EPI Issue 20 by Logan Plaster

Kit Check: Omni Pro’s 11-in-1 Exam Tool Cameron: Is Analgesia Killing Our Patients? Transplant Surgery Training in Kurdistan After Ebola: Healing Healthcare in Sierra Leone EMERGENCY PHYSICIANS INTERNATIONAL

ISSUE 20

. FALL 2016 . WWW.EPIJOURNAL.COM

Holliman: EM Diplomacy in Iran Australia Puts an *odd* Face on MVA Trauma

OH THE HUMANITY: WHY EMERGENCY MEDICINE NEEDS MORE HUMANCENTERED DESIGN

“In low-income countries, I’d love to see [drones] used more. In Rwanda, I think if they can make it sustainable it’d be awesome.” prof. lee wallis

THE INTERNATIONAL CONFERENCE FOR EMERGENCY MEDICINE

EDITOR’S DESK

A Bridge Between Nations

n May of this year I was invited by the Iranian Ministry of Health to travel to Iran to assist in the initial development of the sub-specialty of Pediatric Emergency Medicine for Iran. This trip reminded me of the “bridging” and diplomatic effects that EM can offer to countries beset by political or ideological differences. As you know, the governments of the USA and Iran have not exactly gotten along well since 1979, and both governments have targeted each other with plenty of critical rhetoric. That said, I have had nothing but good experiences in Iran, and I was received with kindness and friendliness by all my colleagues and acquaintances there. I first got involved with Iran in 2000, at the request of the Iran Ministry of Health and Iran University, in Tehran. The Ministry had studied different models of emergency health care delivery, and elected to go with the US model to improve emergency care throughout Iran. Together with my colleagues Drs. Jeff Smith and Mo Mazaheri, and others, we helped set up coordinated EM curricula, residency training, and faculty development. The first EM residency program became operational at Iran University, and soon thereafter additional EM residency programs were started at most of the big university hospitals throughout the country. The Iranians quickly brought the specialty of emergency medicine in Iran to a mature level with the formation of a national emergency physicians organization, national conferences on EM, standardized residency curricula, national specialty board certification, publication in prestigious journals of numerous clinical research projects, and active participation in the International Federation for Emergency Medicine. Now that the specialty of EM is well established in Iran, the need and value of starting pediatric EM as a recognized sub-specialty and post-residency fellowship training program came about this year. This project opens up possibilities for further increased collaboration and cooperation between the USA, and other countries, with Iran, in efforts such as faculty and fellow exchanges, curriculum development, sub-specialty certification exam development, and clinical research. The process of sub-specialty development for pediatric EM in Iran could serve as a model for the creation of other sub-specialties such as emergency medical services, toxicology, critical care medicine, and/or geriatric EM, and others. In the longer term, the development of EM sub-specialties in Iran could be used to help some of the countries bordering Iran, which do not have highly developed health care delivery systems.

C. James Holliman, MD, FACEP, FIFEM editorial director

ABOUT EPI EPI is the essential hub connecting global emergency care, sparking dialogue and creating a space for new collaborations. Find copies of the print magazine at international EM conferences around the world, or read it online at www.epijournal.com

editorial director C. JAMES HOLLIMAN, MD managing editor LONNIE STOLTZFOOS executive editors PETER CAMERON, MD TERRY MULLIGAN, DO, MPH LEE WALLIS, MD PROF. V. ANANTHARAMAN regional corespondents CONRAD BUCKLE, MD MARCIO RODRIGUES, MD CARLOS RISSA, MD KATRIN HRUSKA, MD SUBROTO DAS, MD MOHAMED AL-ASFOOR, MD JIRAPORN SRI-ON, MD editorial advisors ARIF ALPER CEVIK, MD ANITA BHAVNANI, MD KATE DOUGLASS, MD HAYWOOD HALL, MD CHAK-WAH KAM, MD GREG LARKIN, MD PROF. DONGPILL LEE SAM-BEOM LEE, MD ALBERTO MACHADO, MD JORGE OTERO, MD advertising RHONDA TRUITT

rhonda.truitt@wt-group.com publisher LOGAN PLASTER

Logan@EPIJournal.com Join us @epijournal Twitter / Facebook / Instagram

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EVENT CALENDAR 11/16–6/18 THE COMPREHENSIVE GUIDE TO GLOBAL EM CONFERENCES

American College of Medical Toxicology 2017 Annual Scientific Meeting Satellite Session // San Juan, Puerto Rico March 30, 2017 www.acmt.net/2017ASMSatellite_Session.html

Field Reports

March 31–April 2, 2017 www.acmt.net/ACMT2017.html

8 | Trinidad and Tobago

APRIL 2017

The 3rd African Conference on Emergency Medicine // Cairo, Egypt

VII Congreso Internacional de Urgencias, Emergencias y Cuidados Intensivos // Havana, Cuba

IV World Congress In Emergency Medicine // Riviera, Maya, Mexico November 16-19, 2016 www.urgenciasmexico.org

33rd Annual Scientific Meeting of the Australasian College for Emergency Medicine // Queenstown, New Zealand November 20-24, 2016 www.acem2016.com

DECEMBER 2016 SriLanka 2016 (DevelopingEM) // Colombo, Sri Lanka December 5-8, 2016 srilanka.developingem.com

Emirates Society of Emergency Medicine (ESEM) Scientific Conference // Dubai, UAE December 7-10, 2016 www.esem.ae

MARCH 2017 American Academy of Emergency Medicines 23rd Annual Scientific Assembly // Orlando, Florida

www.epijournal.com

American College of Medical Toxicology 2017 Annual Scientific Meeting // San Juan, Puerto Rico

NOVEMBER 2016 November 9-11, 2016 www.afcem2016.com

IN THIS ISSUE

April 12–14, 2017 www.urgrav2017.sld.cu/index.php/ urgrav/2017

Annual Vietnam Emergency Medicine Symposium // Hue, Vietnam April 24–27, 2017 www.vsem.org.vn

MAY 2017 2017 Annual Society for Academic Emergency Medicine Meeting // Orlando, Florida May 16–19, 2017 www.saem.org/annual-meeting

OCTOBER 2017 9th Asian Conference on Emergency Medicine // Istanbul, Turkey October 12–15, 2017 www.acem2017.org

JUNE 2018 18th International Conference on Emergency Medicine // Seoul, Korea

6 | Slovenia

10 | Sierra Leone

Departments 12 | Source Reader-submitted dispatches from the four corners 16 | Tech A field physician reviews an 11-in1 medical examination kit 18 | IFEM Q&A President Lee Wallis on IFEM’s emerging change of course

Reports 20 | Iraq Rebuilds A native Kurd brings transplant surgery and international training to Duhok 23 | Trauma An unlikely collaboration brings a strange new face to MVA trauma 26 | Design Human-centered principles are the skeleton key to unlocking effective ED design 30 | Grand Rounds Peter Cameron: are analgesics helping our patients, or killing them?

June 12–15, 2018 http://www.emergency.or.kr/english/index.asp

March 16-20, 2017 www.aaem.org/aaem17

LIST YOUR NEXT INTERNATIONAL EVENT FOR FREE ON THE EPI NETWORK – WWW.EPIJOURNAL.COM/EVENTS

Issue 20 // Emergency Physicians International

The mHealth Toolbox The first hands-on digital health workshop for emergency physicians.

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FIELD REPORT

q The founding meeting of the Slovenian Emergency Medicine Association (SEMA), which is actively forming new relationships with other international EM organizations.

FALL 2016

SLOVENIA After building 10 new EDs with EU grants, Slovenia is slowly adopting a more standardized emergency care system, and a new organization, SEMA, is focused on streamlining EM training. by drs. matej marinšek,

gregor prosen, nejc gorenjak

n Slovenia today, emergency medicine is in the midst of great flux and transition. Historically, emergency care in Slovenia was divided between primary care health centers, located in almost every town, and a secondary level of emergency care in hospitals, where it was further divided between different specialties. The system basically follows the Franco-Germanic model of EMS, 6

with doctors on board ambulances, and division between different specialties at hospital entry. For the last 30 years, until today, prehospital care has been provided by community health centers in 50 towns across the country, comprising 20,000 square kilometers with a population of 2 million. In most of these smaller towns, family doctors join ambulances and provide emergency care in the field, usually during their regular GP working hours. Only in about a dozen towns, comprising roughly 30,000 people, are there dedicated EMS units with their own doctors. Such prehospital emergency care is provided 24/7, and doctors are present on board the ambulances in the vast majority of all interventions. One of the reasons for such micro-organization is the absence of a unified nationwide dispatch system.

Issue 20 // Emergency Physicians International

Slovenia By the Numbers

78/84 Years Life expectancy at birth (2015)

$2,698 USD Annual health spending per capita

9.2% GDP Health expenditures

As of today, all of these 50 smallest EMS units perform their own dispatching, and follow their own procedures to gauge the needs of interventions in the field. On the secondary level, until the end of 2015 there were no emergency departments per se. Basically, each hospital had numerous receiving wards, divided both by location and concept. As there were no universal EDs that could be accessed “straight from the street” without a referral letter from a GP, there were no simple and defined entry points into hospital emergency care. Fortunately, this has started to change. In 2006, a decision was made to begin building EDs in every hospital, and European Union “cohesion funds” were granted. As per contracts, all EDs had to be built and operational by December 31, 2015, and that was actually achieved! Today, we have ten brand new EDs — half a year old — into which Slovenia now is trying to breathe life. Since there aren’t enough emergency physicians, the core concept for getting EDs to start functioning is combining former surgical and medical receiving wards (and their staff ), thus quite literally assembling an “Accident & Emergency” department. Along with that, a nationwide dispatch system is being built, which will rely on the concepts of the Norwegian Index for Emergency Medical Dispatch. Prehospital systems are being reshaped concurrently, decreasing the number of physician-led EMS ambulances and expanding the net of paramedic-staffed EMS vehicles, and creating a dense network of civilian first-responders to cover rural areas. EM Specialty and Training EM was established as an independent specialty in 2006. In the

p The new emergency department in the city of Maribor, the largest ED in Slovenia.

