a new magazine by
EMERGENCY PHYSICIANS INTERNATIONAL
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EM Development reports from around the globe including
bhutan Turkey Colombia Hong Kong Vietnam South Africa Panama Korea Spain Croatia Ghana Issue O ne // Summer 2010
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epinternational.ning.com
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The Future of IFEM
An interview with Drs. Gautam Bodiwala and Peter Cameron
Could The Netherlands be a template for EM development in Europe?
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Summer 2010 // Emergency Physicians International
Editor’s Desk
Brave New Specialty
W
hen I think of international emergency medicine, one of the first things to come to mind is my friendship with Professor Yitang Wang of Nanjing, China. I first met Professor Wang in 1994 at an EM meeting in Hyderabad, India. A cardiovascular surgeon by training, Wang became a champion of EM specialty development and quickly developed a deep and complete understanding of the specialty. That trip we toured the Taj Mahal together and began what became a long friendship. Over the years, Professor Wang made many trips to the U.S., attending various EM meetings, and then became one of the early presidents of the Chinese Association of EM. He has enabled me to undertake several extremely enjoyable and professionally productive trips across China. What’s more, he’s been a gracious host, giving me the opportunity to see China in a way that I never could otherwise – now I can say I’ve tried boiled ducks’ feet and puffer fish. I’ve learned much from Professor Wang’s energy and enthusiasm for EM development, and yet he is just one of many individuals and organizations involved in development in this field. Emergency Physicians International (EPI) enters into this arena as a central platform, an open forum for cross-border communication. This inaugural issue of EPI began largely as the brainchild of Logan Plaster, the Editor and Creative Director for Emergency Physicians Monthly. But it quickly grew in scope, garnering an editorial advisory board representing a wide range of countries and a depth and breadth of experience in international work. One of the central goals of this publication is to address the question: “What is international emergency medicine?” The phrase means different things to different people, but here are a few of the ways that we define it (see sidebar). If we’ve left something out, just let us know. EPI is about open dialogue. To that end, we’ve also set up a social network (www.epinternational.ning.com) where physicians from around the world can gather, chat and share information on conferences or clinical updates. The site, which can be translated into nine languages with a click of a button, has already garnered hundreds of physician members, making it a robust tool for international communication. Rather than go the route of an indexed, peer-reviewed journal, EPI is an open door, providing the opportunity for physicians from all over the world to submit articles. In the spirit of promoting free and open communications, EPI would like to receive and publish all types of articles (clinical, research, academic, political, business, etc.) from any country. We are hopeful that people will take advantage of EPI to publicize and promote their IEM activities or programs, and that EPI can foster and facilitate more international collaboration. The field of IEM has a bright future and EPI hopes to expand those opportunities and bring people together for collaboration. We very much welcome your input, advice, and suggestions. Welcome again to Emergency Physicians International!
What is Int’l Emergency Medicine? This new specialty means many things to many people. Here’s how we define it at Emergency Physicians International
1
Delivering clinical care for emergency patients in countries other than one’s native country.
2
Developing and obtaining official recognition of the specialty of emergency medicine in countries where it is not yet officially recognized.
3
Developing and conducting training courses in emergency care for the public at large, non-physician healthcare workers, medical students, postgraduate residents, and physicians in practice in other countries.
4
Developing and operating prehospital care systems in other countries.
5
Developing and conducting academic aspects of EM, including research, faculty development, and educational program development and improvement.
6 7
Developing and equipping clinical facilities to provide emergency care.
Providing medical care in “repatriation services” which return patients from one country back to their country of origin to receive additional or follow-up medical care.
8 9
Operating travel medicine clinics.
Conducting exchange programs for healthcare personnel from different countries. C. James Holliman, MD, FACEP, FIFEM editorial director
10 11
Conducting international conferences on EM.
Developing and operating specialty societies of EM practitioners.
www.epinternational.ning.com
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letter from the publisher
EPI: An Introduction
O cover illustration by Tracey Jolliffe traceyjolliffe.com
n a beautiful evening two years ago, I arrived with my wife at the ICEM opening reception in San Francisco, California. I was covering my first international conference for Emergency Physicians Monthly and all I knew was that I was the guest of one Jim Holliman. Jim and I met, shook hands, and then it was off to the races. I quickly learned that when you’re with Jim – a man who has dedicated his life to the development of emergency medicine around the globe – you’re an honored guest. Over the course of the evening, Jim introduced me to literally dozens upon dozens of EPs with a passion for international EM development. Many of these men and women had worked tirelessly for years to lay the groundwork for the development of their specialty, often in places where it was previously nonexistent. Physicians gave me their reports on development, shared their stories from globetrotting adventures, and, towards the end of the evening, even extended warm invitations to visit their far-flung homes. That night the seed was planted for Emergency Physicians International (EPI), the first issue of which you now hold in your hands. The goal of EPI is to accelerate emergency medicine development around the globe by bringing EPs together for an on-going dialogue. We hope this conversation will light the way to improved patient care and greater physician satisfaction. Given the dedication and knowledge possessed by the IEM community, it is impossible to say what great developments are in store. But every building begins with a foundation, every book with an introduction. We at EPI look forward to helping tell that story. Along the way, I hope EPI captures a hint of that ICEM opening reception, with its excited talk of people, progress and new adventures.
editorial director James Holliman, MD executive editors Peter Cameron, MD Terry Mulligan, MD Mark Plaster, MD editorial advisors ARIF Alper Cevik, MD Kate Douglass, MD Haywood hall, MD Chak-Wah Kam, MD Greg Larkin, MD Prof. Dongpill Lee Sam-Beom Lee, MD Gladys Lopez, MD Alberto Machado, MD Lee Wallis, MD associate editors EMILY DEBUSK LONNIE STOLTZFOOS
to order reprints, contact Greg rucker PARS Int’l 253 W. 35th Street, 7th Floor New York, NY 10001 p: 212.221.9595 ext. 105
Logan Plaster Publisher
on the web
connect with your international colleagues on EPI’s online Network www.epinternational.ning.com
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publisher Logan Plaster
•
Join more than 400 current members from around the globe
•
Create a professional profile for networking and communicating internationally
•
Post international events and learn about new conferences being held
•
Share photos, videos and educational materials with colleagues
•
Join a discussion in progress or start a thread of your own
•
Reconnect with old friends, or make new ones through interest groups
Summer 2010 // Emergency Physicians International
advertising Michelle rucks mrucks@epmonthly.com 5 College Avenue Annapolis, MD 21401 Submissions & Letters c/o logan plaster Emergency Physicians International 210 Columbia Heights Brooklyn, NY 11201 lplaster@epmonthly.com
EP International is a product of M. L. Plaster Publishing Co., LLC ©2010 Founder / CEO
mark L. Plaster, md
Executive Vice President Rebecca r. Plaster
A World of Possibilities with M. L. Plaster Publishing Co., LLC since 1992
Use the strength of one of the largest EM publishing companies to help your EM society... Increase attendance at your next conference through targeted advertising Increase society revenue by building a regional EM publication Increase EM awareness and education through professional content Bring eps together online for networking and educational opportunities
“Those boys in The er” // An EP reflects on 37 years working in the same emergency department. page 3
May 2010 | Volume 17, Number 5 | www.epmonthly.com
NightShift
A Couple Days
Reading Between the Lines JeRoMe HoffMAn, MD on How To ReAD THe LiTeRATuRe part i in a series
This month Night Shift changes gears, publishing a post from one of our favorite medical blogs, StorytellERdoc.blogspot.com
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enter the iPad
I
walked into Room 17 to see a sixty-ish woman who, by the nurse’s triage note, had come to our ER for shortness of breath. A smoker, with a history of chronic obstructive pulmonary disease (COPD). The nurse’s note reflected her suspicions that this
how Apple’s new tablet is already changing emergency medicine by Nicholas Genes, MD
Oh heNry
Too Much Technology?
Are gadgets gathering dust in your ED? Ask a few questions before jumping on the next tech trend by Greg Henry, MD “The philosophies of one age have become the absurdities of the next, and the foolishness of yesterday has become the wisdom of tomorrow.” ~Sir William Osler.
I
continued on page 17
in this issue Managing Managers Getting complaints about your nurse manager? If mentoring doesn’t work, you may need to take it to the top >8
14
have no interest this month in sounding like a malignant Luddite. I am not against all change; some change may actually be good. But, we cannot confuse change with progress. The two have nothing to do with each other. There are people who change for no good reason. There was time in the Unitcontinued on page 31
Visual Dx The eye cannot see what the mind does not know >5
Wal-Mart Medicine
in Case of emergency...
Are retail clinics eroding our business or are they the next step toward cost containment?
Your ED is the saftety net for your community. But where do you turn when YOU have a financial disaster? Here are four simple strategies for protecting your assets from life’s worst case scenarios.
by richard bukata, MD
Pediatric Journal Club Can ultrasound-guided IV placement really help in those hard-to-stick pediatric cases? Ghazala Sharieff knows and has the research to prove it. >16
CME
T
your society or regional publication
by setu Mazumdar, MD
he United States is a capitalist country in which entrepreneurs who see opportunities and are willing to take some risks can generally do well. Finding the opportunities is the hardest part of the equation. One wide open market that would seem to be a slam-dunk opportunity is that of health clinics in retail stores. The concept seems compelling for several reasons. They are instantly credible because of the mega-businesses they are associated with (Wal-Mart, K-Mart, major grocery chains). They don’t require high cost physicians to provide the care – nurse practitioners can
f I asked you to list the biggest risks to your assets, I’m sure malpractice lawsuits would appear near the top. But lawsuits are only one of the many catastrophes that put your assets at risk. Whether you’re preparing for a natural disaster, a potential disability, or even death, you should seriously consider asset protection. Step one? Establish an emergency fund.
continued on page 18
continued on page 9
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tech trends automated ed registration & other innovative game changers Emergency Physicians Monthly | 5 College Avenue | Annapolis, MD 21401
Partner with the company that knows emergency medicine. Between Emergency Physicians Monthly (30,000 U.S. circulation) and epmonthly.com (90,000 impressions per month) Plaster Publishing has been reaching the emergency medicine market since 1992. Now with the introduction of EPI, the EPI Online Network and custom regional publications, there are even more ways to build your EM presence.
Find out how to partner with plaster publishing by emailing info@plasterpub.com
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3 | Editor’s Desk 7 | Event Calendar 47 | IEM Fellowship Directory
EMERGENCY PHYSICIANS INTERNATIONAL
10 | Interview p Drs. Gautam Bodiwala and Peter Cameron on the state of the International Federation for Emergency Medicine (IFEM). 11 | Travel How one physician used his profession to travel the globe 12 | Academics Want to take your interest in international emergency medicine to the next level? Get connected with one of many IEM fellowships. 13 | Opinion Haywood Hall on the importance of having a community-based approach to EM development. 14 | Case Study q Flank pain with a twist. Test your ability to read bedside ultrasound. by Brady Pregerson, MD & Teresa Wu, MD
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Source 16 | Dispatches Reader-generated updates on emergency medicine development around the globe. 18 | Bhutan p Emergency medicine takes strides forward high in the Himalayas with Jim Holliman, MD 21 | Turkey Emergency medicine bridges continents 24 | Vietnam Emergency medicine takes strides forward through historic symposium
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Features 32 | Bridging the Gap p Could The Netherlands serve as a template for emergency medicine development in Europe and beyond?
26 | Colombia New growth through specialty societies and academic programs
40 | The Canadian Head CT Rule Is the rule reliable enough for more litigious nations? Drs. Kevin Klauer & Christopher Carpenter square off.
