environment and a lack of consistency between the educational programs and the
This open-access article distributed under the terms of the Creative Commons Attribution NonCommercial 3.0 License (CC BY-NC 3.0). Copyright © 2014 Shahid Beheshti University of Medical Sciences. All rights reserved. Downloaded from: www.jemerg.com
75 Emergency (2014); 2 (2): 71-76
Table 4: The relationship between knowledge about tetanus risk factors and demographic factors
Variable
Poor knowledge
Good knowledge
P
n
%
n
%
Gender
male female
77 2117..25 2363 7882..85 0.69
Educational status
first year
25
86.2
4
13.8
second year
14
60.9
9
39.1
<0.0001
third year
2
9.5
19
90.5
Job experience
less than a year
3
23.1
10
76.9
1-2 years
2
9.1
20
90.9
0.38
> 2 years
9
23.7
29
76.3
Participation in educational courses
nyeos 122 1288..26 554 8711..84 0.61
Table 5: Relationship between knowledge about correct
Variable
Poor knowledge
n
%
Gender
male
10
30.3
female
8
20.0
Educational status
first year
20
69.0
second year
11
47.8
third year
3
14.3
Job experience
less than a year
4
30.8
1-2 years
4
18.2
> 2 years
10
26.3
Participation in educational courses
no
17
25.8
yes
1
14.3
therapeutic measure and demographic
Good knowledge
n
%
23
69.7
32
80.0
9
31.0
12
52.2
18
85.7
9
69.2
18
81.85
28
73.7
49
74.2
6
85.75
factors P
0.31
0.001 0.38 0.67
needs of the community and the students. Therefore, the existing educational system should be thoroughly revised. One of the limitations of the present study was the absence of an educational intervention. If an educational intervention had been available, it wound have been possible to evaluate the effect of education on improving the knowledge of residents. On the other hand, the resident’s awareness of the fact that he or she was under evaluation might have resulted in bias, affecting the results of the study, showing an increase in knowledge of residents in a false manner. However, since the mean knowledge level of the residents was low, the authors believe that the results are valid and reliable largely. Nevertheless, it is suggested that in future studies, the emergency medicine residents’ knowledge be evaluated
in a double-blind manner next to the patient bed and then an educational program be designed and the residents’ knowledge be evaluated again so that the effect of education on promoting knowledge can be evaluated. Conclusion: According to the findings of the present study, the knowledge of emergency medicine residents about correct management of patients suspected of tetanus was low, which emphasizes the necessity of providing further instructions on prevention of tetanus in wound management. Acknowledgments:
The authors appreciate the insightful cooperation of Medical Sciences and the staffs of the Emergency Department of Imam Hussein Hospital in Tehran, Iran. Conflict of interest:
This open-access article distributed under the terms of the Creative Commons Attribution NonCommercial 3.0 License (CC BY-NC 3.0). Copyright © 2014 Shahid Beheshti University of Medical Sciences. All rights reserved. Downloaded from: www.jemerg.com
76 Derakhshanfar et al
None Funding support: None Authors’ contributions: All authors passed four criteria for authorship contribu-
tion based on recommendations of the International
Committee of Medical Journal Editors.