coming years, as more and more EM specialists graduate from residency programs, they will slowly take over the workload and expand the concept of emergency care practiced in the newly devised A&E departments. This transition will take years, so the main burden of future EM development in Slovenia rests on the shoulders of the trickle of EM specialists and the slowly expanding stream of EM residents. Thus, the entire present generation of EM doctors and residents will have to take charge of their own professional growth and establish the field of EM outright in Slovenia. To achieve that while concurrently providing quality medical care, we also have to put great emphasis on efficient and quality education— focusing on our training residents! This will be particularly challenging, as in Slovenia, similarly to continental Europe, there is a very weak tradition of effective clinical teaching. The Slovenian Emergency Medicine Association (SEMA) was recently founded to aid in these ef-

forts—to help coordinate efforts in establishing clinical pathways and standards of care, in helping to improve and standardize residents’ education, and in helping to establish the proper institutional position and remuneration of emergency physicians. The EM community in Slovenia will need, and will gladly accept, all the help it can get. One of the key agendas of SEMA is forging connections with other world organizations in order to help us adopt the best clinical and educational practices. Final Word: From Slovenian EM Residents The establishment of SEMA was made possible by a group of enthusiastic specialists and EM residents aiming for a better future. EM residents were especially interested and supportive throughout the way, and a great number of them are now part of the SEMA board, proving the point. With the current residency education system being outdated and inef-

fective, clinical education therefore suffers gravely. The resident’s training has mainly consisted of observerstyled or secretary-like work outside their designated working posts, unwillingly bringing up the paradox of rotations versus ED work, or “from zero to hero.” Great efforts have been made by current EM residents so far to try and change the educational system and training conditions, without a “bigger brother” looking after us—without much success. Thankfully with the rise of FOAMed resources, some of the obstacles, like running simulation training or incorporation of new ideas, seem manageable, although implemented in a rough, guerilla-style way. As word of SEMA began to spread, residents quickly embraced the organization in hope of effecting our visions and changes through it. As SEMA becomes more operational, hope continues to grow of finally establishing a functioning and sustainable EM system in Slovenia.

A nationwide dispatch system is being built, which will rely on the concepts of the Norwegian Index for Emergency Medical Dispatch. Prehospital systems are being reshaped concurrently, decreasing the number of physicianled EMS ambulances and expanding the net of paramedicstaffed EMS vehicles.

www.epijournal.com

FIELD REPORT FALL 2016

TRINIDAD AND TOBAGO Between 2005 and 2007, four new EM training programs began in Trinidad and Tobago, creating an explosion in new training and widespread coverage of qualified EM physicians. by dr. joanne f. paul and dr. ian a. sammy

he Caribbean is made up of a series of islands that follow a gentle, sloping trajectory from Miami to just east of Venezuela. Trinidad and Tobago is a twin island state (population 1.3 million) in the southernmost part of the Caribbean, and is the main and larger of the English-speaking islands in the Caribbean, which also include Jamaica (population 2.7 million), and Barbados (population 300,000). The specialty of emergency medicine came to the Caribbean in 1990, in Barbados, and then Jamaica in 1996, with the start of the DM (Doctor of Medicine) training program. Prior to that, emergency departments were called “Casualty” and were staffed by non-specialized nurses along with interns and junior doctors who were supervised in various degrees, usually via telephone, by senior doctors with non-EM special8

ist training—typically surgeons and internal medicine specialists. Prehospital care was almost non-existent and mainly functioned as a transport system, where patients were picked up, given oxygen or CPR as required, and taken to the hospital as quickly as possible—literally scoop and run. There was also little exposure to life support courses such as Advanced Trauma Life Support (ATLS), Advanced Cardiac Life Support (ACLS) and even Basic Life Support (BLS). Actual medical treatment did not really begin until the patient arrived at the hospital. Triage was inefficient, and life threatening emergency cases frequently waited long hours, sometimes with unfavorable outcomes. Contributing factors included limited availability of medical services, along with a large number of patients seeking medical care. This was in addition to an ineffective and unstructured primary care system, a lack of responsibility and ownership by patients with regard to their personal health, and the increasing popularity of alternative and herbal medicine, especially in the rural areas. Trinidad and Tobago took a slight turn from the rest of the Caribbean

Issue 20 // Emergency Physicians International

Trinidad and Tobago by the numbers

1.18/ 1,000 Physician density rate/ population

99% Literacy rate

5.9% GPD Proportion of health expenditures

on its course toward an EM training program. The four-year DM program began in Trinidad in 2005, led by Dr. Ian Sammy. An 18-month diploma program also began at this time, which was geared toward doctors working in peripheral and rural EDs, and rotating through primary centers, to give them some EM knowledge base to improve the standard of patient care before transfer to a tertiary center or before discharge. The diploma program was also meant to bridge the gap in EM training until there were enough DM graduates who might then consider working in these peripheral centres, a process that was estimated to take 5–10 years. A three-year MSc program was also added to cater to those senior doctors already in EDs, for whom it was not feasible to do the DM. Finally, the Diploma in Pediatric Emergency Medicine was started in 2007. This was available only for those already with DM or MRCPCH specialty degrees. (Three graduates of the pediatric EM program are now consultants in the Pediatric ED.) Thus, in one short space of time, four programs were started, each approaching EM training deficiencies at multiple levels.

Fast forward ten years. Ian Sammy is presently in the U.K. pursuing his PhD in EM (which is nearing completion), and the program coordinator is now Dr. Joanne F. Paul. Following the establishment of these four EM programs, training mushroomed and exploded after critical mass was achieved. Approximately 100 students have completed the Diploma; 16 have graduated from the DM program; and 33 are currently residents in the DM program. The Head of the ED at three out of four of the major hospitals in Trinidad and Tobago is a DM graduate, and the other is headed by an MSc graduate. The Diploma graduates are registrars in the tertiary hospitals, or heads of unit at the peripheral centers. Some have also gone on to do their DM in EM, while others are doing family medicine and other related specialties. What is especially distinctive, though, is that this explosion in training also created an environment where, separate from the training within the program, the DM graduates teach and mentor the current DM residents in each tertiary hospital. In turn, DM residents teach and mentor the current Diploma students. The result is that, in Trinidad and Tobago, the EM revolution has not devoured its children but, instead, these children have grown up and are taking care of each other. Eventually the specialty will be saturated and there will be an EM specialist in all tertiary, secondary, and peripheral rural centers. This may be another ten years away. At present, though, the result of seeding the initial ‘Casualty Departments’ with concurrent and multiple programs is vastly improved standards of care for patients in a middle- to high-income developing country, at the end of the line of the Caribbean Islands.

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FIELD REPORT

q Connaught Hospital, in Freetown, one of the epicenters of treatment during the Ebola crisis here in 2014–2015.

FALL 2016

SIERRA LEONE In the aftermath of the worst Ebola epidemic in history, this West African country is working hard to apply hard-earned lessons and international resources to strengthening its health surveillance systems, and slowly easing access to timely care through the ED. by dr hooi-ling harrison, dr

mark sesay, dr richard lowsby

ierra Leone has long suffered from a weak health system, further exacerbated by the 1991-2002 civil war and, recently, the worst Ebola epidemic in history, affecting 14,124 people and killing 3,956, with 6.85% of the dead being health care workers. In 2012, the King’s Sierra Leone Partnership (KSLP), a small NGO affiliated with King’s College Lon10

don and the hospital collective of King’s Health Partners, embarked on a partnership with the main government hospital, Connaught Hospital, in Freetown, the College of Medicine and Health Sciences (COMAHS), and the Ministry of Health and Sanitation (MOHS) in order to support these institutions to build a stronger and more resilient health system. The organization operates through international volunteers partnering with local leaders across a wide range of disciplines, of which emergency medicine is the key pillar. A UK-based voluntary team offers expert technical advice, and systems are strengthened through a fourpronged approach: policy development, clinical services, training, and—underpinning all of it—research, which not only evaluates the service, but also develops the individuals involved academically.

Issue 20 // Emergency Physicians International

Sierra Leone by the numbers

5.9 million Population

1/ 50,000 Physician density rate/ population

47 years Life expectancy at birth

181 UN Health Development Index ranking

There is no formal emergency care system in Sierra Leone, so it was not uncommon at Connaught hospital to see patients lying for hours unconscious or in pain on trolleys in the waiting room. Because of the lack of free health care, priority would be given to patients that had ability to pay, or those with minor injuries that walked into hospital. Mortality rates are high and the A&E was neglected, so patients complained or stayed away. Progress in developing a new concept in this context has been highly challenging. For example, there exists a lack of information on the scale of the problem or what emergency care facilities could provide; the MOHS struggles to recognize or understand the need and therefore there is no funding; there is no post-graduate specialization in the country, other than in family medicine, so why and who should be interested in EM? However, working alongside our partners, we are pleased to report that several important steps in EM development have been made possible, giving the specialty more of a voice in Sierra Leone. Clinical Services In May 2014, the Connaught Hospital, the MOHS, and KSLP collaborated to introduce a new triage system, the first of its kind in Sierra Leone. Amazingly, despite so much fear of health care worker deaths, the triaging continued throughout the Ebola epidemic, offering an additional level of security to the hospital, and which meant that Connaught Hospital was one of very few (<30%) hospitals that

remained open. Not unsurprisingly, attendance rates to the hospital dropped during this period, but patients who did attend to hospital were more severely unwell with conditions unrelated to Ebola, highlighting the importance of effective emergency services with triage systems even during a humanitarian crisis. This evidence, and significant lobbying of the MOHS to maintain a resilient health system, resulted in the representation of emergency services in the governmentâ&#x20AC;&#x2122;s guidelines for a minimum standard of care, the Basic Package of Essential Health Services, and the MOHS has assigned a medical officer and four mid-level emergency care providers specifically to the Connaught Hospital Emergency Department. The