28 | Hong Kong Towering city begins foray into EM subspecializations
42 | Disaster Relief: Haiti After Action Report MSF deputy considers the weight of emergent amputations, plus Eight disaster relief lessons learned, by Mark Plaster, MD
Advertiser Directory // MedSpanish 2 Emergency Medical Abstracts 8 The Morgan Lens 23 ER PocketBooks 27 EM:RAP 30 ACEM Conference 51 GE Vscan 52
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Summer 2010 // Emergency Physicians International
EVENT CALENDAR 2010/2011
12 months of int’l conferences EuSEM’s European Congress on EM will be held in Stockholm, Sweden in October, 2010
JULY / 2010 PACEFEST // San Miguel de Allende, Mexico A multinational effort to develop and enhance the specialty of emergency medicine in Mexico and Latin America. July 10 – 18, 2010 www.pacemd.org Phone: 01 415 152 7532
AUGUST 10th Asia Pacific Conference on Disaster Medicine // Sapporo, Japan A conference aimed at studying and improving regional disaster medicine and deepening relationships between Asian and Pacific Rim countries. August 26 – 28, 2010 www.sapmed.ac.jp/~disaster Official Language: English
SEPTEMBER Learning from Each Other: Civilian and Military Emergency Care // Birmingham, U.K. Sponsored by the U.K. College of Emergency Medicine and the Assoc. of Paediatric Emergency Medicine September 13-15, 2010 www.cembirmingham.co.uk
ACEP Scientific Assembly // Las Vegas, United States The annual meeting of the American College of Emergency Physicians. Large international section (1000+ members) plus numerous educational programs. September 26 – October 1, 2010 www.acep.org/SA
OCTOBER The 6th European Congress on Emergency Medicine (EuSEM) // Stockholm, Sweden A multi-faceted look at current advances in emergency medicine all over Europe. October 11 – 14, 2010 www.eusem2010.org Fees range from 4,950 to 7,250 SEK
8th International Conference of Emergency Nurses // Canberra, Austrailia Emergency nursing conference “emphasising the challenges of delivering emergency care in a global village.” October 14 – 16, 2010 www.cdesign.com.au/cena2010 Earn up to 15.75 RCNA CNE points
IAEM 2010 // Waterford, Ireland Ireland’s annual academic meeting will be held in Faithlegg House Hotel and Golf Club and will culminate in a blacktie gala. October 14 – 16, 2010 www.iaem2010.webs.com
ENAO Provincial Conference // Kingston, Ontario A provincial conference hosted by the Emergency Nurses Association of Ontario. October 21 – 22, 2010 http://enao.on.ca Held at the Confederation Place Hotel
2nd EurAsian Congress on Emergency Medicine // Antalya, Turkey EACEM is the biennial international congress of the Emergency Medicine Association of Turkey (EMAT) in collaboration with SUNY Downstate and the Singapore Society of Emergency
Medicine (SSEM) October 28 – 31, 2010 www.eacem.org
1st International Critical Care Symposium // Chennai, India This meeting aims to “bring together world renowned speakers” in a “friendly environment allowing informal discussion,” while providing CME credits. October 29 – 30, 2010 www.critcaresymposium.co.uk
NOVEMBER CSEM Scientific Assembly // Antofagasta, Chile Academic conference hosted by the Chilean Society of Emergency Medicine November 10 – 13, 2010 www.medicina-intensiva.cl/urgencias Official Language: Spanish
ACEM International Conference // Bogota, Colombia Asociacon Colombiana de Medicina de Urgencias y Emergencias (ACEM) is hosting its 1st International EM Conference, “New Horizons in Emergency Medicine” November 11 – 13, 2010 www.acemcolombia.org Spanish and English language tracks
JUNE / 2011 1st IFEM Symposium on Resuscitation // San Miguel de Allende, Mexico An advanced international resuscitation symposium, held at a UNESCO World heritage site. June 22 – 24, 2011 info@Centro-PACE.org English with Spanish side events
To have your international event listed in an upcoming issue of EPI, email events@plasterpub.com
www.epinternational.ning.com
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Summer 2010 // Emergency Physicians International
www.epinternational.ning.com
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INTERVIEW
This June, Dr. Peter Cameron (right) will succeed Dr. Gautam Bodiwala as president of the International Federation for Emergency Medicine (IFEM). EPI caught up with them to discuss the future of EM’s only global body. interview by logan plaster
The Future of the Federation EPI: What trends are you seeing in international emergency medicine? Dr. Peter Cameron: I think the positives are that emergency medicine is expanding into virtually every country in the world, in some form or another. It is still not a specialty in many countries, but roughly one-third of all countries have some formal emergency medicine organisation and training. Along with this, IFEM has been able to bring the disparate concepts around emergency care delivery into a more consistent approach through conferences, committees and most recently a curriculum that has been agreed to around the world. This is very exciting, even in comparison with other more established specialties. In addition to the expansion of emergency medicine as a specialty, there has been increasing interest in broadening the scope of subspecialization. Now we have prehospital care, toxicology, disaster medicine, ultrasound and so on. I guess the other really big positive for IFEM is that it is the only true global emergency medicine organisation – this is most unusual in international medical specialties. It means that potentially IFEM can play a big role in advocating for improvements in emergency medicine systems around the world.
+what are IFEM’s primary weaknesses moving forward?
Cameron: The main negative for IFEM is that it is still essentially a loose conglomeration of national organisations with minimal funding. The IFEM Board has been examining ways to improve financial viability through conferences and so on. It is important that funding does not constrain the organization, either by association with large corporations or through lack of finance. It is a complicated path to follow.
+Dr. Bodiwala, how have you seen inter-
national em change during your term in office? Dr. Gautam Bodiwala: To start with statistics, there are now more than 40 national societies that are members of IFEM, not counting three regional ones covering Asia, Europe and Latin America. There is more awareness in providing emergency
10 Summer 2010 // Emergency Physicians International
care and setting up emergency care systems around the world, particularly in countries where emergency medicine does not exist as a specialty and certainly where there is no EM national organisation. IFEM has brought awareness of the importance of organised EMS, delivery of quality emergency care and that too by trained staff. WHO now recognizes the importance of these aspects of medical care and with the help of IFEM and other interested parties has worked towards it. World Health Assembly has passed a resolution in favour of providing appropriate emergency care. There are more and more national and regional meetings exchanging science of EM and practice round the world. With IFEM producing undergraduate and postgraduate curriculum, it will promote the quality even further.
+In regions where attending international
conferences might not be feasible, what first steps can be taken towards improving em systems? Cameron: One of the first steps is to get a group of interested people together – often we are all fighting the same battles without realising it. Once there is an organisation with local champions, the group can learn from international experience. There is extensive help available online at no cost. Avoid making the same mistakes that everyone else has made. Get a “jump start” by using the collective experience of 30-40 years of hard labour in other countries. Visiting experts are also useful. They can say the same thing that the locals say, but have more authority because they are “experts” and they have no local vested interest. There are many people willing to help. Vietnam, for example, recently hosted a conference in Hue where 60 overseas emergency experts came at their own cost to assist in specialty implementation.
+Is there a role for IFEM in international
disaster relief efforts, in conjunction with organizations like Doctors Without Borders? Bodiwala: There is a definite role for IFEM in major disaster events. However, we must remember that as IFEM is still evolving. It is limited to notifying member countries/associations
Dr. Bodiwala vital stats
1943 Born in Ahmedabad. He lived there and qualified as a surgeon before moving to England in 1970.
1990 Co-founded IFEM and becomes its first president
25+ Years spent as head of the ED at the Leicester Royal Infirmary, Leicester, England
35 Countries visited
One
Number of emergency departments named after Dr. Bodiwala.
Interests Reading, travelling and listening to classical music
TRAVEL
Your Passport Is Your Profession Advice from an expat on using your profession to travel the globe by Keith raymond, md Dr. Gautam Bodiwala with HRH Princess Anne, at the inauguration of the College of Emergency Medicine in October 2008.
Dr. Cameron vital stats
1958 Born in Australia. Grew up on a farm 300 km east of Melbourne. He went to University in Melbourne, Australia and was one of the first group to do EM as a specialty in Australia and NZ.
10+
Countries visited this year alone
Past President of the Australasian College for Emergency Medicine (ACEM)
Academic Director of The Alfred Emergency and Trauma Centre
where there is a need. After the recent earthquake in Haiti, IFEM successfully circulated information about the need for medical help. IFEM has established committees which are intended to create some basic, generic disaster management plans in due course. IFEM has also taken the first step by producing guidelines for pandemic flu. Cameron: At this point, IFEM can’t be a relief agency like MSF. It is not organised to respond in this way and it is not part of its mission. However, by bringing groups together and developing consistent approaches, IFEM can play a major role in assisting countries with training and planning for disasters. IFEM can also coordinate interested parties to get together and help after the immediate disaster relief operation.
+Given the difficulties of global communication, how would IFEM go about disseminating something like the pandemic flu guidelines?
Cameron: Dissemination within the member societies is relatively easy; the larger organisations have their own internal structures. Getting the message to the outside world in a cheap and effective manner is more difficult. However, I think the web makes this much easier – we just need to be smart in how we use it. Clearly conferences, papers and books etc… are supplementary methods. Bodiwala: English remains the language of communication as it has become an international tool for communication. Once information is sent to national organisations, they disseminate it in their usual way to their members. Electronic communication has made life easy.
Interests +Does IFEM prefer to cast a broad or more narWalking and tending his farm in the middle of the bush.
row net when it comes to defining “emergency medicine”?
Cameron: The definition, as defined on the IFEM website, is fairly broad. I think within EM there is room for subspecialisation. There is also the opportunity to collaborate with other specialty organisations. For example, in CPR training, ILCOR, continued on page
46
M
y interest in international emergency medicine took form after I read Jonathan Kaplan’s book, The Dressing Station. I had worked in Germany three years by that time, and had moved back to the United States where I picked up a copy of the book. After reading his stories of practicing emergency medicine in war zones throughout the world, I knew that I could never settle down. I had to keep moving. In the last few years, I’ve practiced emergency medicine as an expat in five countries, and I learned a few valuable lessons along the way.
// Know your home
It is important to live and practice in your own country first before venturing abroad, in order to be grounded in medicine. This is the only way to appreciate the differences in the world, which may be cultural, scientific, spiritual, or simply a paradigm. If you aren’t sensitive to your paradigm and world view, you will be shucked and chucked like corn. That said, once you know where you are from, you can step out into the world and become an even better physician.
//Once an expat, always an expat
If you spend any significant amount of time practicing medicine in another country, you’re going to want to go home and share your new insights with colleagues and friends. The problem is, home isn’t where you left it. When you explain your adventures to your friends, their eyes may glaze over. They weren’t there and they simply don’t understand your enthusiasm. An expat develops a world view that is unique, unrestricted by the indigenous belief system they came from or live in. That continued on next page
5 in 16
United States 4 Germany 4 Saudi Arabia 4 Botswana 4 United Arab Emirates 4 ?
ACADEMICS
Should I Follow the Fellowship Road? International emergency medicine fellowships offer a range of opportunites to teach and learn, and to connect with like-minded physicians around the globe. by Kate Douglass, MD
I
n the last five years, there has been an explosion of International Emergency Medicine Fellowship Programs associated with U.S. Emergency Medicine residency programs. This is in part due to the increasing recognition by academic institutions of the strong interest among medical students, residents, and faculty members in dedicating time and energy to international development work. The trend in medicine towards development
of global health institutions has fostered increasingly strong international relationships in the medical realm. Emergency medicine as a specialty has been a leader in the development of formal post-residency training in international health, with more and more institutions starting their own International EM Fellowship programs. This is a great opportunity for EM residency-trained physicians interested in global health and international development to
TRAVEL
“
Passport
jump into the field, gain experience and knowledge, have a great learning experience and accelerate their careers in International Emergency Medicine. The structure of IEM Fellowship programs varies depending on the institution. They typically last one or two years, and some – mainly two-year programs – offer master’s degrees. Each program has a unique focus. For example, the fellowship program at Harvard/Brigham & Women’s has a strong focus on international humanitarian relief programs. The fellowship program at George Washington University (GWU) has a strong focus on emergency medicine systems development and sustainable educational initiatives. Each program has a particular expertise, so it behooves potential fellows to do their research. There is not a single formalized core curriculum that is required amongst the different fellowship programs, as there is not at this time a formal accreditation by the ACGME. However, there has been some consensus movement among the IEM community and fellowship directors to standardize certain curricular components across programs. Most programs include exposure to, and education in areas including public health, emergency medical systems, international program development, and humanitarian aid. There is additional opportunity for collaboration across fellowship programs to allow fellows to utilize resources that are a particular strength of a different program. One fantastic thing about the International Emergency Medicine fellowship community is the variety continued on page 46
by defining ourselves by what we do, rather than what we own, we release the flotsam and free ourselves to live a more generous life.
wfrom page 11
flexibility in ideology can make it difficult for an expat to relate to folks who are ingrained in their local world view, constricted by the prevailing thought patterns.
//Don’t bother packing
shampoo
People are pretty much the same all around the world. Everyone wears clothes, eats food and takes care of their health in one way or another. Once you are in country, you will be able to get by on what you have in common. In most of the world, banks aren’t necessary – over 90% of people live hand to mouth. Share your wealth and the people around you will share theirs. In Africa, I learned that living in a village
12
and being a tribal member is not ‘primitive.’ It is simply a different way to live. Their rites of passage might look different, for instance, but they serve the same function as those rituals played out the world over, from high school cliques to medical conferences.
//Learn the language, not
the words
The nuances of social interaction are subtle. They vary from society to society, and you must pay attention. Learning these subtleties of communication is more important than memorizing vocabulary words. At the same time, do not simply mold yourself to the milieu. You have something from your own world to contribute that can enrich the lives of those around you. This
Summer 2010 // Emergency Physicians International
sharing of lives and cultures is what makes international medicine the amazing field that it is.
//Don’t dwell on the past
Do not think about what you left behind, and what it cost. As an expat you learn to give up a house full of furniture without looking back. If you are lucky you can sell it for 50% of what you bought it for, and if not, you pay to haul it to a dump, or a charity. You also learn that you needed it at the time, but in your next location you don’t. But it served you, for a time. What you received in return may not be material, but it is of great value. Letting go of possessions, the things that weigh us down, can be an ennobling process. I don’t mean abandoning all attachments. But by
defining ourselves by what we do, rather than what we own, we release the flotsam and free ourselves to live a more generous life.
//Give free advice
In most countries, people will give you a certain respect when they discover that you are a doctor. They will also tell about the medical problems they have. Your generosity will make them remember you kindly, and down the road they may help you. Once, I broke down in the middle of Saudi Arabia in the desert. A Bedouin driving by stopped and remembered that we’d met at a Souq, or market, and that I’d given him medical advice. Instead of driving by, he stopped, and not only helped me fix my car, but took me to lunch!