References: 1. Wassilak SG, Kretsinger K. Tetanus. Bacterial Infections of Humans: Springer; 2009. p. 813-32. 2. Parveen G, Hussain S, Malik F, et al. Seroepidemiological surveillance of antitetanus antibodies in Pakistani childbearing women: A population based survey. Afr J Pharm Pharacol. 2012;6(36):2621-8. 3. Hüllstrung HD, Mäusezahl D, Feuz M, Herzog C, Conzelmann M, Zimmerli W. Tetanus immunisation in geriatric patients with accidental wounds: how much is needed. Swiss Med Wkly. 2003;133(15-16):227-32. 4. Kapoor AN, Tharyan P, Kant L, Balraj V, Shemilt I. Combined DTP-HBV vaccine versus separately administered DTP and HBV vaccines for primary prevention of diphtheria, tetanus, pertussis, and hepatitis B. Cochrane Lib. 2010;6(1):7-65. 5. Althouse BM, Bergstrom TC, Bergstrom CT. A public choice framework for controlling transmissible and evolving diseases. Proc Natl Acad Sci. 2010;107(suppl 1):1696-701. 6. Afshar M, Raju M, Ansell D, Bleck TP. Narrative review: tetanus—a health threat after natural disasters in developing countries. Ann Intern Med. 2011;154(5):329-35. 7. Miyagi K, Shah AK. Tetanus prophylaxis in the management of patients with acute wounds. J Plast Reconstr Aesthet Surg. 2011;64(10):e267-9. 8. Scott T. Point-of-care tetanus immunoassay: An audit of unscheduled tetanus prophylaxis. Int J Orth Trauma Nurs. 2012;16(2):97-103. 9. Hatamabadi HR, Abdalvand A, Safari S, et al. Tetanus Quick Stick as an applicable and cost-effective test in assessment of immunity status. Am J Emerg Med. 2011;29(7):717-20. 10. McVicar J. Should we test for tetanus immunity in all emergency department patients with wounds? Emerg Med J. 2013;30(3):177-9. 11. Örtqvist Å, Blennow M, Carlsson RM, et al. Vaccination of children–a systematic review. Acta Paediatr. 2010;99 (s461):1-192.
12. Gall SA. Prevention of pertussis, tetanus, and diphtheria among pregnant, postpartum women, and infants. Clin Obstet Gynecol. 2012;55(2):498. 13. Reid PM, Brown D, Coni N, Sama A, Waters M. Tetanus immunisation in the elderly population. J Accid Emerg Med. 1996;13(3):184-5. 14. Heydari G, Yousefifard M, Hosseini M, Ramezankhani A, Masjedi M. Comparison of Cigarette Smoking, Knowledge, Attitude and Prediction of Smoking for the Next Five Years and Their Association between Students, Teachers and Clergymen. Int J Prev Med. 2013;4(5):557-64. 15. Dabas P, Agarwal C, Kumar R, Taneja D, Ingle G, Saha R. Knowledge of general public and health professionals about tetanus immunization. Indian J Pediatr. 2005;72(12):1035-7. 16. Brand DA, Acampora D, Gottlieb LD, Glancy KE, Frazier WH. Adequacy of antitetanus prophylaxis in six hospital emergency rooms. N Engl J Med. 2007;309(11):636-9. 17. Adeboye K, Sangowawa O. Tetanus prophylaxis in the A&E department. J R Soc Med. 2002;95(3):113. 18. Chowdhury R, Mukherjee A, Lahiri SK. A Study on the Knowledge of Tetanus Immunization Among Internees in A Government Medical College of Kolkata. Nat J Community Med. 2011;2(3):432-9. 19. Talan DA, Abrahamian FM, Moran GJ, et al. Tetanus immunity and physician compliance with tetanus prophylaxis practices among emergency department patients presenting with wounds. Ann Emerg Med. 2004;43(3):305-14. 20. King RA, Liu KY, Talley BE, Ginde AA. Availability and Potential Impact of International Rotations in Emergency Medicine Residency Programs. J Emerg Med. 2013;44(2):499– 504. 21. Smith-Coggins R, Carius ML, Collier RE, et al. Report on Residency Training Information (2011-2012), American Board of Emergency Medicine. Ann Emerg Med. 2012;59(5):416-24. 22. Bakhtiyari M, Mehmandar MR, Mirbagheri B, Hariri GR, Delpisheh A, Soori H. An epidemiological survey on road traffic crashes in Iran: application of the two logistic regression models. Int J Inj Contr Saf Promot. 2013 (ahead-ofprint):1-7. 23. Heydari ST, Hoseinzadeh A, Sarikhani Y, et al. Time analysis of fatal traffic accidents in Fars Province of Iran. Chin J Traumatol. 2013;16(2):84-8.
This open-access article distributed under the terms of the Creative Commons Attribution NonCommercial 3.0 License (CC BY-NC 3.0). Copyright © 2014 Shahid Beheshti University of Medical Sciences. All rights reserved. Downloaded from: www.jemerg.com