Ebola epidemic resulted in funding for the complete refurbishment of the old Ebola isolation unit into a new A&E department, which is now capable of providing emergency services and includes a new fully functioning triage, resuscitation room, and trauma room. Training Regular training, following the African Federation of Emergency Medicine signal functions, is being delivered to the 45 A&E nurses and clinicians at the Connaught Hospital. Unfortunately, there is still no recognized postgraduate training for these cadres. However, the medical school has for the first time included EM training within their curriculum, hopefully generating enthusiasm for the specialty amongst

students who will hopefully be our future EPs. Policy Seventy-percent of Sierra Leoneâ&#x20AC;&#x2122;s health system is financed through out of pocket payments, meaning that provision of emergency care is highly challenging. A pilot program for free emergency medication and a cost recovery scheme has resulted in patients receiving more timely care, and allows relatives time to mobilize funds for subsequent services. Data collected from this pilot program is helping us to produce advocacy documents to lobby the MOHS and donors for publicly funded free health care. In addition, bleakly, 75% of HCWs do not receive a salary. Through strong hospital man-

Clockwise from top left: 1. the Ebola holding unit at Connaught Hospital during the epidemic 2. the same unit is pictured empty and undergoing renovation following the epidemic 3. the former Ebola holding unit again, as a functional resuscitation room 4. (from left to right) Dr. Richard Lowsby, KSLP emergency doctor volunteer; Dr Alie Amin Sesay, Medical Officer, Connaught Hospital; Dr Ling Harrison, KSLP Emergency doctor volunteer, pictured at Connaught Hospital

continued on page 14 www.epijournal.com

SOURCE // DISPATCHES READER-SUBMITTED UPDATES FROM THE FOUR CORNERS

Q. How greatly does toxicology factor into your EM care, and how do you stay current with evolving and emerging substances? ______________________

01 BOTSWANA Formally, about 2% of our patients in A&E are identified as toxicology patients. About 10 percent of these patients have ingested paracetamol, making it the most common substance. Parrafin and Ibuprofen are common as well and in the summer numbers of snake and scorpion bites go up. However, these numbers don’t include the main substance of abuse, which is alcohol. Alcohol truly disrupts society being correlated to a major spike in assault and traffic related trauma during the weekends as well as at month’s end when salaries are being paid. Crystal meth, known locally as ‘tik’, is being used as well as other amphetamine

like substances, however numbers are unknown. To keep up with emerging trends we perform local audits at A&E and ICU. -Dr. Michiel van Veelen ______________________

02 CANADA In Canada Tox is very important. We read updates and use poison centres. -Dr. Ziauddin Hassan ______________________

03 COLOMBIA Toxicology is definitely important in the practice of emergency medicine. -Dr. Leonar G. Aguiar

Issue 20 // Emergency Physicians International

______________________

04 INDIA We are witnessing use of lots of party drugs besides usual pesticides and other chemicals. The illicit drug supply chain is expanding throughout the country and we are struggling to detect and treat such overdoses. -Dr. Tamorish Kole ______________________

05 IRAN Iran is a country in Middle East and near Afghanistan, an important site of opium and its derivative production in the world. It has a great amount of opium consumers. Opium addiction is

something more than a disease and we can consider it as a social behavior. We encounter its acute and chronic manifestations in our routine practice. In recent years other synthetic and newly emerging substances are more frequently used as well. Severe lead poisoning is a recently recognized phenomenon in oral opium addicted patients in our country. We do not have an official report but I can tell you we have seen lots of symptomatic patients in our EDs and even all our students are familiar with the presentations. I can call it a catastrophe and you may hear about it in near future. So we are all familiar with this aspect of toxicology and we have near collaboration with our toxicologists. -Dr. Hamidreza Reihani

______________________

09 PANAMA Emergency medicine in Panama needs more information support in relation to toxicology. Still we do not have direct lines to a toxicology information center by phone. -Dr. Gurnam Singh ______________________

10 UKRAINE Toxicology has very big influence in emergency medicine. We stay up to date by reading the literature. -Dr. Yurii Markov ______________________

______________________

06 IRAQ This area needs more improvement because we don’t have all toxic substance antidotes so we have to search online and take time to manage the patient. -Dr. Bara H. ______________________

07 ITALY Toxicology has had a great impact on our EM care. We stay current with an in-hospital toxicology service. -Dr. Roberto Cosentini ______________________

08 THE NETHERLANDS In my practice (cruise ship medicine) toxicology is not a big issue. I keep upto-date by reading emergency medicine journals and listening to EM podcasts. -Mark

UNITED KINGDOM We see a significant number of overdoses. But we have good liaison with our national toxicology service. -D.D. ---Toxicology patients are seen almost every shift in my ED. We used TOXBASE for the management. -Dr. Misbah ---Toxicology has become a large part of our workload. We use the Toxbase system to keep current (www.toxbase.org) -Dr. Tim Coats

Q. What has changed most about EM in your country over the past two years — for better or for worse? ______________________

01 BOTSWANA Two major improvements are first of all the ongoing development of the local MMED residency program in Emergency Medicine. This increases the quality of healthcare delivery at the department, which spreads to other doctors working in the department and beyond. Secondly, we have experienced an improvement in the delivery of prehospital care as a consequence of the Ministry of Health prioritising the governmental EMS program. Main challenges are still found in logistics such as drug supplies and equipment maintenance. For instance the very affordable drug and antidote to paracetamol overdose N-acectylcysteine has been out of (national) stock regularly. -Dr. Michiel van Veelen

______________________

12 UNITED STATES Toxicology factors in as a 3/5. And yes I stay current and it is important. -Dr. Kevin Lunney ----I see overdoses daily and will usually contact Poison Control for any questions. We read about the newest designer drugs and will try to keep up but PC is usually tops for me. -Dr. Lynn Barlow ----Toxicology isn’t too much of a factor. The population I see is relatively well behaved. I keep up with Tox by listening to podcasts and reading online updates. -Dr. Adan R Atriham

______________________

02 CANADA In the last couple years I have seen a decrease in the use of AC/ Adsorbent and induce vomiting. -Dr. Ziauddin Hassan ______________________

03 COLOMBIA In short, it’s getting better. -Dr. Leonar G Aguiar ______________________

04 INDIA Indian EM is now a developed system. In the last two years our own capacity and capability has increased

almost 10 fold. We are now focusing to develop emergency care for 67 percent of Indians who live in villages. Our key principles are accessibility, affordability and safety. -Dr. Tamorish Kole ______________________

05 IRAN Emergency medicine was first introduced in 1999-2000 in our country. Since then, more than 1500 emergency physicians have been trained and work in different EDs in our country. We had the same problems that other countries experienced in first years of emerging of emergency medicine. These problems resolved gradually and emergency rooms were changed to emergency departments and equipped slowly. The most influencing factor in our practice is the acceptance of emergency medicine role in the patients’ management and more equipped departments. Ultrasonography is more available in our EDs and other specialists are persuaded about the emergency physicians’ abilities in handling the critical patients and exact diagnosis. Two years ago we had a change in the payment rules for medical services in our country that all people could benefit from baseline insurance, something like Obamacare in US. This phenomenon overcrowded the public EDs and hospitals. We lacked the supporting beds in our wards on the other hand there is not the capacity to expand our EDs. This had a negative influence in our practice as emergency physician in our country. -Dr. Hamidreza Reihani

continued on page 14

SOURCE // DISPATCHES

Q. What has changed most about EM in your country over the past two years — for better or for worse? continued from page 13

______________________

06 IRAQ There is no changes it’s the same no update still we have bad guidelines. ______________________

07 ITALY We now have better education, but worse staffing (we are understaffed) and more overcrowding (difficult inhospital collaboration) -Dr. Roberto Cosentini ______________________

08 THE NETHERLANDS Not enough has changed. This is a problem. We seem to be reaching a steady state without sufficient progress. -Mark

09 PANAMA In my country we continue to train medical specialists in hospital emergency care, but there is a lack of trainees. The few acquaintances have been appointed to work in the emergency services. On a positive side because graduates have specialty training they can work up to two jobs. There are few specialists in university teaching areas. The downside was that having knowledge in the various emergencies other specialties tend to leave a lot of work in the hands of EM specialists. That means more night shifts and worse labor standards. -Dr. Gurnam Singh ______________________

10 TURKEY Several years ago the prime minister (to win votes for his party) declared that all ED visits would be ‘free’ for patients. After 6 months, abuse of this became obvious and a copayment was

FIELD REPORT: SIERRA LEONE continued from page 11

agement a financial incentive scheme has been introduced where staff receive a small proportion of the admission fee, which has helped to motivate and recognize their hard work. Where Now? Our resident Medical officer, Dr. Mark Sesay, comments: “The concept of Emergency medicine in Sierra Leone has started gaining momentum and its importance has

then made a requirement for those determined (after exam) to be ‘nonemergent’. The government became swamped in bills (this strategy became too expensive for them). Just recently they changed their criteria to ‘only paying for life-threatening’ problems. ______________________

11 UKRAINE In general, nothing has changed. -Dr. Yurii Markov ______________________

12 UAE Delayed payments are a routine in UAE and one can’t do any thing about it as law is biased in favour of locals. ______________________

13 UNITED KINGDOM We are experiencing increasing budgetary pressure, leading to manpower pressure, and subsequent increase on EM demand. -D.D. ---------I would say Team Leadership! Involvement of ED Consultant in manage-

been felt by many patients, especially those presenting acutely unwell with deranged physiology. It has been satisfying to see the transformation of the poorly managed outpatient department into a modern A&E department with appropriate equipment, along with improvement in the working environment. The consequences of these developments are that record keeping and patient flow have improved, staff are more motivated, and patients and relatives have more confidence in the service which has resulted in increasing hospital attendance.” Dr. Mark does say, however, that in order to sustain progress and maintain momen-

ment issues as well for instance ED Crowding, breach of patients, bed management, etc. -Dr. Misbah -----“Failure” of EDs against the 4 hour performance target has led to people outside the ED taking over the management of the ED and making decisions (sometimes incorrect) about how we should be working. -Dr. Tim Coats ______________________

14 UNITED STATES What has changed is that we are now readdressing the use of opiates in the United States. -Dr. Kevin Lunney ---The biggest change is the evolution of the electronic medical records and how bad they really are. The time they take to document, that I really need a scribe or a secretary to document properly. It has taken medicine down a few notches. It has also increased the normal stress of the ER. -Dr. Lynn Barlow ----More government regulations is making the practice of medicine a burden. -Dr. Adan R Atriham

tum, emergency care centers will need to be developed and linked together across the country along with a prehospital ambulance service. In addition, there is a need for specialty recognition and curriculum development at the postgraduate training level. Some of this can be achieved through the initiation of the Sierra Leone Emergency Medicine Society, and improved collaboration with other West African Societies, and public and private EM providers. Ultimately, though, what the specialty really requires at this point is long term financial investment.