Haywood hall, MD
OPINION
Building a Specialty from the Ground Up
//
While academic development in urban centers is important, a community-based approach, such as life support courses for existing emergency care workers, can be critical in the long-term establishment of emergency medicine as a specialty.
T
here are many paths that support emergency medicine development around the world. One way is a more academic approach which supports the development of specialists in academic, often more urban, centers. While this is one of our highest goals, in the developing world we also need to focus on basic emergency care training for the vast majority of providers. This large group, many of whom are general physicians, provide emergency care on a daily basis. If emergency medicine, as a new specialty, does not provide leadership in this area, we will lose significant moral authority and foster other alternatives to the development of the singlespecialty model of emergency medicine that we all embrace. In Mexico, where I am currently involved in training programs, there are over 100,000,000 people and 11,000 new physicians are graduated every year. Only 15% of those ever receive any training beyond medical school. There have been about 2,500 emergency specialists designated since 1991 and only a few hundred graduate from residency programs every year. The IMSS, which provides 60% of the care in Mexico, states that it needs 16,000 emergency physicians in its EDs. Mexico has about 1/30th the EM physician capacity per capita that the United States has, and Mexico is much better off than most of the rest of Latin America in this regard. General physicians provide the vast majority of medical care and emergency care in the country. There is a similar lack of training throughout the health care system for all health care providers. For emergency medicine – a new specialty being introduced to a new environment – there is typically a sensitive ecology which needs to be considered if we are to make advancements. There is the old
guard, legacy specialists (none of which want to give up turf to “the new kids in town”). There are the rank and file general physicians (typically a large number) who provide most of the labor force in emergency care. Given that in developed countries where EM is not yet an official specialty), our specialty is seen as of questionable value, how we fit into developing systems is a crucial tactical issue. And these struggles occur as much in the community as in academic centers. It is important to realize that historically, when we say “emergency medicine” in Latin America, it is understood as “pre hospital medicine,” or worse, “first responders”. Additionally, the multi-specialty (“FrancoGerman”) model of emergency care, further lends itself to the identity crisis as a emerging specialty. Mastery and leadership in the full spectrum of life support courses helps to differentiate us from the multispecialists while providing a valuable, high visibility service to the community. Although emergency medicine specialists often reject “merit badge medicine,” we
How EM fits into developing systems is a crucial tactical issue. And these struggles occur as much in the community as in academic centers.
need to embrace life support courses for the existing emergency health care practitioners, especially for those working in community hospitals. These courses are vitally important in developing systems and assuring quality of care (in a completely different context from our own). It is critical that the emergency specialist provide leadership in these courses, since generations of generalists and specialists need this training and many lives will be lost if we can’t “train the system.” In the process, we increase our credibility and assure a place in the ecosystem as leaders in emergency care. Of course, the whole needs to be greater than the sum of its parts. The emergency physician needs to integrate these life support disciplines in a practical, highly valued way. Since we are “new,” our young leaders often don’t have the political power needed to overcome the obstacles of institutional change. Programs which provide opportunities for the emergency physician to mingle with the health care system and to learn the language and culture (and the context of care) can be very valuable in terms of providing support to our fellow emergency physicians, but may also provide additional leverage and opportunities for these new specialists in their new settings. As a specialty, we have much to offer, not just in resuscitation, but in EMS development, toxicology, forensics, resource management, ultrasound training, to name a few. In the metro-centric academic centers, we need to fight the important battles to develop our credibility base. But let us not forget that in the community, at the grass roots level, emergency physicians have many tactical advantages for advancing the cause, be it through mission work, disaster response, infrastructure development, training and certification. It does not take much to convince the public that emergencies need to be managed well and that other problems can wait (by definition). Our efforts will provide deeper roots in the community and lend more force to development in academic and tertiary care centers. Let emergency medicine go forth in the world and multiply! Dr. Hall is the ACEP ambassador to Mexico and Cuba and is an Ashoka Fellow. He is the director of the Pan American Collaborative Emergency Medicine Development (PACEMD) and MedSpanish Programs, as well as the co-founder of the UTSW International EM Fellowship program.
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CASE STUDY
Skills Test
What structures are shown in the image? What abnormal finding is shown? +Answers on page 50
Flank Pain With a Twist by Brady Pregerson, MD & Teresa Wu, MD
Y
ou are working in a small, rural hospital in South America whose imaging modalities are limited to plain X-ray and a portable ultrasound machine. There is a much larger hospital in the nearest city, but it is over a day’s journey away. Your current patient is a 55-year-old obese diabetic male who presents with right flank pain that has been getting worse for about seven days. He was started on Bactrim three days ago for a urinary tract infection, but continues to worsen. He denies diarrhea, hematuria or dysuria, but has had fever and has been vomiting about once per day. His medications include glipizide, Tylenol, and Bactrim. On exam he is calm, nontoxic, and pleasant, but looks to be in mild distress. His vital signs aren’t bad. Temperature is 97.4, blood pressure 98/58, pulse 108, and respiratory rate is 16 with
a pulse-ox of 98% on room air. Eyes are anicteric. Oropharynx is moist. Lungs are clear. Abdomen is soft and non-tender, but the back has right-sided CVA tenderness. The remainder of the exam is normal. Laboratory data showed a nondiagnostic urinalysis, possibly because he was already taking antibiotics. The metabolic panel was notable only for a glucose of 216 mg/dl, a sodium of 122 meq/L, and a creatinine of 1.6 mg/dl. The CBC had a white count that was elevated at 21,400. An ultrasound of the kidneys was normal, but the following image of the liver was also taken (above).
// What structures are shown in
the image above? What abnormal finding is shown? Conclusion on page 50
To sumbit a case study for publication in an upcoming issue of EPI, email editor@plasterpub.com
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Summer 2010 // Emergency Physicians International
source Firsthand reports of specialty development around the globe
dispatches 16 Bhutan 18 turkey 21 vietnam 24 colombia 26
This past spring, Vietnam took a strong step towards greater EM development through a historic international collaboration Details on page 24
hong kong 28
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SOURCE // DISPATCHES READER-SUBMITTED UPDATES ACROSS THE CONTINENTS
What struggles does your country face in developing emergency medicine? What hurdles have been overcome? Source is your section for updating the world . . . and keeping up with the latest EM progress across the continents. Nicaragua: Developments: Both residency programs, Baptist Hospital of Nicaragua and the National University, continue, with ups and downs in recruitment. Challenges: To keep the powers that are in charge of allotting residents positions constantly aware of the need to prepare new EM residents. The graduates of EM have been recognized for their knowledge and abilities, and yet there doesn’t seem to be the awareness or sense of need to train new ones. Predictions: EM is here to stay in Nicaragua, however, there needs to be more involvement of the graduates in public and prehospital affairs. -Nour E. Sirker, MD Panama Developments: Residency program established in 2002. Unique system of emergency care 9-1-1 started in 2009. Challenges: The adequate training of all who work in the emergency system Predictions: There is much interest, so we expect a great technological and professional growth. -Elis E. Gonzalez Portugal, MD Argentina: Developments: In Argentina, EM is not yet recognized as a specialty. The vast majority of doctors working in EDs are general practitioners, internists, cardiologists and intensivists. There are only about fourteen specific training programs in EM in the country, therefore trained specialists are scarce. Today, we who work in emergency services are responsible for encouraging the creation of more residencies in EM, with the intention that the majority of human capital which develops in the emergency area is increasingly better trained. -Alberto Machado, MD Brazil: Developments: The 2nd EM residency program in Brazil is in its second year. The 2nd Brazilian EM Congress took place in 2009, and the Brazilian Association of Emergency Medicine
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(ABRAMEDE - Associação Brasileira de Medicina de Emergência) has a new web site: www.abramede.com.br. Challenges: To become a recognized specialty. Our board of specialties is controlled by a few people who don’t know what EM is, or don’t want us to become a specialty for political reasons. Other people understand the importance and support the idea but won’t fight for us. Predictions: We are in a crucial moment since we presented our intentions to become a specialty to the national board of medicine and we are about to be voted. The future is to become a specialty. When? Maybe now, maybe in the future. What matters is that we are growing in number, in knowledge and importance to our community. -Márcio da Silveira Rodrigues, MD Ghana: Developments: An EM residency training programme was started in 2009, with the first batch of 7 residents starting in Oct. 2010. The programme is run as partnership among Komfo Anokye Teaching Hospital (KATH), Kwame Nkrumah University of Science and Technology (KNUST), Ghana College of Physicians and Surgeons, Ministry of Health, the University Of Michigan Department of EM and the University of Utah Section of EM. Information at www.med.umich.edu/ em/education/ghana/ghanacollaborative.htm
In 2009, a faculty of EM was formally and Ghanaian colleagues will lead to established in the Ghana College of development of an appropriate hybrid Physicians and Surgeons by the inducmodel of EM training for Ghana that can tion of three new Foundation Fellows, all serve as model for other emerging EM trained and currently working in UK. training programmes in Africa. The next More info: www.ghcps.org OR email: 3 to 5 years will see the graduation of ghcollege@4u.com.gh first few batches of residents and this Challenges: Currently, EM faculty should provide much needed boost to consists entirely of diasporan fellows. the development of EM in Ghana and Efforts are being made for one of access to trained EPs in different parts fellows to relocate to Ghana shortly. of the country. Also, the curriculum needs to evolve -Conrad Buckle, MD to suit Ghana. Currently, it’s based on IFEM model curriculum, with adaptaSouth Africa tion to American and UK curriculum. Developments: EM recognised as a Also, Ghana needs to further refine the speciality in 2004, now we have over application and admission process for 60 specialists. This year added a 5th new residents applying for 2010 entry. training site for registrars, in Kwazulu Training of other emergency care health Natal. Critical Care officially recognised professionals (nurses, paramedics) is as a sub-speciality for EPs this year. another challenge. Moved this year to a 4-year BTech for Predictions: We’re optimistic that continued collaboration between foreign Spain: EM programmes Developments: We are doing better in 3 fields: professionals, technology and Informatics/computers. Triage procedures have been implemented, and ED design (not “decoration” but architectural flow considerations) is also much more seriously considered. Challenges: That emergency medicine becomes a specialty like it is in U.S., UK, etc... Doctor scarcity makes it difficult to achieve quality. Predictions: In my opinion, we must shift towards a less “medicalised” model. Less MD and more technicians. I don’t think that paramedics will be considered in the system, so a mixed model with MD, RN and technicians seems the most convenient way. -Santi Ferrandiz
Ecuador Developments: The recent introduction of a compulsory insurance system for victims of traffic accidents is a major advance and has a favorable impact on the overall operation of emergency rooms in Ecuador. Challenges: Still pending is the task of putting into operation a plan for emergency response that achieves joint coordinated work of hospitals with prehospital care. Predictions: There is still much to do, but the outlook is favorable. The staffs are committed to improvement, and you can glimpse some increase in support from some institutions. -Byron Ruiz-Lapuerta MD
Summer 2010 // Emergency Physicians International
paramedic training and 2-year diploma for Emergency Care Technician training – with a new 2-tier EMS system replacing the old 3 trier (AKS ILS BLS). First PhDs in EM registered in 2009. Challenges: Resources, high trauma load, high HIV TB load. Also, buy-in is a challenge. EM is well established in 3 areas only. Middle management capacity in health sector is also an issue. Predictions: Health research outputs, Peds EM as a sub-speciality by 2011. Becoming the training ground for “western”
EM specialists to get into Africa to help develop EM there. Being the African leader in EM. -Lee Wallis, MD IRAN Developments: After the 4 EM residency programs were established, two other programs have become accredited by the National Board to start their
residency program. The 4th Iranian Emergency Medicine Congress took place in January, 2010. Challenges: Limited number of graduates and the current policy of the Ministry of Health to distribute them after graduation have led to some problems with the establishment of the new programs. There are few opportunities for graduates to pursue toward a
Slovenia: Developments: Efficient prehospital network of physician-delivered emergency care has been built throughout the country over the past decade. Equally important is a recent start of EM as a primary medical specialty. Core-curriculum with a 5-year training schedule covering both prehospital and hospital competencies and skills started in 2008. Challenges: Successful integration of existing prehospital and in-hospital emergency care into uniform hospital-based Emergency Medical System. Predictions: With the recognition of EM as primary medical specialty and construction of new EDs in many hospitals, Slovenia is hopefully entering a decade of completion of Emergency Medical System. -Matej Marinsek, MD
croatia: Developments: Reform of EM in cooperation with the World Bank including reform of EMS, establishment of EDs in all hospitals, development of integrated dispatch and telemedicine and primary specialty in EM. Challenges: Switching the focus from autonomous out-of-hospital emergency medicine to emergency departments. Predictions: Integrated emergency medicine with involvement of EM specialists in all segments of emergency medicine: ED, out-of-hospital interventions (in ambulance cars, helicopters), education, research, education. -Fred Zeidler, MD
subspecialty of fellowship. Predictions: With the number of graduates increasing and with more and more emergency rooms upgrading to emergency departments with emergency medicine coverage round the clock, the benefit of this specialty for patients becomes more evident and unobjectionable. Pakistan Developments: A department of EM has been established in an academic medical university. A new society for Pakistan EM has been formed with country-wide representation, as well as a wider understanding of the need for emergency medicine not seen before. Challenges: Lack of an exit examination for our residency graduates. The other challenge is making the practice of emergency medicine viable in terms of remuneration and practice opportunities. Predictions: There is going to be a specialty certification examination in EM in near future. A practice model will be evolved which will make it feasible to practice emergency medicine in the country. -Junaid A. Razzak, MD, PhD
Australia: Developments: Ultrasound is filtering in to EDs, as is video laryngoscopy. We already do most fracture reductions. Procedural sedation is rampant. More web-based resources. We’re looking forward to quality hand-held ultrasound devices. Successes: Doctors have a much more realistic workload here than in the United States. They are expected to see 2 to 3 pts per hour – interns 1 to 2. I can order any test/med/transfer and know that it is free to the patient. There is no ER bill generated, no ambulance bill. Everyone has a medicare card entitling them to ‘free care,’ which is a much lower stress model. My first malpractice bill for 2.5 years of coverage (a supplement to free
Korea: Developments: Korean EM is still developing after the Korean Society of Emergency Medicine (KSEM) was founded in 1989. (www.emergency.or.kr). There are over 100 emergency medical centers and EM residency programs in Korea. The spring Korean EM Conference was held in April in Daegu. The main topic was “Resuscitation – System of Care and Post-Resuscitation Care.” The Journal of the Korean Society of Emergency Medicine is bi-monthly published in Korean and English. Challenges: Subspecialty in EM is now a great challenge (Resuscitation, Toxicology, Traumatology, Critical care medicine, Disaster medicine, etc.) The difficulties in EM originate from ED overcrowding, long-staying time for hospitalization and an insufficient number of nurses or doctors in the ED. Predictions: The continuing efforts for escalating financial support and introduction of new ED systems, short-term observation unit, trauma and critical care or sub-specialty care system is needed instead of conventional ED management systems in the ED. We are now thinking about the introduction of simulation or CPX / OSCE on national board examination of EM in the future, which was already applied in Korean Doctor’s License Examination in 2009. -Sam-Beom Lee, MD
Sri Lanka: Developments: Attempts are being made to appoint junior doctors trained in EM to man emergency treatment units in the out-patient departments of hospitals and the intensive care units. Towards this end we have selected and conducted a training course working towards a diploma in critical care and emergency medicine. The first exam was completed last month. We are now working towards an MD in Critical care. The challenge would be to appoint consultant intensivists to be in charge of these units. Challenges: Political pressures and political bungling as well as internal conflicts among the profession as to whether anesthetists or physicians should be in charge of these units has hampered the progress. -Kolitha Sellahewa, MD
2010. Challenges: We are in short supply of well-trained EPs. We have too many patients visiting the EDs without emergency conditions. Predictions: EDs are hopefully less crowded with the modification of national policies for medical insurance. Postgraduate resident training programs will produce more well-trained EPs. -Haichen Sun, MD, PhD
china: Developments: In 2009, the Ministry of Health published a national guide for the construction and management of hospital EDs. The 13th biannual congress of the Chinese Association of Emergency Medicince was held in April,
gov’t policy) was AU $145.00. Seriously. Challenges: It’s hard to recruit enough docs to treat this aging population. It’s also difficult to challenge each other and the specialty to grow and to evolve. Predications: Australia has a resourcebased economy – a bit like Saudi Arabia in the 60s. We have enough iron ore to supply the entire world for 1000 years, as well as lots of gas, oil, gold, beaucoup uranium, coal and lots of land. Australia’s future is bright, and with it Australian EM. -Bruce Campbell, MD
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source
“
It would seem from the outside that Bhutan’s kings have successfully balanced modernization with preservation and enhancement of the country’s rich, unique culture.