FCEM ER PHYSICIANS REQUIRED International SOS (internationalsos.com) is the world’s leading medical and travel security risk services company. We care for clients across the globe, from more than 850 locations in 92 countries. Our expertise is unique, employing more than 11,000 employees are led by 1,400 doctors and 200 security specialists. Our Teams work night and day to protect our members. We globally deliver unrivalled emergency assistance during critical times ranging from illness, civil unrest or accidents to mass evacuation due to earthquake or tsunami with teams whose local knowledge and global reach is key for success with the medical teams leading. We are passionate about helping clients put Duty of Care into practice. With us, multinational corporate clients, governments and NGOs can mitigate risks for their people working remotely or overseas.

JOIN THE TEAM FOR … Exciting Emergency medicine appointments in a large Company Hospital and Clinics in Saudi Arabia. Immediate and future vacancies for a 3 to 6 month contract with a view to a permanent position. We are seeking Certified FCEM ER Physicians to work flexible shifts in an internationally staffed and equipped environment of the highest standard. Excellent accommodation and benefits associated with a very competitive expatriate package. Register your interest NOW for immediate and future vacancies. Deployment from May 2016 onwards.

--------Please submit a comprehensive CV to Maxine O’Fee Lawson Resourcing Manager at maxine.ofee@internationalsos.com www.internationalsos.com

The Kit

Field Tested: Using the Omni Pro in Europe’s Refugee Camps by keith raymond, md

ith more refugees moving across the world than ever before, and with so many doctors now volunteering for remote assignments, it is just the right time for a system that allows a complete physical exam without the need for the traditional Medical bag. “Omni Pro Multifunction Medical Devices” provides 11 exam tools in a single medical device. A Hong Kong physician, Dr. William Hasbun, along with a team of engineers, designed Omni Pro to do in 145 grams what has traditionally been accomplished with five kilograms; the device includes—among other features—a stethoscope, oto/opthalmoscope, audiometer, tuning forks, and an examination light. When medics have to carry all their equipment, medications, and supplies on their back, the weight savings with Omni Pro is significant. Omni Pro makes sense in the field, but it is also precise enough to be used in the clinic or hospital. The micro USB recharging unit and cable can be attached to all electrical sources worldwide, including photovoltaic or solar panel backpacks. It typically takes two hours to charge fully from zero, and lasts up to several days depending on duration of use. My colleague and I put Omni Pro to the test in a refugee hostel in Austria, just north of Slovenia. There, we examined Afghan and Kurdish refugees from 3 weeks old to 50 years of age. Unlike most first time gadget users, I read the instructions, but for the most part the exam system was intuitive to use. The dimmable light for oto/ ophthalmoscope is a nice touch, making the experience more pleasant and useful for both patient and examiner. All the features of the Omni Pro function remarkably well, with rare exceptions, although some physicians may find the unit small in the hand. Adjusting and adapting the units from otoscope to ophthalmoscope was easy and quick. The specula provided are Omni Pro specific, and, although disposable, are also amenable to multiple use following an alcohol swab. The replacement specula tube price is pending but will likely be minimal. Omni Pro’s manufacturer, HMD, states that standard specula can be used, but those do not lock in place. We also found that, due to the small aperture, one cannot pass instruments through it for procedures as with standard otoscopes. The audiometer is a nice field screening tool, but significant defi16

Issue 20 // Emergency Physicians International

Omni Pro packs 11 medical devices—including a stethoscope, oto/opthalmoscope, audiometer, tuning forks, and an examination light—into a single device weighing 145 grams. Learn more at hmdmedical.com.

Dr. Raymond uses Omni Pro to examine a patient at a refugee hostel.

cits identified would warrant referral to a proper testing facility. Reading the tiny display required reading glasses, but with regular use the steps could be memorized for easy documentation. I found the electronic tuning forks did not meet expectations. They simply werenâ&#x20AC;&#x2122;t powerful enough. Even placing it on the forehead, rather than the top of the head, in the 512 setting was insufficient to produce the needed bone conduction for a Weber test. Similarly, the Rinne test was limited, as it performed well in air conduction, but bone conduction was dodgy. When compared to normal tuning forks the results were inconsistent. Tuning forks are very useful in the field, so I was pleased that they were available in the Omni Pro, but disappointed when they failed. In addition to the standard function, I use the 128 hertz tuning fork to assess for bone integrity. As we cannot carry an x-ray machine to a remote outpost, a 128 tuning fork, when applied to a bone, is a quick and dirty way to determine if a fracture is present. The bone fragments will vibrate against each other with a fracture when there is no obvious displacement or deformity of the bone. Under such circumstances, the test, when performed, is exquisitely painful, but if a fracture is absent the patient remains comfortable. This test essentially determines or eliminates the need for splinting. The Omni Pro could not perform standard tuning fork tests, much less this one. Ideally, in the next iteration, replacing the electronic tuning fork with a digital thermometer would be preferred. The only other items I carried with me included a blood pressure cuff, fluorescein strips, and a thermometer. Eliminating the latter would add utility to an already marvelous exam tool. Iâ&#x20AC;&#x2122;d also like to see the charging cable attached to the stethoscope hose, as it is easily lost. This is the view of the Omni Pro from orbit. In the hands-on faceto-face encounter, the patients felt the instrument was professional in function and appearance. The reflex hammer did not appear

makeshift and was useful in abdominal percussion with the hand in place, allowing us to diagnose a sigmoid volvulus. The sensitivity of the Omni Pro stethoscope was excellent. Detection of subtle cardiac valvular disease could be appreciated and was no different from a standalone Littmann Master cardiology stethoscope. For infants, the diaphragm was much too large, but the tradeoff was its multiple functionality. A standard adapter could be carried and added to meet the needs of pediatric patients. Neurological exams were easily accomplished using the device, particularly with peripheral two point discrimination. An Afghan refugee with a history of seizure disorder, possibly as a result of traumatic brain injury, tolerated and even preferred the smaller device during the testing. (Interestingly, while attending a German lesson he suffered a violent outburst, one of many apparently, which we suspect was due to accessing a damaged part of his frontal lobe when learning. Police were called and he was detained, but I pointed out to them a possible medical cause to his violent behavior which they took under advisement for future encounters.) HMD is poised to introduce Omni Pro for the use of medical students and residents, allowing them to do complete exams on the fly. Besides being clever, the device also saves them money. Due to be released in October 2016, Omni Pro has a suggested retail price of $499 USD. To compare Omni Pro to standard equipment, I referred to Amazon.com to price out the standalone tools. Littmann Master Cardiology stethoscope: $199.72; Welch Alyn Oto/Opthalmoscope set: $574.20; Maico Diagnostic Portable Audiometer: $696.51; Taylor Pocket reflex hammer and 2 Tuning Forks: $13.25; Pen light: $5.48. Total cost for the standalone comparable system: $1,489.16 vs. $499.00 for Omni Pro. Basically, a complete set of equipment for one-third of the price. Personally, as the price for handheld ultrasound comes down, I believe they will replace stethoscopes entirely. Transducers can now be attached to smart phones and used with an application, but the price is simply out of reach for the average practitioner (â&#x2030;Ľ$3000.00 USD). My colleague felt that the unit was overall too flimsy and could be subject to breakage when tossed into a backpack with other equipment. The plastic makes it light, but metal reinforcement, while adding weight, might also provide some greater durability and reassurance for the practitioner. The temperature range advised for operation is 59 F to 104 F, making its utility in cold climates limited, although I suspect this has more to do battery life than anything else. As most exams are done within this temperature range, this is a minor issue. I still believe strongly in the power of the physical exam, and Omni Pro is a step into the future with equipment that is precise, portable, light, and inexpensive. For the physician in the field it is an indispensable asset.

IFEM Report

A New Lancet Commission Puts the Spotlight on EM Lee Wallis, president of the International Federation for Emergency Medicine (IFEM) serves on a newly formed Lancet Commission, which has 23 commissioners across a range of specialties. Their task? Examine how the effects of non-communicable diseases differ around the world, particularly between high and low income countries, and promote pathways for better healthcare. EPI caught up with Dr. Wallis to learn more about this initiative, as well as his thoughts on ‘technology leapfrogging’ and drones delivering healthcare supplies in Rwanda.

interview by logan plaster EPI: My understanding is that this commission represents the first time that emergency medicine is really getting a seat at the international non-communicable disease table. Is that true? LEE WALLIS: Yeah, it’s the first of its kind that I’m aware of. Emergency medicine is getting a lot of traction at the WHO, which is feeding into this commission. EPI: How is the Lancet Commission tied to the WHO? WALLIS: A lot of the data inputs are provided by the WHO. The lead commissioner for the WHO has worked with Terry Reynolds for a long time, so she kind of nudged him to include emergency medicine in these discussions. EPI: Is there something concrete that you hope to get out of this in terms of EM development? Besides just pushing it forward in general. WALLIS: There are several approaches going on at once. We want to define the minimum standard of care for emergency medicine, as well as the minimum resources necessary, minimum drugs, etc… What are the essentials? Also, in the Lancet commission, we’re going to try and show the evidence base for the whole emergency medicine package. If it was applied in a decent healthcare system that the poorest in the population could access, what size of impact would it make? So we’re really trying to produce some evidence for emergency medicine in terms of the scale of its impact on the whole population, so if we go from no emergency 18

Issue 20 // Emergency Physicians International

care system to a minimum EM system we’d save X number of lives and save X disability years, which would translate into this reduction of poverty leading to X effect on the GDP of the country. It’s that sort of stuff. So it’s not necessarily to put clinicians on the ground, but it is to say to ministers and policy makers and funders: look what you would get for your dollar investment in these poorest people.