CHINA
Thimphu
Mongar
INDIA
Common Emergencies Altitude illness, particularly in tourists Rabies, due to a prevelance of stray dogs Snake bites from one of Bhutan’s poisonous snakes
Bhutan
Carbon monoxide poisoning from indoor cooking fires
Trauma care makes rapid advances in this isolated but modern Himalayan kingdom by Drs. Jim holliman, Kim Forman & Mike Owens
I
n November, 2009, thanks to extensive logistical and financial arrangements by the Bhutan Foundation, Drs. Kim Forman, Mike Owens and myself, Jim Holliman, traveled to the country of Bhutan to present two five-day emergency trauma care courses. Because of Bhutan’s relatively small population it does not have a medical school, so its doctors have had to go to other countries (mainly India, but also even Cuba) for medical and postgraduate training. The trauma course we presented was to be the first practical course of its type offered to healthcare workers in the country. When we were starting to make arrangements for this trip it became
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apparent that many people have not heard of Bhutan. Most don’t even know where it is located. It is a landlocked country in the Himalayas bordering China and India, with a population of about 700,000. The entire country is mountainous, with a number of peaks over 20,000 feet. What we found surprising was how thickly forested most of the country is, with dense forests even at altitudes exceeding 12,000 feet. Even banana trees were growing above 10,000 feet. We were also surprised at the country’s climate: since it was November in the Himalayas we were expecting bitter cold and lots of snow. However, most of the time the weather was like that of early fall in the northeast United States. Unlike
Summer 2010 // Emergency Physicians International
Dzongkha
The main national language. English is widely spoken, however, and most of Bhutan’s signage is in English.
the United States, in Bhutan, the trees had not lost their leaves yet or even started to change into fall colors. Bhutan only started to open up to the outside world in the 1950s; prior to that the country had no roads, airports, or advanced healthcare facilities. Since the 1950s, the country, under the direction of its kings, has undertaken rapid but controlled development. Our trauma care education project is part of the Bhutan Foundation-sponsored plans to help develop improved healthcare for the country. Hence the transition from sending healthcare workers away for training to bringing a practical trauma course to the country itself. Bhutan has a unique Buddhist-based culture certainly distinct from Tibet. English is the main second language and is widely spoken, particularly by most of the medical professionals. Our courses were conducted entirely in English with obvious complete comprehension by the course participants. It would seem from the outside that Bhutan’s kings have successfully balanced modernization with preservation and enhancement of the country’s rich, unique culture. One cultural aspect that took some getting used to was the extensive use of very hot chili peppers in the diet. We made the mistake several times (to the amused attention of our Bhutanese colleagues) of gulping down what we thought were string bean-like vegetables only to quickly discover that they were actually very hot chili peppers. All over the country you can see large amounts of chilies drying on roofs. Thankfully, to help wash the chilies down, Bhutan makes several excellent national beers. Our first trauma course had 30 Bhutanese physician and nurse participants and
During our trip we observed folk dancers at a festival in Mongar, reminders of Bhutan’s unique Buddhist-based culture. was conducted at the Royal Institute of Health Sciences in Thimphu – a city famous for being one of the world’s few national capitals without a single traffic light. We also toured the small but new emergency department in the country’s main referral hospital. In order to give the trauma course a second time, we then traveled to the city of Mongar. The 280-mile journey took two full days because the entire distance was nothing but tight switchbacks along mountain cliffs. While we were concerned about the lack of guardrails along much of the cliff edges, we had a very skilled driver who worked for the Health Ministry, and we were amazed at his ability to pass oncoming vehicles despite the apparent single-car width of the road. We joked about the Bhutanese ability to defy the laws of physics in driving these tight roads, but the winding switchbacks certainly highlight a key obstacle to Bhutanese trauma care. Transporting patients, particularly patients with spine injuries, from outlying areas to the main referral hospital in Thimphu, is extremely difficult. Once we arrived in Mongar (after an overnight stay in the town of Bumthang) the nerve-wracking trip proved worth-
while. The mountain vistas were spectacular and the town was starting its annual folk festival. Many people had traveled from all over the western part of the country to participate in the festival, which involved days of folk dancing, ornate costumes and singing. Our second trauma course again had 30 Bhutanese nurse and physician participants and was conducted at the newly built regional hospital. For a classroom we used the space allocated for the surgical ICU as it had not been activated yet due to lack of medical staff. We found our course participants to be energetic, enthusiastic, obviously interested, and, unlike in many countries, able to start on time and follow tight time schedules. The small group practical skills sessions we conducted seemed to be the most popular and useful for the participants, and these sessions included basic and advanced airway management, radiograph interpretation, case management simulation, and ultrasound. One skill we introduced that was entirely new for Bhutan was intraosseous needle insertion. Due to customs and security issues we were unfortunately unable to bring the intraosseous drill gun with us to demonstrate its use directly. However, even without the drill, the usefulness and practicality of the
1962
First road built into Bhutan by the Indian Border Roads Organization
1983
Airport in Paro opens
intraosseous technique was immediately apparent to the course participants, particularly those who work in outlying smaller healthcare facilities. The Bhutanese have made great recent strides in their healthcare system development, but a number of major challenges remain. The extremely difficult geography causes long time delays in getting patients from outlying areas to the regional or central referral hospitals. There is a lack of healthcare personnel in some facilities, as well as shortages in equipment and supplies. There is a lack of advanced training for most of the ambulance personnel and there is the obstacle of transferring patients needing certain tertiary healthcare procedures (such as cardiac valve surgery) to other countries. Many healthcare personnel still have to travel out of the country for higher level medical training. These obstacles notwithstanding, Bhutan has great strengths in its healthcare system. Healthcare personnel are intelligent, energetic and enthusiastic. The government strongly supports healthcare for all its citizens, including complete immunizations, and has the support of organizations such as the Bhutan Foundation. With its currently limited resources, the Bhutan Health
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One cultural aspect that took some getting used to was the extensive use of very hot chili peppers in the diet (above). We made the mistake several times (to the amused attention of our Bhutanese colleagues) of gulping down what we thought were string bean-like vegetables only to quickly discover that they were actually very hot chili peppers. Thankfully, to help wash the chilies down, Bhutan makes several excellent national beers. The king’s palace in Thimpu (above), has been the seat of the Bhutanese government since 1952
A regional hospital in Mongar recently moved into a brand new building (right), which contains an ED. Pictured above is the new resuscitation room in the ED of the referral hospital in Thimphu.
Ministry had decided to focus much of its healthcare delivery system on preventive services and has organized very effective coverage of the population for immunizations and prenatal care. This cost-effective approach could act as a model for other national healthcare systems. We would like to encourage readers of this article to consider being tourists in Bhutan – the scenery is spectacular and the people friendly and welcoming of visitors – or to consider becoming involved with healthcare system development in the country.
For tourist information, go to www.tourism.gov.bt
u$40 per day surcharge for individuals traveling by themselves
Tourists are charged a daily minimum fee.
The fee must be prepaid through an approved Bhutanese travel agency, which also arranges the traveler’s visa.
u$165 per day for the offseason (January, June and July) u$200 per day for all other months
This fee covers all travel, meals, and accommodations while in country.
Drs. Jim Holliman and Kim Forman are faculty in the Department of Military and Emergency Medicine at the Uniformed Services University of the Health Sciences in Bethesda, Maryland. Dr. Owens is faculty for the Emergency Medicine residency program at the Naval Medical Center in Portsmouth, Virginia. Dr. Owens is also developing the first International Emergency Medicine Fellowship Program in the U.S. military, to be based at his medical center in Portsmouth.
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Summer 2010 // Emergency Physicians International
Source
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Before 1995, most medical students received no EM lectures during their entire medical school experience.
turkey
The dynamic, bi-continental country moves to unify its diverse, highly-stressed EM system by arif Alper Cevik, MD
T
he Turkish Department of Health runs the majority of the country's aproximately 1,200 major hospitals. University hospitals and affiliated medical schools are a very important component of the healthcare system, and have access to the most modern triage and diagnostic systems. Private, for-profit specialty clinics do exist, but account for the smallest percentage of the country's healthcare providers. A once chaotic structure, Turkey's emergency medicine (EM) system has enjoyed a rise to prominence unprecedented for any medical specialty in the country's modern history. Over the last 10 years, emergency
Worlds Collide The Bosphorus Bridge in Istanbul, connects Europe (to the left) to Asia (right).
medicine became one of the major health components of Turkey's system. Emergence of modern Em in Turkey In the early 1990s, government and university leaders in Turkey recognized that the nation of 72 million needed an improved emergency medical care system. They chose to adopt the mature and tested model of emergency medicine, which the Ministry of Health declared an independent specialty in 1993. Now, less than 20 years later, prehospital care remains well controlled by the government. Turkey's dispatcher-based EMS system is known as the “112,” comprising 82
medical dispatch centers across the country. Most ambulances are covered by general practitioners. More recently, however, it is more common for paramedics to staff ambulances with or without doctors. The government has also shown great interest in air medical transport over the past two years, which were done previously by private organizations. In 2009, the government declared a new regulation for emergency departments. The main idea of these regulations includes the categorization of departments by emergency medical care capabilities, architectural capabilities, facility resources, staff, equipment and supplies, etc. The regulations also gave notes for transfers and admissions to emergency department, hospital admissions, shifts and staff work recommendation in the EDs etc. With this regulation, the EM specialty has acquired a more powerful position than we held over the past 15 years. The annual census of patients already has a high effect on the system, considering over 500 cases daily in state hospital emergency departments (EDs) and over 200 cases in university hospital EDs. There are, however, problems applying these regulations in some cities and regions because of reluctant or defiant hospital medical directors. Obviously, a greater precedence for EM is challenging some long-held notions and authorities of the medical system.
A Brief Timeline of Emergency Medicine in Turkey l Emergency medicine is declared a separate specialty l Prehospital care system nationalized widely in 81 cities l Opening of the first EM residency program
l Origination of The Emergency Medicine Association of Turkey (EMAT) l The first EM specialists graduated from the EM residencies
l Origination of the Emergency Medicine Physicians Association of Turkey (EPAT) l The first international EM Congress was held in Istanbul
l Duration of EM residency programs changed from 3 years to 5 years
l Board of Emergency Medicine was built
l Air medical transport system was added more widely into the “112” system
l Over 70 EM residency programs in Turkey
l The first Eurasian Congress on Emergency Medicine was held in Antalya
l Emergency Departments Regulation published by Ministry of Health
l EuSEM Congress to be held in Turkey with collaboration of EuSEM, EMAT and EPAT
l The 2nd Eurasian Congress will be held in Antalya
1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012
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BLACK SEA Istanbul
Ankara
MEDITERRANEAN SEA
The ED crew at the Emergency Medicine Residency Program in Eskisehir, Turkey. The program hosts 5 to 6 international rotators from abroad.
ed statistics There are currently over 1,200 EDs in Turkey, but only about 400 emergency medicine specialists and about another 400 EM residents. Clearly, the limited number of emergency medicine specialists cannot fill these positions. Therefore, general practitioners provide most of the emergency medical care given in hospital EDs. Emergency departments in big cities or select regional hospitals have an EM specialist to work with, but the majority of EDs are waiting for new EM specialists. ED patient volumes in Turkey depend on the category of hospital. State hospital EDs see 200-600 patients a day; state education and research hospitals see 500-1500 patients a day. These are bizarre numbers to most of us, but this is the reality. University hospital EDs see 100-300 patients a day. Admission rates vary between hospitals, but university hospitals and state education hospitals have higher admission rates. Â em training and residency programs Medical education in Turkey is an adopted European system, as advised by French and German physicians who had been working in Turkey during the last days of the Ottoman Empire before its collapse during WWI. The European system remains today, with six years of medical school, starting immediately after high school. The final year is spent doing clinical
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rotations of two months each in internal medicine, pediatrics, general surgery and/ or emergency department, obstetrics and gynecology, and one month each in psychiatry and community health. Before 1995, most medical students received no EM lectures during their entire medical school experience. Today, however, there are 50 academic emergency medicine departments in university medical centers. As a result, we can definitely say that the delivery of EM education to medical students is more efficient than in the early 90s. Sixteen years after their formation, and 12 years since their first graduates emerged, there are now over 70 EM residency programs across Turkey, 20 of which are in state education and research hospitals. The length of the residency is five years, which was recently increased from three years. The country has about 400 specialists and around 400 residents. The first EM residency program (36 months in length) opened in 1994. In 1995, the Emergency Medicine Association of Turkey (EMAT) was established. The Emergency Physicians Association of Turkey (EPAT) was established in 1998 for the first residency's first graduates. The connection between departments is improving with annual meetings organized by EMAT and EPAT. In addition, EMAT is developing international collaboration in the Middle East and Eurasian region.
Summer 2010 // Emergency Physicians International
Population Density South Africa 40 people/km2
Turkey 93 people/km2
Hong Kong 6347 people/km2
SYRIA
The first collaborative congress was held in 2001 as the Middle Eastern Conference on Emergency Medicine. The 2nd Eurasian Congress on Emergency Medicine (EACEM) will take place this year on October 28-31, 2010 (www.eacem.org). The first EACEM was a success in 2008, with 565 participants from 15 different countries. The organizers are anticipating more than 600 participants for the 2nd EACEM, representing more than 20 countries. the specialty that bridges continents The EACEM is the biennial international congress of the EMAT in collaboration with SUNY Downstate and the Singapore Society of Emergency Medicine with endorsement by the International Federation for Emergency Medicine and The Ministry of Health of Turkey. The scientific program will cover multiple aspects of emergency medicine. The congress will feature state-of-the-art lectures, workshops, panel discussions, as well as scientific oral, poster and video presentations. Most importantly, it will foster exchange with international leaders of emergency medicine. The congress will also include a trade exhibition on the latest technologies, pharmaceuticals and systems relevant to the specialty. As evidenced by the success of the first EACEM congress, we believe that EACEM 2010 will again create an atmosphere of superb networking opportunities for EM professionals and leaders of various continents and countries, as well as exposure to the newest EM technology in the region. EACEM will be at an exclusive golf resort in Antalya, one of the major tourist cities of Turkey. The city is well connected to major airports and other
9 out of 10 hospitals depend on the Morgan Lens An ambulance in the city of Izmir, Turkey, outside the Dokuz Eylul University Hospital, where Turkey’s first emergency medicine residency was started.
places of interest. The climate is wonderful during that time of the year and there will be ample opportunity to explore the rich history and culture of its surroundings. Because of the bridging geographical location of Turkey between Europe and Asia, one of the missions of this meeting is to help foster connection and collaboration between European and Asian countries on the bridge of continents, “Anatolia.” EMAT looks forward to welcoming you to Antalya. conclusion As indicated by recent developments, the success of the Ministry of Health's strategy will depend on primary care systems and emergency medical care systems over the next 10 years. With this perspective, the family medicine system was changed to improve this category of medical care, and the new EM residency programs were opened in state education hospitals to graduate a more adequate number of EM specialists. Today, there is a consensus that the system of EM is the correct way to follow to improve emergency medical care in Turkey, although some specialty organizations have some questions about the process. The main issue facing the country's EM education system now is the government's strategy to open new programs in state education hospitals and in new universities without first preparing the facility for academic and structural meaning.
[
1 out of 10 depend on a nurse who has to sit and attempt to squirt fluid into the patient’s eye while not attending to anything else in the ED.
]
For over 20 years, the Morgan Lens has been the most efficient and most effective solution for emergency eye
Common Emergencies Poisonings: Mushroom, carbon monoxide & organophosphate poisonings are an issue Crimean-Congo Hemorrhagic Fever: A problem during spring & summer months in recent years in small areas in the central Anatolia region
To learn more about EM development in Turkey, contact Arif Alper Cevik: cevik@ogu.edu.tr
irrigation. Fast, comfortable and easy-to use, the Morgan Lens delivers a continuous flow of solution to the injured eye within seconds, freeing medical staff to treat other injuries or to transport the patient without interruption. To order the Morgan Lens or to receive our free In-Service Video or PowerPoint Presentation, call 1-800-423-8659 or visit our website, www.morganlens.com.
The Medi-Duct® Fluid Management System makes the Morgan Lens even easier to use.
� �
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“
The central region of Vietnam experiences natural disasters, such as typhoons, on an annual basis, with resultant flooding, mudslides and man made, multi-casualty road and rail crashes.
CHINA
Hanoi LAOS
Special Delivery
vietnam
Dr. Tam Chung uses a “cyclo� to deliver a donated crash cart to the Hue College of Medicine and Pharmacy Emergency Department
Emergency medicine takes strides forward through historic symposia and international collaboration by Kris arnold, MD, MPH & Bob suter, do
T
his past March, a historic event occurred in Hue, Vietnam. More than 60 physicians and nurses from the United States, Australia, The Netherlands, Canada and Thailand volunteered hundreds of hours and travel costs to deliver a series of symposia, workshops and conferences on different aspects of emergency medicine to Vietnamese audiences of physicians, nurses, medical school deans and government officials. This event was coordinated with the Ministry of Health of Vietnam and occurred concurrently with the approval process for Hue College of Medicine and Pharmacy (HCMP) opening the first emergency medicine residency program in Vietnam (titled Level 1 training over two years), anticipated to begin in September 2010. These meetings and the move to develop this residency were the result of several
24
years and hundreds of hours of work by a number of U.S.-based physicians operating independently and representing several universities and organizations. The inspiration and driving energy behind this project has come largely from two community physicians, Carter Hill, MD, an emergency physician in Seattle and Vien Doan, DO, a family physician in the Los Angeles area. Both of these physicians have been dedicated to developing medical capacity in Vietnam for a number of years: Dr. Hill through organizing emergency medicine training seminars in different cities and Dr. Doan through delivering medical care to rural communities in central Vietnam via the Good Samaritan Medical & Dental Ministry (GSMDM). Their paths crossed several years ago, bringing together the human and financial commitments that formed the seed for Hue University College of Medicine and Pharmacy to apply
Summer 2010 // Emergency Physicians International
sept 2010
The Hue College of Medicine and Pharmacy is set to open the first EM residency program in Vietnam
CAMBODIA
for the first emergency medicine residency and for the 2010 Hue Emergency Medicine Symposium and Conferences. The GSMDM provided full financial support for the five-day symposium, the one-day Leadership and EMS/Disaster Response conferences and the two-day nursing conference, including stipend/ travel support for Vietnamese physicians attending. Excellent simultaneous translation was provided by several Hanoi-based physicians practicing emergency medicine at Bach Mai Hospital. The five-day clinical emergency medicine symposium was opened with remarks from Peter Cameron, president of the International Federation for Emergency Medicine (IFEM), Howard Blumstein, president of the American Academy of Emergency Medicine (AAEM), Bob Suter, past president of the American College of Emergency Physicians (ACEP) and of IFEM, the Deputy Chief of Mission from the U.S. Embassy in Vietnam and the Vietnamese Deputy Minister of Education and Training to more than 200 Vietnamese physicians from throughout the country. Lectures and skills workshops were attended with enthusiasm. The physician attendees came from varied clinical settings from tertiary care facilities to commune outpatient village health centers. Dr. Joe Lex from Temple University, the Symposium Chair, attracted a diverse faculty from the United States along with extensive material support from equipment manufacturers and digital/educational resource providers. The emergency department faculty from
A symposium attendee practices ultrasound technique (top right). In the Advanced Airway Skills Lab (right), attendees inaugurated Hue Central Hospital’s new clinical training center, using mannequins supplied by the Japanese International Cooperation Agency.
Bach Mai hospital in Hanoi provided outstanding simultaneous/interactive translation while providing local perspective to the organizing committee and conference attendees. A parallel nursing symposium with hands-on training workshops, organized by Michele Suter, RN, was delivered by American emergency medicine nurses to nurses from the Hue College of Medicine and Pharmacy and Hue Central Hospital Emergency Departments. The faculty nurses were highly impressed by the clinical knowledge and enthusiasm of their Vietnamese colleagues. Having recognized the national value of developing the resource of trained physicians to deliver emergency care, the Ministry of Health co-sponsored a oneday conference for deans of other medical schools in Vietnam and directors of provincial departments of health. In cooperation with the dean of the HCMP, Drs. Tamara Thomas and Kris Arnold brought together a group of physician leaders from around the world to review issues in developing and managing emergency medicine residency programs. This conference was highlighted by the signing of a consensus statement by representatives of the national government affirming and recognizing the values of emergency medicine and cement-
ing their commitment to developing EM and training of EPs. Training physicians in emergency medicine is but one part of improving emergency medical care capacity. In recognizing and underscoring the role of emergency medical services (EMS) in response to disasters and other time-sensitive health conditions, the Thua Thien Hue provincial Department of Health sponsored a concurrent one-day conference attended by 19 agencies involved in disaster response in the province. U.S. faculty organized by Dr. Graham Nichol from the University of Washington’s Center for Prehospital Emergency Care, delivered information on disaster management principles, EMS organization and communication. The central region of Vietnam experiences natural disasters, such as typhoons, on an annual basis with resultant flooding and mudslides along with man made multi-casualty road and rail crashes. The underlying theme for the conference was improved coordination of services among the different agencies. Following small group discussion among the agency representatives on the topics presented, there was general agreement that these agencies should continue to work together to improve EMS in the region. The events of this historic week have also been preceded by the hard work of several
academic and community EP colleagues, Drs. Sam Cloud, Craig Cooley, Heather Crane, Richard Guth and James Ramseier. Under the leadership of Prof. Cao Ngoc Thanh, Dean of HCMP, Dr. Nguyen Lo, Director of the HCMP Emergency Department, a proposal had been submitted to the central Ministry of Health and the Ministry of Education to develop a clinical training program in emergency medicine using the U.S. “Model of the Clinical Practice of EM” as the foundation for their proposed curriculum. The Vietnamese medical system is currently based on a government-funded insurance scheme, a separate health insurance for the poor, and a fee-for-service system. Physicians with a basic 6-year post-high school medical education and no residency training provide the majority of health care. U.S. family physicians have been active in developing family medicine training in Vietnam over the past 10 years with several active residencies and approximately 350 physicians having received this training. Vietnam is experiencing rapidly increasing economic activity. Along with this transition have come issues such as increased urbanization, increased motorized vehicular traffic encumbering roads with inadequate design for the multiple users from pedestrians to space-hogging tractor- 3
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trailers and tourist buses playing chicken. Although a national helmet law went into force in 1997 with a marked reduction in head injuries, motorbike crashes still contribute a significant amount of trauma to the overall health burden. Coupling these development factors with the decreased childhood mortality, greater longevity outpacing global advances, increased personal purchasing power and a high percentage of tobacco smoking is leading to a rapid increase in chronic diseases of developed societies such as COPD, CAD and diabetes. As was brought to attention in the Disaster Management/EMS conference, further development of infrastructure for mitigation of the effects of natural disasters such as dams and other hydrologic control projects are advancing slowly. It was also recognized by Vietnamese participants at all levels that improved out-of-hospital emergency medical care is urgently needed to alleviate the burden of diseases. Additionally, the point was made that, despite needs for more and more capable material support such as equipped ambulances, the foundation for improving out-of and in-hospital emergency medical care and disaster response will be in training and developing increased coordination among stakeholders, including the general public. This week of teaching, learning and bonding between a multinational visiting faculty and local practitioners is a milestone in the development of emergency medicine as a distinct medical specialty in Vietnam. Much hard work remains to be done, but the eagerness and dedication of the Vietnamese physicians to serve their people with improved healthcare despite the poor base salaries of physicians will, undoubtedly, make a significant improvement. Through the consensus statement signed at the Leadership Conference, officially proclaiming government support as well as recognition of a desire to work with visiting faculty, an invitation for participation in the future development of EM in Vietnam has been sent forth. In support of future participation of visiting faculty and residents, the GSMDM has leased a house – a multi-story, air-conditioned, fullyequipped and renovated home – just 10 minutes from the HCMP and the HCH.