Prof. Lee Wallis is the head of emergency medicine in South Africa’s Western Cape Government.

EPI: How does the Commission line up with the goals of the International Federation for Emergency Medicine (IFEM)? WALLIS: IFEM has identified that in order to meet the needs of the 2016 EM world, we need to train new EPs. My personal take is that we should be promoting access to EM care to everybody, and not just via specialist emergency physicians. IFEM defines EM in the way I use the term emergency care, but I want to use EM to talk about specialty, and emergency care to talk about wider access to, for instance, a nurse who knows what’s going on. My vision for IFEM is that we should be promoting access to quality emergency care – not just emergency medicine – across the world. That’s not a vision that has been completely bought into. There are some very reasonable and well rationalized arguments as to why the focus should remain on specialist care. We’re still going through the process of working that out. We recognize that we need to either accept that we are what we are, with the current sides and functions, or IFEM needs to change. And I’m pushing to change, and several others in the leadership are pushing to change. But if we’re going to change we need to know to what. So the first thing—before we change—we need to say who are we as an organization, what we stand for, what we do, and how we should do it. The first step is to at least have a common vision. So that’s what we’ve been working on. It’s been three months now, and we have a good draft of the mission that the executives share support for, and we have it coming before the board soon for approval. Our next stage is to present that to the assembly electronically with a very specific ask of them to think about who we are, where we’re going, how we should do it, before the October assembly meeting at ACEP. At the ACEP meeting we’ll have a dedicated half-day small group brainstorm and trying to help us get the strategic document right. EPI: I could see how that process is one you could get mired in for a while. Pretend you’ve gotten past that and tell me where you’d love for IFEM to be five years from now.

I’m pushing to change, and several others in [IFEM] leadership are pushing to change. But if we’re going to change we need to know to what. So the first thing—before we change—we need to say who are we as an organization, what we stand for, what we do, and how we should do it.

WALLIS: It would be great if we had dedicated streams of funding that we were supporting on the ground work at country or sub-national levels. It may be working with individual hospitals, but as an international organization we shouldn’t be focusing on hospital-level buckets, we should be focusing on national and subnational buckets. We would have, in my ideal, dedicated streams of funding to support those in countries where EM is in some degree of unity, working with local leadership to advocate change, build a platform of emergency care, and a prehospital system, and we’ll be building capacity. That’s a long way to get in five years, but I wouldn’t say it if I didn’t believe it was achievable. EPI: What about specific initiatives? What is feasible on the local level? WALLIS: It’s always easy for me to frame it in African contexts. Let’s take Uganda. They’ve got a person in the ministry that’s been appointed to lead emergency care development. They’re developing a strategic plan for the country and they’re developing five-year deliverables for improving emergency care. But they don’t have the money to do it. They certainly don’t have the money to do it well. The partners they’ve engaged with—AFEM, and my university in Cape Town—we don’t have the money to do it. So it would be great for IFEM to be a main partner as a funding stream that puts IFEM people on the ground, whether it’s longitudinally or intermittently, but on the ground with the ministry, with the universities, to drive local development and training programs, specialty residency programs, helping them identify a career path for graduates of the residencies. We’d have dedicated undergraduate and post-graduate training for nurses, dedicated post-graduate training for clinical officers and EMS. We’d have IFEM experts set up their EMS policies and protocols in place, and do the equip-

ment lists for their ambulances. We would be helping the hospitals put the clinical protocols, patient-flow protocols, triage protocols, and quality control trainings in place. Everyday emergency care in the US at a more basic level. It just didn’t exist there. These places might have a casualty unit if they’re lucky. They would benefit from doing it properly, and not from what we’ve been forced to do. We just don’t have the resources to do what we need to do, so having those resources would redirect our focus. EPI: Any thoughts about how to get into those different streams of resources flowing, in an ideal world? WALLIS: This is one thing that we’ve been engaging in some dialogue about. We already have lots of relationships with ministry and universities, and we would go to them and ask them for their support on the basis that 20 or 30 small contributions add up to something decent. And then build a track record with those funds for 2-3 years, and then we’ll be able to attract larger funders. And at the same time start to lobby and get ourselves known among the larger funders. Funders need to be asked, not just by IFEM, but they need to be asked by countries, too. That is happening now, so I think in the next five years you’ll start to see a shift in more international funders. There’ll be money starting to come in to emergency care, which hasn’t been the case. EPI: Switching gears, we’ve heard a lot of about ‘leapfrogging technologies’ recently, in our pages and elsewhere. Given your experience in Africa, do you think it’s true that the world’s most underserved markets will lead telehealth because of greater need and accelerated adoption of technology? WALLIS: I think that is absolutely true. Look at southeast Asia. There is a massive pride and a massive need, and the people are there, and the technologies are in everyone’s pocket. In southeast Asia I think it’s going to be transformative. They are poor countries, but I think it’s easier to set clear guidelines, and what they’re doing with technology and emergency care is just astounding. They’re leaving us in Africa a very long way behind. India, Africa – that’s a different story. The regulatory framework is slow in those areas and it’s hard and slow to effect technology. The medical regulators tend to be very conservative in their approach to technology. I think in terms of wide impact in large parts of the world, I don’t see leapfrogging happening yet. EPI: How do you feel about the stories coming out about drones delivering healthcare supplies in Africa? WALLIS: I hope it’s not just a gimmicky pilot—I hope it’s sustainable. I think in middle-income countries they’d be great. In low-income countries, I’d love to see them used more. The one that we used in Cape Town was stolen. But in Rwanda, I think if they can make it sustainable it’d be awesome. www.epijournal.com

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Return, Rebuild: One Kurdish Surgeon Brings Healing in Northern Iraq In the Kurdistan Region of northern Iraq, at the Azadi Teaching Hospital, in Duhok, a native son of the region established a successful international collaboration to teach surgery and transplant medicine in a region still climbing out from under decades of political oppression.

by lisa moreno-walton, md, ms

fter decades of armed conflict, Iraq is emblazoned on the consciousness of many people as a television news report, with Baghdad in flames, car bombings, and international military incursions. Dr. Gazi Zibari, a member of the Kurdish ethnic minority that composes about 17% of the Iraqi population, can recall a different Iraq—an Iraq where the sick and the injured travelled 8–9 hours on horseback to see a nurse with only three months of training, who would call for help from the few doctors in the area when she was able to reach them; where children died from ruptured appendices, and women and their unborn babies died for the lack of anyone with the skill to turn breeches or do caesarian sections. It was in the Kurdish region of Northern Iraq where Saddam Hussein closed the borders to prevent supplies from

Timeline: 15 Years of Health System Capacity Building 20

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getting into Kurdish provinces and swore, quite proudly, not only to cleanse the country of the ethnic Kurds but to wipe out the name of the Kurds and Kurdistan from every school textbook and from history itself. Dr. Zibari left in order to survive. After a year in Iran as a refugee, he went to the United States in 1976, learned English, went to college at night while working during the day, attended medical school, did a residency, and then completed a transplant fellowship at Johns Hopkins during the First Gulf War. While the younger brother was becoming Dr. Zibari, the older brother became General Babaker Zebari (the spellings of their surnames differ, as both are English translations from the Kurdish language, which is written in Arabic script). General Zebari served in the New Iraqi Army and was Chief of Staff of the Iraqi Army from 2003 till 2015. Dr. Zibari’s dream was always to return to his homeland to improve the quality of medical care by providing capacity for the bright, skilled, and dedicated physicians there to be able to function at the highest levels of their abilities. The first step to the realization of this dream came at the close of the Gulf War, when General Zebari told his brother that if he could manage to reach Zakho, in Northern Iraq, the General would facilitate his en-

1992 Saddam Hussein Hospital reclaimed from the dictatorship and re-opened as Azadi Freedom Hospital

try into his homeland. In June 1992, under the protection of NATO and the United Nations, the Kurdish people voted for the first time to elect their own Parliament, and two brothers, parted for almost two decades, greeted each other on opposite sides of a bridge in Zakho. Dr. Zibari recalls that he cried at seeing a sign stating “Welcome to Kurdistan” in Arabic, English, Turkish, and Kurdish. The Kurdish

1992 Dr. Zibari's first trip to Kurdistan as a physician

1992 Medical School opened at the University of Duhok

people were validated, if not in their own autonomous nation, at least in territory where they could live openly, in democracy, without fear of genocide. The brothers walked off the bridge and headed immediately to the Azadi Teaching Hospital in Duhok, the former Saddam Hussein Hospital, where Dr. Zibari promptly began the fact finding mission that formed the basis of all of our future work in Kurdistan. He

1998 Graduation of first medical school class

found antiquated textbooks, no internet access, empty pharmacy shelves, procedure trays with incomplete sets of instruments, and dedicated, intelligent, passionate physicians who were eager to acquire the knowledge and skills that had been denied them during the reign of Mr. Hussein. During his vacation time from his academic position in the US, Dr. Zibari returned to Kurdistan each year to bring medications, pharmaceu-

2005 Introduction of laparoscopic cholecystectomy at Azadi Hospital.

2006 University of Duhok grows to 12 colleges

ticals, textbooks, journals, and instruments, and to teach his colleagues how to use them. By day, he taught the doctors, and at night locals lined up wherever he was staying to consult him on clinical conditions for which they had not found adequate care. One of these clinical conditions was renal failure. In a nation lacking dialysis machines, only the fortunate were able to be dialyzed, for a two hour run, twice a week.

2010 Renal transplant program begins, training experienced general surgeons through a minifellowship model

2016 >1,500 renal transplants have been performed using live related donors

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The Azadi Teaching Hospital (formerly the Saddam Hussein Hospital), in Duhok.

True capacity building involves providing knowledge and skills to native physicians and allowing them to develop resource sensitive and culturally competent best practices for their own country and culture.