26
*Academic Focus Funducion de Bogota is one of the country’s premier emergency care training facilities
*
The combination of trauma and subsidized insurance for 80% of the nation’s poorest patients led to a flooding of the country’s emergency departments.
Colombia
New specialty societies and academic programs enrich the training of dedicated emergency physicians in Colombia by Gladys H. Lopez, MD, MPH & Luis Edo Vargas, MD
C
olombia is a difficult country to categorize. It has the highest rates of traumatic injury-related deaths, including injuries from landmines, in all of Latin America. At the same time, it ranked third – after Denmark and Iceland – when Nation News scored the “World’s Happiest Countries.” Colombia is the second most biodiverse country in the world and is the second largest coffee and flower exporter in Latin America. Most importantly for this article, however, Colombia was the fourth Latin American country to create an Emergency Medicine (EM) academic program. t For more info on assisting with this project through donations or volunteering as faculty, contact Carter Hill, MD, at carterhill@ comcast.net
Summer 2010 // Emergency Physicians International
A Brief History Prehospital care and Disaster Medicine, the precursors to academic emergency medicine, really began in the mid-70s in Colombia with the rapid growth of Colombian cities. This growth increased all indexes of traffic accidents and violence, social changes that demanded the development of a well-designed medical specialty
to take care of these specific issues. During the 80s, Colombia faced challenges very similar to the ones faced by the United States in the late 60s. Families felt they needed two full-time wage earners in order to increase their income and economic status. A large population was displaced from rural settings to urban areas because of unsafe living conditions. There were guerrilla attacks in small towns and there was a shrinking market for agricultural products. Jobs were also easier to find in Colombia’s biggest cities. Uniquely for Colombia, the 80s also saw an increased rate in violence throughout the country because of the blooming of the narcotrafficking business. The National Health System, instituted in Colombia in 1993, separated the population into two groups. The “contributive group” comprised workers that could pay for their health insurance coverage (similar to the U.S. model) while the “subsidized group” contained the population unable to pay for coverage because of severe poverty.
This health reform (Ley 100) was far from being a perfect model, having been based on several national health care reforms in higher income countries. But it has helped to support health coverage for up to 80% of the poorest citizens (subsidized group) up to the present day. Emergency departments got flooded with patients that finally obtained “some” health coverage and this phenomenon persists even today.
Acceptance of Academic EM in Latin America MEXICO 1986 COSTA RICA 1990 PERU 1993 COLOMBIA 1996
The Birth of a Specialty Emergency medicine as a specialty in Colombia was initiated by CES University in Medellin in 1996. This three-year program used the American model as a basic blue-print but it also included the specific feature to train emergency medicine leaders in the ED administrative realm. These new leaders were given tools beyond the theoretical, clinical and practical skills of the EM physician. In 2003, a graduate from CES University’s program supported the creation of the second program by the Universidad del Rosario in Bogota. Universidad del Rosario, in consortium with Fundacion Santa Fe de Bogota, supported and currently hosts this second program in emergency medicine with special rotations in intensive care units (including burn units) and prehospital care. The third EM program, launched in 2004 and supported by Antioquia University, marked the very first public university in the country opening a residency training in emergency medicine. Antioquia University was the first institution to “grandfather” physicians from other specialties into emergency medicine as part of their own faculty. One year later, the CES University opened a new EM program in Cali, the third most important city in the country. The program, designed in conjuction with Fundacion Valle del Lili, had a special interest in trauma care and research. In 2009, two more three-year EM programs opened in Bogota, one at Fundacion Universitaria de Ciencias de la Salud and the other at Universidad Javeriana. Overcrowding, multispecialty care and lack of training in the EM specialty are currently the most concerning issues that the country is trying to resolve in its ED setting.
founded within the last six years and have hosted more than ten international EM conferences. One association has even been working with the Ministry of Health to create Emergency Care and EMS guidelines for the entire country. Colombia has been an active member of the International Federation of Emergency Medicine (IFEM) since 2006, only the second Latin American country to have this distinction. IFEM membership kicked off the expansion of the Colombian EM group in the international arena. A select group of Colombian EM specialists has had the opportunity to expand their learning and experience at New York University ∕ New York Poison Control Center, Pittsburgh University and at George Washington University in Washington, D.C., over the last 6 years. However, there are not currently enough U.S. clinical rotation sites to satisfy the thirst of knowledge
and further need for experienced international mentors which has characterized this initial cluster of fine and newly trained Colombian EM specialists. As you could see, there is still a lot to do. But a great foundation has been laid, and new, intelligent emergency physicians are taking up the call in Colombia every year to be dedicated emergency physicians. Gladys H. Lopez, MD, MPH International ACEP Ambassador, Past International EM Fellow at George Washington University. EM attending at Holy Cross Hospital, Maryland. Luis Eduardo Vargas, MD EM Residency Program Director, Universidad del Rosario-Fundacion Santafe de Bogota. Co-founder of the Asociacion Colombiana de Especialistas de Emergencia y Urgencias (ACEM)
The Societies Three Colombian EM associations were
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l
Dr. Chak-Wah Kam (middle) in 1995, soon after the establishment of Hong Kong’s EM society, journal, and certification exam process.
CHINA
New Territories
SOUTH CHINA SEA
Hong Kong
0
This densely-populated city maintains an excellent EM delivery structure as it forays into EM subspecialization
population
by C.W. Kam, MD
E
mergency medicine is a specialty of breadth and selected depths. More than 30 years ago in Hong Kong, the emergency department – formerly the casualty department – provided simple wound management and treated minor ailments. Most patients with moderate to severe conditions were transferred to the in-patient ward for care. Traditionally, the casualty department or emergency room was known as the gate-keeper or watchman of the hospital. The 1980s saw the appointment of ED consultants and the formation of the Hong Kong Society for Emergency Medicine and Surgery – a title indicative of the specialty’s mixed parenthood. In 1996, the credentialing body of the Hong Kong College of Emergency Medicine (HKCEM) was established). The breadth and depth of emergency medicine expertise have rapidly evolved to meet not only the expectation of the professionals but the needs of the community.
28
Hong Kong Island
7 Million
The HKCEM has promptly developed the three levels of Fellowship Examination to attain maturity and international recognition. There is one element to emergency care in Hong Kong that is quite different from overseas counterparts. Whereas many emergency departments have a conventional observational approach – a more passive methodology – Hong Kong has created something called Emergency Medicine Ward (EMW) Services. EMW services “treat and actively review” rather than
ed annual attendance/ census 2.1 Million
language
Cantonese (a Chinese dialect) with patients. Written records in English.
# of Eps
Around 250 fellows & 200 trainees
10 mi
waiting to see if patients are deteriorating. According to Dr. Lau Chor-Chiu, the clinical service co-ordinator of the Hospital Authority’s Hong Kong East cluster, EMWs relieve pressure on inpatient wards. Patients who need treatment for only a few days may stay in the EMWs instead of the general or specialised wards. Emergency physicians diagnose and treat these patients, with the help of specialists. “We will gradually increase the manpower to meet the heavier workload,” said Dr. Lau. “I think the supply of doctors is OK, but it is quite difficult to hire nurses as there is an overall shortage in the city.” Emergency medicine in Hong Kong, as in many overseas cities, has taken a major leadership role in collaborating with other related specialties. The specialty has established the Clinical Toxicology Services
Levels
Aim to Test
Format
PEEM (Primary Exam in EM)
Applied Clinical Science
Automated (Computerized) MCQ & OSCE
IEEM (Intermediate Exam in EM) – Conjoint with RCSEd till 2008 & with CEM of UK since 2009
Clinical Knowledge & Skills
-Written Short Answer Questions -Clinical OSCE
PEEM (Exit Exam in EM)
Clinical Maturity & Resourcefulness
-Written OSCE -Oral Exam
Summer 2010 // Emergency Physicians International
With a population density several times that of most other cities, Hong Kong emergency physicians cannot afford to ‘wait and watch’ their patients. Instead, they have had to develop special skills to ‘treat and actively review’ emergency patients.
Developing EM Subspecialties in Hong Kong 1. Resuscitology
7. Sports Medicine
2. Traumatology
8. Disaster, Catastrophe, HazMAT & Conflict Medicine
3. EM Cardiology
9. EM Short-stay Therapy
4. Toxicology
10. Interhospital Transport Medicine
5. EM USG
11. EBEM (Evidence-Based Emergency Medicine)
6. PHEC & Aeromedics
Q.
What is unique about emergency medicine development in 2010? One interesting thing about emergency medicine developing in Hong Kong is how western medicine has met the eastern traditional herbal medicine. Take toxicology, for instance. Chinese herbal poisoning can be grouped into the following 5 major groups: a) Aconitine Group - cardiotoxicity (ventricular arrhythmia &
and Poison Info Centre, for instance. A major proportion of toxicology cases are now treated in the ED or on the EMW. Many post-ICU treatment Toxicology patients are now transferred to the EMW for subsequent management and followup instead of the conventional in-patient wards. Herbal poisoning is a special issue in Hong Kong owing to the proximity to the mainland of China. USG has become the regular visual stethoscope of the EP for about 10 yrs. The POCT has transformed the clinical management and disposition of patients from gynae, traumatology, acute abdomen, calculous diseases, chest pain of cardiopulmony conditions, shock to cardiac arrest. There two arenas will probably be in-
corporated into the Subspecialty Fellowship Exam of the College in the coming five years. Prehospital emergency care including aeromedics and sports medicine (mass gathering medicine) are gaining popularity. Clinical simulation training is currently an international and local trend to prepare the novice, to train the registrars and to reconsolidate the expertise of the specialists with the aviation crew resource management fashion. In line with the common international mission of EM to upkeep the community emergency illness treatment and health maintenance by continuously upgrading and sustaining the service standards through the provision of well-trained, high-
hypotension) b) Podophyllin Group - neurotoxicology (convulsion & coma) c) Anticholinergic Group - tachy-arrhythmia & change in sensorium d) Digoxin-liked agents e) Others
quality emergency physicians in collaboration with other stakeholders by utilizing the modern, robust, competence-aligned and outcome-based education, training and examination, Hong Kong is going to be formulate the new milestones of the evolving frontiers to create landmarks for this new millennium! Dr. C.W. Kam is the Director, Clinical Skills Training Centre, Tuen Mun Hospital, Hong Kong. Chairman, Examination Committee, Hong Kong College of Emergency Medicine Editor, Hong Kong Journal of Emergency Medicine
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EMERGENCY MEDICINE: Experience the monthly series enjoyed by more than 8,000 of your colleagues.
WHAT IS EM:RAP?
EM:RAP is a truly unique monthly audio program designed to give listeners an in-depth review of specific EM-related topics in a format especially designed for easy listening. Each month, EM:RAP provides its listeners with two tightly edited CDs (or equivalent MP3s or iPod files) providing information from leading-edge conferences, grand rounds presentations, phone and SKYPE interviews, and in studio presentations with authorities and news makers in Emergency Medicine and beyond.
WHO ARE THE HOSTS OF EM:RAP?
Each month EM:RAP is hosted by two internationally recognized Emergency Physicians, Mel Herbert and Stuart Swadron. Both are award-winning educators and innovators and full-time faculty at the Los Angeles-County/USC Medicine Residency. Both have been recipients of awards from ACEP and AAEM, as well as from the University of Southern California and the University of California, Los Angeles. They have participated as faculty at CME conferences on the national and international level, and are generally recognized as two of the brightest lights in Emergency Medicine today. Their style is fresh, up-beat and often politically incorrect, but always targeted at delivering the best, most focused and thoughtful information possible!