Even so, they were dying. Two needs became very apparent to Dr. Zibari: first, he needed more US-trained physicians, and second, he needed to teach renal transplantation. In 2004, when the ban was lifted on travel to Iraq by individuals not born there, Dr. Zibari began to compose a team of trusted physician friends from various specialties to accompany him. By 2010, both needs were met: Dr. Zibari had a team representing the specialties of transplant surgery, general surgery, traumatology and emergency medicine, neurosurgery, critical care, ophthalmology, otolaryngology, and surgical oncology. The local Kurdish surgeons had also been sufficiently trained to open their own renal transplant service, currently performing 2â&#x20AC;&#x201C;3 living donor transplants per week in Duhok, and 3â&#x20AC;&#x201C;4 per week in Erbil. Members of this surgical team, which I joined in 2010 as a professor of emergency medicine, trauma, and intensive care, now make multiple visits a year to Kurdistan of Iraq, with sponsorship from the Americas Hepato-Pancreato-Biliary Association, Operation Hope Foundation, the World Surgical Foundation, Prime Minister Nichervan Barzani Health Foundation, and Duhok Province Ministry of Health. True to the original mission, capacity building is our focus. Team members work in the OR alongside Kurdish surgeons and residents, teaching complex transplant, laparoscopic, neurosurgical, and oncologic procedures. We work in the Emergency Department alongside attendings and residents managing difficult intubations and trauma cases, and we make rounds on the critical care unit and in the ICU, discussing management while sharing journal articles and best practices. 22

Several formal educational seminars and procedure labs are held for all levels of providers: nurses, medical students, residents and attending level physicians. Training is also provided in disaster management, austere medicine, ultrasound, and the management of exposure to chemical and biological weapons. Quality capacity building must also include the skills necessary for academic advancement, so each year an academic seminar is sponsored in which both US-trained and local physicians present topics that are common to emergency medicine and surgical conferences worldwide, providing an opportunity to develop presentation skills and build their curricula vitae. Residents at the Azadi Teaching Hospital are currently working with me to develop case reports for publication in regional journals, and we are reviewing the literature in preparation for the first ever journal club, which will take place on our next visit to Kurdistan and will include residents, faculty and community physicians. The next visit will also include a seminar on scientific writing and preparing manuscripts. One of the pediatric urologists, the first in the region to use minimally invasive technology to treat uretero-vesicular reflux, is working with me to prepare a case series for publication, and two of the renal transplant surgeons have completed data entry on a

Issue 20 // Emergency Physicians International

10-year non-inferiority study of transplant outcomes which we plan to publish. Since true capacity building involves providing knowledge and skills to native physicians and allowing them to develop resource sensitive and culturally competent best practices for their own country and culture, plans are in progress to bring an attending level physician to the US for a 2-year toxicology/research fellowship in collaboration with Louisiana State University Health Sciences Center-New Orleans and Emory University. Plans are also ongoing to develop observerships and explore the possibility for emergency medicine residency training of Iraqi Kurdish physicians in the US. Eventually, emergency medicine will emerge as a specialty in Kurdistan of Iraq, and the ravages of the dictatorship that barred the transmission of modern knowledge and equipment to a people whom it destined for genocide will be erased. For a commitment to global health to be true, we must believe in equal access to the best possible care for every person on the planet. For Gazi Zibari, bringing equal access to the best possible care to Kurdistan has been the passion that has fueled his life and career. He has infused this passion into the hearts, and minds, and hands of a select team of friends who are making this happen, one small step at a time.

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Meet Graham, the New Face of Vehicular Trauma An artist, an accident researcher, and a trauma surgeon joined forces to put a surprising spin on an Australian traffic safety awareness initiative.

by emily thompson, md

“T

he skid marks were there for a couple of decades.” In the summer of 1976, Robert Linstrom had a summer job delivering Wayne Works school buses from Richmond, Indiana to Framingham, Massachusetts—a 13-hour drive. “We would drive out and back, and out and back, about 2 times a week…it was a great job for a college kid.” Around 6:30 am on July 28, Linstrom was about 15 miles outside of Columbus, Ohio, only one hour into the trip. A typical thick morning fog enclosed I-70 East. “I saw the back end of the semi maybe a second

before hitting it.” Several minutes earlier, a truck driver had parked his rig in the right lane of the interstate, mistakenly thinking he had pulled it off the road. Linstrom crashed into it at full speed. “The shock I took through my arms and legs was cataclysmic,” Linstrom said. “Instinctively, I went for the brake and gripped the steering wheel with my arms…I was a pretty strong young adult, had played some football, and was in pretty good shape.” The impact shattered Linstrom’s arms and legs in nine different places. His feet broke through the floor of the bus, trapping his legs in the engine compartment. His

hand went through the console. After the initial shock he was thrown back into the seat and then forward again, flattening the steering wheel with his chest. He was wearing a lap belt only, as shoulder harnesses were not common at the time. When he regained consciousness, his eyeglasses were embedded in the dashboard. Linstrom referred to his injuries as “a cacophony of fractures.” After a fourhour extraction with the help of the West Jefferson Volunteer Fire Department’s newly purchased Jaws of Life, Linstrom was taken to Doctors’ West Trauma Center. Over four days he had a total of 12 surgeries, including an exploratory laparotomy for internal bleeding. His course was complicated by gangrene of his leg, and, at one point he signed the surgical order for amputation of his own leg. Miraculously, the next day the inflammation had improved enough for his surgeons to save his leg. Despite this, it was projected he would never walk again.

t is almost impossible for most people to recognize their risk of injury in a serious road accident. According to the WHO, road trauma was the 9th most comwww.epijournal.com

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mon cause of death globally in 2012, killing over 1.2 million people. It is the number one single cause of death between the ages of 15 and 29. But for the average person, even such dramatic and tragic statistics are sterilized, faceless. “We sort of have this positive outlook, this sort of optimism bias that things will be okay—that we can survive higher speed car crashes,” said Samantha Cockfield, the Senior Manager for Road Safety at the Transport Accident Commission (TAC) in Victoria, Australia. “We’re not designed to survive, as humans, to travel at high speeds on our roads. We can survive around 30 kilometers per hour, 25 miles per hour, before we start to break, and very quickly. What can we do about it as individuals? How do we take care, how do we make sure that we buy the right cars, travel at the right speeds, and then try to understand the [road] system…in order to make changes? TAC officials in Victoria had already confronted citizens with the idea that nobody deserves to die on the road, and that perhaps it wasn’t so outlandish to have a target of zero deaths or injuries from car and pedestrian crashes. “We did that quite intentionally through a campaign called ‘Man on the Street,’” said Cockfield, who noted that TAC is well known for its public education strategies, and for bringing a different and creative approach to safety education. In ‘Man on the Street,’ TAC went out into the streets and asked Victorians directly: first, how many people did they think died in traffic accidents per year? Second, how many people should be dying? Cockfield has no hesitation over making road safety personal. “We found one person who said about 70 people; 70 people was the right number of people who would die on our streets,” she said. “And then we actually asked him to come back and do a training film for the TAC.” During this training film, however, the TAC interviewers flipped the script. “So when he went back and said ‘70 people’ in the training video, we actually brought his family—70 of his family and friends—into the picture,” said Cockfield. “Of course, it’s a very emotional moment.” This year TAC introduced a new project 24

called “Meet Graham” which attempted to put a face (and body) on human vulnerability behind the wheel. For the Graham project, Cockfield’s team wanted to commission an art installation that would bring this concept to life. The Australian artist Patricia Piccinini was one of the first collaborators to join the Graham project. Piccinini’s work explores the effects of technological advances, including biotechnology. “[She] worked in the space between art, science, and trying to bring social meaning to art,” said Cockfield. “She was quite a natural choice.” Two additional contributors provided scientific and medical expertise to the project: David Logan, a researcher at Monash University Accident Research Center, who knows specifically how energy forces in a crash affect vehicles and humans; and Christian

Issue 20 // Emergency Physicians International

Since hyperflexion and hyperextension injuries cause so many problems, Graham has no neck; Graham’s skin is thicker and tougher to prevent abrasion injuries; Graham’s ribs are thicker and stronger, and “airbags” protect his internal organs from impact.” Learn more at www.meetgraham. com.au

Kenfield, a surgeon at the Royal Melbourne Hospital, who deals with road trauma on a daily basis. After months of work, this multidisciplinary team created Graham, a flat-faced, barrel chested, neck-less man-creature who, according to the Towards Zero website, is “the only person designed to survive on our roads.” “The anticipation about what Graham would look like lasted for many months,” Cockfield said. “We had no idea what he would look like until about a week and a half before he was launched, so that was definitely the most exciting part of it.” Graham’s name was selected almost at random as that of a mid-forty-ish, average Australian male. “It was a working title, but it stuck,” said Cockfield, laughing. “We did try to find another name for him, but we just thought, no, now he’s Graham. He was born Graham.” Graham is not built for looks. Anything but average-looking, he is bulky and distorted. While his over-padded face gives him an almost sweetly simple expression, his hulking chest and limbs suggest he might be able to crush a less crash-proof human. His body has multiple features meant to protect him from the forces at play in a traffic accident: his brain is held in place by ligaments and cushioned with extra cerebrospinal fluid, intended to preserve it from abrupt deceleration injuries; his chest serves as a fleshy airbag; his hoof-like feet allow him to spring out of the path of an oncoming car. “You realize how much there is to be gained when you work in a partnership across disciplines,” said Cockfield. “These are really different fields that would never have crossed paths otherwise, and the power of those three people working together was also really exciting to see.”