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Each month you’ll be one of the more than 8,000 Emergency Physicians who have come to depend on EM:RAP for up-to-the-minute clinical information from a diversity of sources interspersed with insightful commentary from your hosts Mel Herbert and Stuart Swadron and the entire EM:RAP team! Check out the EMRAP.ORG and EMRAP.TV websites to hear an issue free of charge and receive additional information
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Summer 2010 // Emergency Physicians International
Reviews and Perspectives EMRAP.TV
Subscribers to EM:RAP receive: More than 2.5 hours of the best audio education available today, provided each month on CD, MP3 or iPod download Eight page written summary of the audio content-downloadable from the internet Exclusive access to EMRAP.TV, the video component of EM:RAP that includes X-rays, ultrasound images, lectures, round table discussions and much more Access to EM:RAP Forum, where you can interact with colleagues and national faculty Free CME – up to 4 hours per month! Access to the Free EM:RAP-Podcast on iTunes. Internet access to ALL previous EM:RAP monthly issues dating back to 2001 Free access to EM:RAP audio updates
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Each month subscribers to EM:RAP will be able to access EMRAP.TV online, with videos linked to the audio portion of the program. X-rays, ECGs, ultrasounds and other components that require visual demonstration are covered in this segment of the program to enhance the material presented on the audio CDs. In addition EMRAP.TV presents bonus videos that include round table discussions of clinical EM topics by some of the most respected EM faculty in this country, focusing on relevant x-rays, ultrasound images, ECGs and other visual components, as well as presentation of bedside clinical cases, pictures and videos from the cadaver lab, new product reviews, procedures and much more.
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EM:RAP subscribers receive free EM:RAP TWITTER updates, which are free short text postings to your phone or internet. Posts include notes regarding the EM:RAP production process over the month, pearls from upcoming EM:RAP issues, emphasis points and just fun anecdotes! Follow the EM:RAP team as they put the program together and get educated on the fly!
the topic-based, upbeat, provocative audio program, specifically designed for emergency medicine professionals www.epinternational.ning.com
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bridging the gap// Why emergency medicine in The Netherlands could serve as a template for comprehensive EM development around the world by Terrence Mulligan, DO, MPH
Erasmusbrug (Erasmus Bridge) in Rotterdam, a towering symbol of Dutch modernization
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Summer 2010 // Emergency Physicians International
“
There is nothing more difficult to take in hand, more perilous to conduct, or more uncertain in its success, than to take the lead in the introduction of a new order of things. Because the innovator has for enemies all those who have done well under the old conditions, and lukewarm defenders in those who may do well under the new.” –Machiavelli
Abstract
E
mergency Medicine (EM) is a burgeoning medical specialty that is rapidly developing worldwide. Focused on the recognition, stabilization and treatment of lifeand limb-threatening conditions, EM is established as a fully “mature” specialty in only a handful of nations, with 45+ countries in the early stages of development, including the Netherlands. [Arnold, Smith, 2005; IFEM website] Nevertheless, in the Netherlands, emergency medicine (called spoedeisende hulp in Dutch—“quick, urgent help”) has developed at an intentionally quick pace, and has achieved many of the landmarks of EM development in just over 10 years. This article examines the development of EM in the Netherlands and elsewhere, and attempts to explain how regional-specific elements of emergency medicine development in the Netherlands embody a reasoned, deliberate approach to national development that can be used as a template for EM development strategies in the rest of Europe and the world. The Need for Global EM development Epidemiologic and demographic public health data reveal an already overwhelming need for Emergency Medicine (EM), trauma and acute care development. According to 2006 WHO studies on the Global Burden of Disease [WHO 2006], the worldwide forces of demographic and epidemiologic shift have elevated non-communicable diseases to the single largest cause of morbidity and mortality worldwide. The non-communicable diseases of trauma, cardiovascular disease, stroke and cancer have surpassed traditional communicable diseases as the major global causes of death for the first time in history. The so-called “diseases of Western Society” have become global, are increasing at a much faster pace than earlier anticipated, and in precisely those areas with the least-developed health care systems [WHO 2006]. Through first-hand and shared experiences in international medicine development, many in the IEM field have realized
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bridging the gap// the difficulties and complexities of emergency medicine and acute care system development, and ensuring longevity of provision of high quality, affordable care. Collectively, the emerging discipline of international emergency medicine is learning that national and international medical development require expertise in many areas outside the field of medicine, and that any successful development of health care delivery systems, be it in emergency medicine or in other areas, requires extensive collaboration between the sometimes disconnected fields of clinical and academic medicine, administration and management, health economics, health law, health policy and public health. As study of the evolution of EM development in the USA has shown, and as extensive study of EM development in the 45+ other countries in the world where EM is currently in early or intermediate stages of development has reinforced, national and international EM development has (at least) 3 areas of focus: Primary development: academic and clinical medicine (undergraduate, training and graduate physicians), patient care systems development, setting up residencies, teaching students and other health professionals, etc... Secondary development: administrative and managerial training, financial and economic systems development, reimbursement, systems analysis, and Tertiary development: health legislation, health policy and public health systems / agendas, patient safety, acute health care as a human right. Over the short 10-15 year history of organized international emergency medicine development, most of our collaborations, projects and exchanges have focused on primary stages of EM Development. Until recently, this focus has been natural and well-reasoned: EM development depends heavily on the knowledge and skills of emergency physicians and other medical professionals, and on their ability to provide high-quality, focused care of acute patients. In general, we have had much less collaboration and exchanges focusing on non-clinical secondary and tertiary stages of EM, despite evidence that these stages of development are often as important or more so than clinical and academic stages, especially as rate-limiting steps in mature EM system formation. Many new and emerging EM systems have focused solely or mostly on building
34
TERTIARY STAGES
The EM Development Pyramid
Legislative Structure National Health Policy
SECONDARY STAGES
Local Variations
Management systems Economic Structure
PRIMARY STAGES Specialty systems; Academic development Education / Patient-care systems
Figure I: Despite local cultural, socioeconomic and political differences, most evolving patient care systems (for example, acute care / emergency medicine) pass through similar developmental stages. Development often follows a commonly shared structure regardless of national or cultural differences. The sequence of development experienced in advanced systems is useful as a template for development in other countries. the primary stages of EM in their systems, only to later encounter blockages and barriers to further development which might have been avoided if time had also been spent developing secondary and tertiary stages. For example, an examination of the mature EM systems from Canada to Singapore, as well as the quickly-maturing EM systems like Poland and Mexico, shows emergency medicine developing into the areas of EM administration and management, EM finance and health economics, health insurance expansions, emergency health care legislation, and public health. This multi-level, multi-disciplinary approach is absolutely essential to ensure successful medical development, and to ensure program longevity, resilience and self-generation. EM development strategies should include training and development in each of these areas to facilitate capacity-building in local EM expertise. Overview of International Emergency Medicine “Among the most important factors affecting health system convergence are the dynamic character of medical knowledge and technology and the forces that sustain it; the effect of medical demand on national
Summer 2010 // Emergency Physicians International
economies; changing demography and, particularly, the aging of populations; changing disease patterns; and increasingly rapid mass communication coupled with rising public expectations.” [Mechanic and Rochefort, 1996] Over the past twenty years, emergency physicians (EPs) have begun to examine the scope of EM and its extension into the fields of public health and primary care. Specifically, EPs have increasingly looked beyond their borders to learn how emergency medicine is practiced in other parts of the world. The emerging field of International Emergency Medicine (IEM) is concerned with the development of emergency medicine and acute care systems development in countries and regions where EM development is needed, and can be viewed as a subspecialty of EM; it allows emergency physicians and other health professionals who are involved in emergency medical care to learn from each other, and involves the educating and training of emergency care providers throughout the world. [Rupke, 1993] EM is established as a fully “mature” specialty in only a handful of nations, and another 45+ countries are in the early stages of development, including the Netherlands. In
many underdeveloped and developing countries, the emergency medical care systems are much less established, with often regional clinics, local general practitioners, nurses or other local healers providing the bulk of emergency medical and primary care. In more developed regions where hospitals provide primary, secondary and tertiary care, very often there is only a rudimentary emergency department, often staffed by under trained and inexperienced physicians, often with no dedicated 24-hour coverage of the emergency room, and rarely with emergency medicine specialty training. Usually the EMS/prehospital system is highly variable, understaffed and underdeveloped, and there is in general vastly inadequate training for emergency care providers, for doctors, nurses and medics alike. While the need for emergency medical care is as large or larger in these developing areas, too often these countries have inadequate or overwhelmed emergency medical care systems [Alagappan and Holliman, 2005]. In some regions, such as subSaharan Africa, EM is mistakenly seen as less pressing than more traditional primary health concerns such as infectious diseases, maternal and child health and other public health issues. In fact, EM can still play a role in underdeveloped regions in supplying acute episodic care and a much-needed link to the public health care system, as well as supply care for the emerging chronic diseases as depicted by the data supporting epidemiologic and demographic shift.
Overview of Emergency Medicine in the Netherlands In the Netherlands, emergency medicine does not yet exist as an official, fully-developed medical specialty. Health care delivery in the Netherlands is organized in a two-tiered system with a network of community-based general practitioners (GPs) providing primary care and acting as gatekeepers to hospital-based specialists. These GPs refer chronic problems to specialty clinics based in the hospital and acute problems to the emergency department for specialist consultation. Patients can also go to the emergency department on their own (selfreferral). To date, of the 126 hospitals in the Netherlands, 106 have emergency departments (RIVM, 2007). As described by Elshove-Bolk, Mencl, Simons, et al in the European Journal of Emergency Medicine: [these emergency departments] are staffed by loosely supervised interns and junior residents, without any specific training and are employed as emergency physicians. The specialists’ consults are also often conducted by loosely supervised residents, with varying degrees of training. It is these doctors who are responsible for the initial evaluation and treatment of the approximately two million patients treated in Dutch emergency departments annually. [Elshove-Bolk, 2005]
Most patients presenting to emergency departments in The Netherlands are received by the most inexperienced young doctors: socalled artsen-neit-in-opleiding [doctors not in residency: first-year doctors waiting for residency opportunities elsewhere], together with older nonemergency residents in family practice, surgery and other specialties. This model of allowing the youngest, most inexperienced doctors tend to the sickest, most urgent patients is unfortunately not uncommon in most parts of the world, and is not particular to The Netherlands. In recognition of this problem, in the 1990s, several Dutch medical professionals laid plans for training programs for emergency physicians in the Netherlands, and in 1999, the first national emergency medicine society was formed, the Nederlandse Vereniging van Spoedeisende Hulp Artsen. In 2003, the Stichting Opleiding Spoedeisende Geneeskunde was formed—the Foundation for Education in Emergency Medicine, which, until recently, acted as a certifying body of emergency medicine training programs. As of October 13, 2008, the Medical Specialist Review Committee (the national certifying body for new specialties) declared Emergency Medicine a “medical specialty profile”—a temporary intermediate-level specialty designation. Presently, there exist 16 accredited emergency medicine training programs in the Netherlands, with 10+ more currently in the process of obtaining accreditation. These
About the Author // I first became interested in a career in international emergency medicine... ...during my EM residency in the Bronx, New York. I Mediterranean EM Congress in Nice, France in 2005, had long been interested in international emergency I decided to accept their offer. In July 2006, my new medicine (IEM) as a career, and witnessed the huge wife and I moved to Rotterdam, where I started as need and opportunity in this arena. I realized that the first ED Director and the Director of the new EM while my EM residency training showed me how residency at Erasmus Medical Center in Rotterdam, to practice EM in a health care system where EM one of the initial EM residencies in the Netherlands. already exists, it did not teach me how to develop Since July 2006, I have been living and working in The EM systems where they don’t exist or exist only in Netherlands as a fully-licensed, practicing emergency pieces. physician, helping to establish EM residencies and EM Deciding to gain as much understanding and as a full specialty in that country, and have continued expert training in this new field as possible, I working in the worldwide IEM community in multiple completed an International Emergency Medicine fashions: as chair of the ACEP Section for International (IEM) Fellowship at George Washington University Emergency Medicine, as Committee member for the Dr. Terry Mulligan, in in 2003 (their first IEM Fellow), an MPH in 2003 as International Federation for Emergency Medicine The Netherlands with his part of the IEM Fellowship, and a one-year Health (IFEM), as director and organizer for multiple national daughter Louisa. Policy Fellowship in 2006 and immediately began and international EM conferences and teaching looking for a full-time IEM position to practice programs, as Board member for the newly-formed what I had learned. After introductions and interviews with Dutch African Federation for Emergency Medicine (AFEM), and as a trauma faculty who were looking for an experienced EP at the 3rd member of multiple national and international EM societies.