obert Linstrom’s physical recovery was slow. After five months of various treatments, “…what would have been common at the time would have been a body cast. “His surgeon used an unusual technique to promote healing by early weight bearing on the broken bone. He was in full leg braces when he returned to college the following spring as a sophomore,

braces that would stay on for over a year. Returning to daily life was difficult for Linstrom. “I went from a strapping college freshman, and being as independent as I can be, to wearing this identity as a disabled person.” Because of his doctors, “great support” from friends and family, and certainly in part due to his own attitude, his recovery was remarkably complete. “Five years later I was backpacking in the Cascades. I never really had a sense I wasn’t going to continue to improve.” Today, Linstrom is a senior pastor of a church in Grand Rapids, Michigan, husband of 32 years to his wife, Rebecca, and father of three sons. “In general, I’m just amazingly fortunate.” The goal of Project Graham was to highlight that humans are not built for the impacts and forces involved in a car crash. Linstrom understands this vulnerability more than most: a scattering of small scars on his forearm marks the spot where he laid his head during his extraction, not knowing there was glass embedded in his face. “For months and months I had a bruise in the shape of the steering wheel on my chest, which was a very poignant reminder of the force of that impact,” he said. “I appreciate the Australian initiative to say ‘this is what we would have to evolve to, to survive these impacts.’ The shock to the body is phenomenal.” Education is just the beginning for members of TAC. Cockfield spoke of encouraging new safety innovations, such as lane departure warnings, and emergency braking, which detects vehicles and pedestrians in a vehicle’s path. “Human behavior is going to become less and less of a problem because the vehicles will be interconnected and so advanced that it’s going to be very hard to have a crash,” she said. Linstrom also spoke of safety advances in vehicles: “I was intrigued by how easily people climb out of Formula One accidents unscathed. We have the technology, and we have the ability to not need to be so evolved.” These new innovations are not a solution for everyone, especially some of those at highest risk. The WHO points out that while low- and middle-income countries have only about half of the world’s vehicles,

they suffer 90% of the world’s fatal traffic accidents. In the wealthiest countries, the wealthiest people—those who can afford safe, new cars—are those least likely to die on the roads. Linstrom and Cockfield both expressed concerns that both cost and convenience limited progress. “Some of those changes are changes that people don’t necessarily think are going to improve their lives,” said Cockfield. “When we start putting out barrier systems down the middle of the roads, or we look at speed limits and sometimes drop them, people feel like they’re being punished sometimes. We just need them to understand why we’re doing it.” Despite the practical challenges, the last thing TAC and the creators of Graham can accept is complacency. “No matter how well intentioned or how well-behaved or how much we improve our road-user behavior people, will still make mistakes, people are fallible, and those mistakes shouldn’t cost people their lives,” Cockfield said. “We realized that in fact there’s this sort of feeling of inevitability—that people must be killed or seriously injured for us to have an effective and modern transport system,” Cockfield continued. “But we know that with these technology advances, and better design of roads, and just setting the speed limits right, that we can eliminate most road trauma. It’s not impossible that, say, in 30 to 50 years, we could see a day where nobody gets killed on our roads. So for us the whole campaign was about how to get people to believe that ‘zero’ is actually our long-term aim and it is achievable.”

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R report

design

Applying HumanCentered Design Principles to Emergency Medicine Healthcare systems resemble microclimates, with a unique set of functions, resources, patients, vulnerabilities, and strengths. There is, however, a template for ED design that can account for these many variables, and guide all the stakeholders through the process of building an effective and efficient ED.

by manuel hernandez, md, mba 26

young man is brought to the ED in a war-torn part of world. He is bloodied, bruised, and crying out in pain. Only 60 minutes earlier he was sitting with friends at a café when an explosion and gunfire erupted. Now, he sits on a trolley in an ED corridor. The ED staff are overwhelmed with the casualties. Adding to the challenge is the reality that the hospital is regularly “off the grid.” Access to running water and

Issue 20 // Emergency Physicians International

electricity is unreliable at best, and the gaspowered generator is running out of fuel. A world away, a large extended family begins to gather around the bed of the family matriarch. Elderly and frail, her disease has taken its toll and she is nearing death. As she lies in her ED bed the staff are making every effort to ensure her comfort. Her family has begun their culture’s death ritual. It’s long and complicated, but beautiful nonetheless. Elsewhere, a 5-year-old boy is hurried through the ED entrance by his parents. They are rushed and nearing a panic state. It seems their little boy tried to test the boundaries of his bicycle riding abilities. Things were going well until he hit a hole in the road. He’s got a few scrapes and bruises but seems alright otherwise. In fact, his parents seem more stressed about the situation than he does. Three patients. Three stories. Three very different ED experiences. Over the last decade I’ve had the opportunity to offer assistance to EDs around the globe—EDs large and small, from Asia to North America, Europe, Africa, and beyond. Early in my career in ED design, I dedicated the majority of my focus and resources to helping organizations create spaces reflecting world-class ED design. I, like the large majority of my colleagues in ED design, focused on volume projections, technologies, and many of the quantitative aspects of creating clinical spaces. Only, something was missing. It turns out that something was human-centered design.

Opposite: Iterating is a continuous process of using knowledge and experience gained from creative exploration to further refine and improve a solution until it is ready to be developed as a prototype. This page: High-fidelity mock-up of rooms, departments or an entire building facilitate understanding of processes, flows and experiences in three-dimensions. © CannonDesign 2016.

Human-centered design is a framework that develops solutions to problems by actively engaging stakeholder perspectives in all steps of the process. In a less academic vernacular, human-centered design is all about understanding the lives of stakeholders, be they patients, providers, EMS staff, families, or hospital administrators. It’s about understanding their backgrounds, their goals, their values, the challenges they encounter, and the fears they face when it comes to emergency care. Why does any of this matter? Isn’t an ED just an ED? Don’t healthcare architects know enough about ED design to make the right choices? Don’t physicians and nurses know best how the ED needs to function? Simply put, no. Anyone who tells you they have all the answers is invariably wrong. Every healthcare organization, every ED, is its own unique ecosystem. This ecosystem evolves in direct response to internal and external influences; in other words, it adapts to survive. Planning an ED to manage patient volumes when the bus pulls up and 40 or 50 laborers step off and walk into the ED for their episodic care is very different from planning an ED in a community where ED waiting room times are posted on billboards along the highway in an effort to entice people to come to the ED. Planning an ED that exists as a part of a hospital lacking an ICU or access to a surgeon is very different than planning an academic ED with all of the latest and greatest technologies at the ready.

With the understanding that healthcare systems are like localized micro climates, how do you plan an ED that balances bestpractice design against local realities of healthcare delivery and resource availability, to say nothing of the cultural nuances tied to healthcare and its role in the larger community? How can the ED you design work for patients, families, providers, and work within the healthcare system? It’s not as difficult as you may think, but it does require focus and discipline. There are countless iterations of humancentered ED design used by design experts. One of the more successful is a five-step process that begins long before architects begin drawing floor plans and continues well into design of the physical spaces. Understand. The process of designing a new ED begins by understanding the current state of emergency care. Understanding today requires an appreciation of not only quantitative data such as ED volumes, arrival distribution patterns, quality metrics, and cost models but it also includes developing a healthy knowledge of the qualitative factors that can influence emergency care. For example, what are the goals patients and providers have with respect to the ED care process? What are the barriers that currently prevent realizing these goals? What are the implicit, explicit, and latent needs tied to the ED care process? The needs surrounding the ED patient in a war-torn part of the world are very different

from those in a wealthy community where the ED is used partially as a convenience more so than a necessity. It’s also important to understand the evolutionary factors that may affect tomorrow’s emergency care: ED volumes may change over time, new or expected regulatory changes may affect ED care delivery, and new technologies will find their way into emergency care. In consideration of factors such as these, how is the model of care evolving in the community, and how will the ED need to respond? In almost every instance, developing a true understanding of today’s realities has a profound influence on the design process. It provides an opportunity to use the design process to craft solutions to challenges we might not have even known existed. Define. The next step in any design project is to define what success looks like. In reference to the three aforementioned patients and the EDs they’ll access, the definitions of success will look very different at each ED. In an ED without reliable access to energy infrastructure, success may be defined as ensuring the power stays on. In an ED in a community with deep and rich cultural customs, success may take the form of ensuring healthcare doesn’t interfere with or disrespect tradition. In an ED that functions as a profit center, success might mean designing systems to attract patients willing to pay cash for their care. In any case, establishing critical success www.epijournal.com

R report

// design

the best way to get a good idea is to get a lot of ideas.

factors for the ED is an important way to communicate what matters in the future design and what needs to be top-of-mind for the architecture team, who may or may not know a great deal about your community. When defining success, itâ&#x20AC;&#x2122;s important to move beyond the obvious areas of clinical quality and efficiency and to consider what success might look like if we were to consider the final performance of the ED, patient satisfaction, staff satisfaction, or ability to successfully manage future growth. Brainstorm. Itâ&#x20AC;&#x2122;s been said that the best way to get a good idea is to get a lot of ideas. The next step in the design process is to begin brainstorming solutions to respond to your understanding of the current state of the project, the challenges that exist, and the established definitions of success. 28

This stage is an opportunity to dream big, exercise creativity, and take some risks in a safe environment where no idea is a bad idea. Engaging physicians, nurses, technicians, patients, families, and others into the process provides a unique opportunity to approach the same challenge from different perspectives while neutralizing the user bias that clinicians have when designing solutions. By the end of the brainstorming process, a number of outputs should be completed. Most importantly, patient and process flow diagrams should be finalized and handed off to the architectural design team. These diagrams are invaluable for helping the architectural team understand how the spaces they are creating will be used. This facilitates the objective evaluation of multiple design solutions to understand how each solution

Issue 20 // Emergency Physicians International

supports the proposed processes. Equally important, the process flow diagrams serve as a memorializing document that guides staff training when the time comes to prepare for building occupancy. The diagrams also help to ensure that plans that have been developed survive any staffing changes that occur during the design project. Iterate. A lot of ideas are going to come out of the brainstorming process, and you will need to determine which hold promise and which need to be set aside. During the iteration process, the collaboration between clinicians, patients, architects, and other stakeholders will continue. The goal of this process is to advance potential solutions to the point where they are ready for inclusion into the final design solution. Going back again to our three patients:

Opposite: Brainstorming provides an opportunity to explore a wide range of ideas quickly and in a judgement-free manner. This page: Low-fidelity mockup of patient rooms or other clinical areas can be achieved using simple tools like cardboard or styrofoam. ÂŠ CannonDesign 2016.

each design team may have brainstormed a new approach to the patient arrival and triage process. This is the chance to test the proposed triage solution and try to break it. Itâ&#x20AC;&#x2122;s important to ask why the proposed triage solution might fail and what would have caused the failure. Chances are the causes of failure and the final iteration of the initial solution will look very different at each of the EDs. This is the chance to fix things before they ever break, and is a prelude to the next step in the human-centered design process: prototyping. Prototype. ED design and construction projects require a significant investment of time and money. The decisions made during the design process are going to affect how care is delivered in the ED for 10, 20, even 30 years or more. There is one chance to make the right decisions. The wrong decisions can infuse the process with inefficiencies, create patient safety issues, frustrate the staff, and so forth. How do we prevent this, and how do we acquire as much information as possible before finalizing our decisions? We do it by prototyping our proposed solutions. Prototyping is the process of creating mock-ups of proposed solutions to test the solution and gather more user feedback. Mock-ups range from inexpensive, low-fidelity versions using cardboard, styrofoam, etc., to more sophisticated mock-ups using three-dimensional models or imagery, to fully-functional mock-ups of individual patient rooms, procedure areas or staff work

Spending more time in the pre-design and early design phases can help avoid unnecessary delays and redos during later phases of the design process. Moreover, having the architectural team involved from day one is essential to ensure that outputs of the human-centered design process inform the final architectural solutions.

stations with all of the equipment and furniture installed. The benfits of mock-ups cannot be understated. Giving providers and patients the opportunity to see new environments, which are typically a vast departure from existing spaces, can yield valuable insights. For example, using a treatment station mock-up to explore how the clinical team might deliver care during a major medical resuscitation, management of a STEMI patient, or trauma resuscitation can yield invaluable insights on where to position equipment, supplies, staff documentation stations, handwashing stations, and even the patient trolley. The human-centered design process, while a proven and successful methodology, is dependent upon a team that is experienced in the process and in how to adapt it to local culture and customs. Spending more time in the pre-design and early design phases can help avoid unnecessary delays and redos during later phases of the design process. Moreover, having the architectural team involved from day one is essential to ensure that outputs of the human-centered design process inform the final architectural solutions. Only through this process can you ensure that the ED caring for patients in the middle of a war zone is not designed to care for patients in the middle of a gated suburban community.

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Grand Rounds PETER CAMERON, MD // PAST PRESIDENT OF IFEM

Analgesia in the ED Is analgesia in the ED helping our patients?—or killing them?

Pain is the most common reason for people to attend an emergency department (ED). Pain reported in an emergency can result from direct physical injury, ischemia, and inflammation, and the degree of reported pain is influenced by many factors such as severity of illness, patient attitudes, chronicity of pain, environment, and previous experience.

Over the last two decades there has been a particular focus on ensuring that emergency patients receive rapid and effective analgesia,1,2 along with an emphasis on accurate documentation of patient-reported pain and the response to interventions to relieve pain. Quality improvement programs have been developed to ensure that EDs have effective pain mitigation processes.3 This has all resulted in a much greater degree of analgesic use in EDs, and much greater use of narcotics, which, for many clinicians, represent the “ultimate” analgesic. In parallel, we have seen explosive growth in the use of prescription analgesics in the general population, including narcotics. So much so that the American Society of Addiction Medicine put out an “Opioid Addiction 2016 Facts and Figures” bulletin stating: “… Of the 21.5 million Americans 12 or older that had a substance use disorder in 2014, 1.9 million had a substance use disorder involving prescription pain relievers and 586,000 had a substance use disorder involving heroin… “…Drug overdose is the leading cause of accidental death in the US, with 47,055 lethal drug overdoses in 2014. Opioid addiction is driving this epidemic, with 18,893 overdose deaths related to prescription pain relievers, and 10,574 overdose deaths related to heroin in 2014….”

Similar figures have been published in Australia and other developed countries as we grapple with a problem that appears to kill more people than car crashes. As an emergency doctor, I have generally felt that the prescription narcotic epidemic is something I have little control over. I see evidence of narcotic abuse when patients come to the ED with overdose, and when malingerers ask me to prescribe narcotic analgesia. Somehow, I have never felt that I am personally a cause of the problem. Recently, however, some commentators have begun questioning our role as acute physicians in propagating the narcotic epidemic,4 and there is evidence that we may actually precipitate addiction in 30

Issue 20 // Emergency Physicians International

some patients.5 Clearly we are not responsible for all societal ills, and many patients with psychosocial problems will experience some form of addiction or substance abuse. We do, however, initiate a lot of analgesia and set the analgesic program for many patients. The starting point for many patients on their journey to prescription drug dependency may very well be our initial prescription, which is then continued into the community. In the ED there are many “minor conditions” such as back pain, renal colic, or a sports injury where patients are frequently prescribed narcotic analgesics to “effectively and rapidly” reduce pain. Nurses are instructed to inquire about pain using a numerical rating score, and patients will respond with a number to report severity. The score given is impossible to validate because it is obviously a subjective number—only the patient can rate pain. Importantly, there are secondary gains that may cause the patient change their score, such as reducing their waiting time, getting more attention, and so forth. At a practical level, the value of the pain score is open to question. All of us have seen a patient sleeping, only to have the nurse report that pain is 10/10. I am not sure what this means. A significant driver toward using “stronger” analgesics is that the nurse is mandated to respond in many EDs to control the pain quickly. This is to meet key “pain metrics” and thus show that the ED is a high performing unit. This whole dynamic has created an interesting approach, such that most EDs now have nurse initiated analgesia, including narcotics.6 It has also created a shorthand style, where the nurse will say, “Pain score is 9/10, can I give oxycodone?” The doctor, in the middle of ten tasks, will reply to give oxycodone, with the intent to review later. In the case of physical injury, reassurance, splinting, elevation, compression, ice, local anesthetic, and many other interventions, may have been more effective. However, given the time imperative and the “quality metric,” all these options would have delayed time to analgesia and affected “quality ratings” for the ED. The irony of the situation is obvious to most EPs. In addition to the time imperative, there are other issues at play. Narcotics are not the most effective analgesic for many emergency conditions. For example, our recent Lancet article on renal colic showed that IM NSAIDs were more effective than IV morphine and had fewer side effects.7 Yet many doctors and nurses persist in the belief that morphine is “stronger.” Paracetamol is as effective for many types of pain, but is often overlooked. Steroids are particularly effective in inflammatory conditions such as gout and tonsillitis and should be considered first line.

For chronic pain, which is a frequent reason for ED presentation, narcotics are commonly prescribed. Yet outside of patients suffering from terminal cancer, the evidence for use is very thin. In fact, there is increasing concern regarding the phenomenon of opioid induced hyperalgesia. This may occur acutely, but is most common in chronic exposure.8 The management of this condition is particularly problematic and is definitely not an ED program. So what should we do about all this? Some EDs, such as St. Joseph’s ED in the USA, are looking at banning the use of opioid analgesia as first line treatment for pain. This may be extreme, but at least it would focus the mind of the clinicians on alternatives and possible consequences of poor analgesic use. Personally, I would change the emphasis in analgesic metrics from pain scores and time to early and effective treatment of the condition. Giving a patient with a strained ankle oxycodone within five minutes of arrival is not the same level of quality care as assessing the patient quickly, elevating the leg, applying ice and compression, and discharging the patient. We should not be forced to give a tablet just because it makes the patient feel reassured and comfortable! Patients presenting to the ED with pain need to be assessed quickly, but giving urgent narcotics is rarely first line management. Let’s help our patients and not kill them.

1. Wilson JE, Pendleton JM. Oligoanalgesia in the emergency department. Am J Emerg Med. 1989;7:620-623. 2. Motov SM, Khan AN. Problems and barriers of pain management in the emergency department: Are we ever going to get better? J Pain Res. 2009;2:5-11. 3. Management Standards. 2000. Cited on Jul 20, 2001. Available from http://www.jcaho.org/standard/pmhap.html. Joint Commission on the Accreditation of Healthcare Organizations. CAMH Revised Pain 4. Yealy DM, Green SM. Opioids and the emergency physician: ducking between pendulum swings. Ann Emerg Med. 2016. 2016 Aug;68:209-12. 5. Hoppe A, Kim H, Heard K. Association of emergency department opioid initiation. with recurrent opioid use. Ann Emerg Med. 2015 May;65:493-499.e4. 6. Kelly AM, Brumby C, Barnes C. Nurse-initiated, titrated intravenous opioid analgesia reduces time to analgesia for selected painful conditions. CJEM. 2005;7:149-154. 7. Pathan SA, Mitra B, Straney LD, et al. Delivering safe and effective analgesia for management of renal colic in the emergency department: a double-blind, multigroup, randomised controlled trial. The Lancet. 2016 May 14;387(10032):1999-2007. 8. Lee M, Silverman SM, Hansen H, Patel VB, Manchikanti L. A comprehensive review of opioid-induced hyperalgesia. Pain Physician. 2011 Mar-Apr;14:145-61.

BREAKING

THE BARRIERS The way ultrasound is used at the point of care can help drive and change patient care every day. Ahead lies a continuing demand and desire for increased standards of quality for healthcare delivery, for everybody. And so too does the demand for ultrasound: more available, more connected, more at the patient’s side. We share your desire to overcome the obstacles standing in the way of patient care, constantly evolving ultrasound technology to help you get the right answers at the right time.

With you we break down the barriers. You make us what we are. See why we continue to put ultrasound machines in your hands. Contact your local customer representative or email eraf-sales@sonosite.com for further information.

Dr. Peter Cameron is the immediate past president of the International Federation for Emergency Medicine (IFEM)

SONOSITE, and the SONOSITE logo are trademarks and registered trademarks of FUJIFILM SonoSite, Inc. in various jurisdictions. FUJIFILM is a trademark and registered trademark of FUJIFILM Corporation in various jurisdictions. All other trademarks are the property of their respective owners. Copyright © 2016 FUJIFILM SonoSite, Inc. All rights reserved. Subject to change.

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Helping healthcare organizations stay ahead in a disruptive world. More than ever before, healthcare organizations need to harness strategy, bold ideas and forward-thinking partners to help them find equilibrium between risks and the opportunities that lie ahead. At CannonDesign, we offer a full spectrum of design and planning services that can help you identify where you are today, where you need to be tomorrow, and most importantly, how to get there.

cannondesign.com 32 Issue 20 // Emergency Physicians International