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bridging the gap// programs have graduated approximately 120+ trained emergency physicians and approximately 150+ residents are currently in training. EM Administration and Management Fellowships in The Netherlands Currently, the training program for Spoedeisende Hulp artsen as recognized by the SOSG and the NL Board of Medical Specialists is only three years in length. This short training program length does not allow for full instruction in advanced, essential elements of clinical, academic, administrative, managerial and specialized areas of emergency medicine. During the presentation at the 1st NVSHA conference, I mentioned that I was in the process of formulating a 1-2 year post-residency “Fellowship” training program in administration and management in EM. Immediately after the lecture was over, I was pleased to notice that 2030 individual EPs and residents came up to me to ask for more information on this Fellowship training program and how they could take part in it. From this initial outpouring of interest, I began to dedicate my time to designing a shorter Fellowship training program to meet the needs of this large group of Dutch emergency physicians. To these ends, we developed the Administration and Management Fellowship in EM, which draws its rationale from the EM Development Pyramid concept illustrated above: that EM development needs to include more than just clinical and academic EM, and that emergency physicians in societies with newly developing EM systems need to gain training, expertise and experience in these areas. Fellowship Overview To date, the Administration and Management Fellowship in Emergency Medicine for emergency physicians and emergency medicine residents in the Netherlands has been run successfully three times, with 29 Dutch EPs having successfully completed the Fellowship, earning the designation of Fellow of the NVSHA (FNVSHA). This Fellowship Program has involved Dutch and international EM faculty and others, and has focused on a “train-the-trainer” model, where Fellows obtain both mastery levels of the course content, as well as specific instruction on how to conduct identical courses at their institutions. This teaching model has been very successful at disseminating the information presented to the Fellows by giving them reading, teaching and instruction materials to use and
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expand on their own. The Fellowships also focus on the production of individually-catered Fellowship Projects, which are specific, problemoriented projects that Fellows bring back to their sponsoring institutions for immediate action and implementation. Past Fellowship Projects have included: 9 the formulation of an EM curriculum for Dutch medical schools 9 the development of an e-Portfolio for the newly released Dutch Curriculum in EM 9 the formation of national quality indicators for Dutch EM (which were officially accepted by the Dutch Ministry of Health) 9 investigations into formal feedback systems for EM education and practice 9 the establishment of EM Student organizations at every Dutch medical school. On-going consultation by Dutch faculty, NVSHA and national and international faculty has been made available on-site, on-line and via telephone, and through advanced video telemedicine linkages before, during and after all forms of training. The Fellowships have consisted of conferences, didactic lectures and academic teaching, reading and writing assignments and the completion of individual Projects for each Fellow. Academic lectures, readings and didactic material: The following areas are covered in conference, lecture, readings and other academic assignments: 9 Administrative Principles in EM 9 Management Principles in EM 9 Hospital Management 9 Academic and Training Principles in EM 9 Patient Safety and Quality in Emergency Medicine 9 Research in EM 9 Development of the Specialty of EM 9 Emergency Department Operations 9 Health Economics, Policy and Law in EM Development 9 Special Topics in EM (Global Burden of Disease, Acute Health Care as a Human Right, EM and Global Health Institute Consortia) This is the first comprehensive international EM training program of its kind. While certain elements of our Fellowship have been taught in pieces for only the most advanced EM systems, our program is unique in that it is the first to bring together all of these requisite development
Summer 2010 // Emergency Physicians International
topic areas into one training program, and is first in offering it to EPs working in developing and underdeveloped EM systems. Interest in the non-clinical topics of Administration and Management and in this course has been large. The first Fellowship class in 2008 was extremely successful and prompted a second to follow in 2009, and then a third in 2010. Interest has also spread outside of The Netherlands. Our particular Fellowship course has been conducted in many places around the world, in developed, developing and underdeveloped regions alike. So far, in addition to the Netherlands, we’ve conducted region-specific courses in South Africa, Australia, Poland and Spain. We have plans for programs in Hong Kong, Botswana, the USA, Canada and elsewhere. The European Society of Emergency Medicine has also validated the program, devoting three days to EM Administration and Management in the 5th Mediterranean EM Congress in Valencia, Spain in October 2009, and will sponsor a 3-day pre-conference on these topics at the EuSEM Congress this October 2010 in Stockholm, Sweden. Many EM systems are struggling with these non-clinical aspects of EM development, and could benefit from concentrated training. There is a general lack of didactic material on the secondary and tertiary elements of EM development in nearly all national EM curricula, and a limited understanding of these traditionally non-medical areas by most physicians. Indeed, many of the international teaching faculty involved in our courses in The Netherlands have remarked about the conspicuous absence of such comprehensive, non-clinical training even for their own residents back home at their “mature” EM systems. It is one of the goals of this program for these nonclinical topics to formally be placed into national and international EM teaching curricula, and for the broader IEM community to become more involved in comprehensive EM development on many different levels. Future directions for emergency medicine in The Netherlands As described by Jeff Arnold in 1999, international EM development stages can be roughly divided into three major groups: underdeveloped, developing and mature. The socalled “mature” group includes the countries that many would consider having a fully-developed acute care system, such as the United States,
Australia and Singapore. The “developing” group now includes 45+ countries that have officially recognized EM as a medical specialty but that are in various states of EM development. In many aspects of its medical and health care system, The Netherlands is one of the best developed nations in the world. They lead the world in transplant medicine, genetic mapping, gene therapy and genomics, and hematology / oncology. They are even among the local European leaders in trauma care, prehospital care and critical care. However, for many historical, cultural, medical and political reasons, The Netherlands is arguably in the “developing” group with respect to its level of EM and acute care systems. It’s as if the Dutch health care system were a modern city skyline filled with skyscrapers, representing multiple areas of medical achievement and clinical excellence. In the middle of that impressive skyline sits a humble, four-story building representing the literal and comparative underdevelopment of EM and acute care delivery systems. Among the 45 or so countries in this “developing” group, however, The Netherlands is emerging as one of the local leaders in national EM development in the EU community. In the short 10 years or so of Dutch EM development, they have achieved what has taken some other countries 30-40 years to develop: In particular, the NVSHA development of the first Dutch national EM curriculum in 2006, now in its 2nd edition, is one of the most advanced and sophisticated national EM curricula so far, having studied and adopted the best pieces of the existing national EM curricula from Canada, the UK, Australia and the USA, and offering region-specific additions and improvements. This EM curriculum has proved to be one of the major influences on the structure and format of the EuSEM-authored “European Curriculum in Emergency Medicine” that was approved by the European Union of Medical Specialists in 2009. In addition, there is large and growing interest in more advanced EM development programs, such as the Administration and Management Fellowship, along with other EM teaching and development programs in Patient Safety, Medical Decision-Making, ED Design and EM Finance that are coming out of the EM development community in the Netherlands. Through the elements in figure II and other examples, the EM community in The Netherlands is intentionally and deliberately addressing national EM development using particular focus on those EM development strategies that have been tried (with or without success) elsewhere. In
FAST TRACK // Since the mid-1990s, the EM community in The Netherlands has been a model of rapid specialty acceleration, accomplishing the following landmark achievements: The establishment of a national EM society (the NVSHA—Nederlands Vereniging van Spoedeisende Hulp Artsen / The Dutch Society for Emergency Physicians) The establishment of 16+ accredited EM residency training programs, with 10+ more in the process of accreditation The gradation of 120+ Dutch emergency physicians from these programs, with 150+ emergency medicine residents currently in training Formal recognition by the Dutch Medical Specialist Review Committee as a medical specialty profile The formation and publication of the national Dutch Curriculum in Emergency Medicine (the first of its kind in any specialty in The Netherlands) The development of a national e-Portfolio, allowing all Dutch EM residents to register and monitor their training centrally and electronically (also the first of its kind in The Netherlands) The incorporation of many elements of the Dutch EM Curriculum in EM into the European Curriculum for emergency medicine The formation and administration of national in-service examinations for evaluation and comparison of EM residencies (also the first of its kind in The Netherlands) Efforts towards a comprehensive “board certification” exam in EM (the first of its kind in any specialty in The Netherlands) Three national EM conferences (called the Dutch North Sea EM Conferences) in 2007, 2008 and 2009, with 2010’s taking place in June Many local, regional and national onderwijsdagen, or EM teaching days The establishment of EM-student organizations at all eight Dutch Schools of Medicine, with the eventual formation of a student chapter of the Dutch Society for Emergency Physicians The development of a national Institute for Dutch EM Fellowships, which, in addition to handling this current Administration and Management Fellowship, is forming other training programs and Fellowships in Research, in Academic EM, in International EM, and in many other areas, and is concentrating on collaborations in research and education
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bridging the gap// this fashion, Dutch EM development is following templates for development as much as creating one. By focusing on comprehensive EM development techniques, by concentrating on the EM development experiences of fellow countries and regions, and by gaining education and experience in multiple areas outside the field of medicine, The Netherlands is historically and politically well-positioned to offer its experience in successful EM development as a template for development outside its borders.
Figure II: Elements to the success of emergency medicine development in The Netherlands
Conclusion Emergency medicine is a new and expanding field in The Netherlands. Given the recent developmental steps that have taken place, the state of Dutch EM is growing and shows all prospects of flowering into full development in the near future. Further, the successes of EM development in The Netherlands will continue to spread to and influence EM systems in neighboring countries in the EU and elsewhere, and can be used as a guide and template for EM development abroad. As one of the “success stories” of goal-directed, intentional national EM development, The Netherlands has the opportunity to establish itself as one of the global leaders in national and international EM development.
3. Concentration outside their borders Using emergency medicine development patterns elsewhere as templates for their own development
1. Champions: mavericks, transformational leaders, network facilitators Individuals who have shown constant support and tireless effort of the EM movement, particularly on the flat part of the sigmoidal development curve, without whom Dutch EM development would most likely be much less developed 2. Concentration outside the field of medicine i.e. simultaneous and deliberate development strategies in administration and management, economics and finance, legislation and health law, public health and health policy
4. Socio-economic appropriateness Emergency medicine and acute care are currently the largest burden of disease on the health care system in The Netherlands, and the time is right for EM development 5. The Fluke Concept, or the “serendipitous accident”: the accidental or intentional ‘spark’ that instigates and aligns the movement culturally, historically, economically or contextually Between 2000 and 2006, and especially recently, there have many national stories in the media revealing the current state of EM in The Netherlands, along with changes in national medical financing and insurance practices, causing national concern and the alignment of social, cultural and economic forces in support of EM development Examples of the “Fluke Concept” around the world: • President Ozal of Turkey died of a suspicious heart attack in 1993, which provided national attention on the state of acute care in Turkey, and spurred a national focus on EM development • The Olympics, World Forum, World Cup and/or other major world sporting or economic events, that crystallize attention on emergency medicine development • Major economic, industrial or private business development that supports EM systems development for economic returns in addition to public health benefits
REFERENCES Arnold, J. International Emergency Medicine and the Recent Development of Emergency Medicine Worldwide. Ann Emerg Med. 1999;33(1):97-103.
Mechanic D, Rochefort D. Comparative Medical Systems. Annu Rev Sociol. 1996;22:239-70.
Arnold, K, Smith J. Emergency Medicine Clinics of North America – International Emergency Medicine. Elsevier, 2005;23(1).
Nederlandse Vereniging van Spoedeisende Hulp Artsen [Dutch National EM Physicians Society] http://www.nvsha.nl
Elshove-Bolk J, Mencl F, van Rijswijck BT, et al. Emergency department patient characteristics: potential impact on emergency medicine residency programs in the Netherlands. Eur J Emerg Med. 2006;13(6):325-329.
RIVM Rijksinstituut voor Volksgezondheid en Milieu [Dutch: National Institute for Public Health and the Environment.] http://www.rivm.nl/
The European Society of Emergency Medicine (EuSEM). www.eusem.org International Federation for Emergency Medicine. www.ifem.cc Holmes J. Emergency Medicine in the Netherlands. Emerg Med Australas. 2010;22(1):75-81.
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Rupke John, ed. American College of Emergency Medicine: 25 years on the front line the ACEP anniversary 1968-1993 (Dulles: ACEP, 1993) 10. SOSG: Stichting Opleiding Spoedeisende Geneeskunde [Dutch EM Certifying Body]. http://www.sosg.nl/ The World Health Report, 2006. (World Health Organization) http://www.who. int/whr/en/
The Canadian Head CT Rule Is the Rule Reliable Enough for More Litigious Nations? a pro/con debate
NO
YES
Use the rule to cut costs and radiation without litigation exposure.
A miss is a miss. Juries don’t care if you’re saving cost.
by Christopher Carpenter, MD, MSc
by Kevin Klauer, DO
P
er capita, the US currently spends twice as much as Canada and every other first-world economy in the world, yet ranks behind on many quality measures. Undoubtedly, the US malpractice environment contributes to this fiscal conundrum. In caring for anyone, anyplace, anytime EM physicians sit at the forefront of the defensive medicine frontier. Rarely, do EM physicians benefit from well-established science to augment clinical gestalt. Deciding whether or not to obtain a cranial CT on head injured patients is one exception. Mild traumatic brain injury can be defined as loss of consciousness (LOC), amnesia, or witnessed disorientation with initial GCS ≥ 13. The Canadian Head CT (CHCT) rule was developed to guide decision making about the use of CT-head ordering excluding those less than16 years old, pregnant, on Coumadin, suffering seizures, lacking clear trauma, LOC, obvious skull fracture, or hemodynamic instability. The primary outcome was the need for an intervention (craniotomy, skull fracture elevation, ICP monitoring, intubation for head injury), while the secondary outcome was clinically important brain injury on CT as defined by a consensus of 129 neurosurgeons, radiologists, and EM physicians. Insignificant CT findings included: solitary cerebral contusion < 5mm; localized subarachnoid blood < 1mm; thick smear subdural hematoma <4 mm; isolated pneumocephaly; and closed depressed skull fracture not extending through the inner table. After being derived and validated on over 3000 Canadian patients, the CHCT rule has subsequently been validated in Germany and England. Ironically, in contrast to the US debate about whether to utilize the CHCT rule to decrease head CT ordering, British physicians debated whether to incorporate it into their guidelines fearing it might increase CT use! Other blunt head injury clinical decision rules (CDR) have been developed, but none explicitly followed the guidelines for CDR development and subsequently none have been externally validated. While the CHCT rule has not been demonstrated cost-effective or widely acceptable, no US legal literature demonstrates appropriate use of the CHCT rule missing a clinically significant, successfully litigated intracranial injury. Nonetheless, no sane physician wants to be the first. Therefore, the CHCT rule should not replace clinical judgment. Instead, the rule should augment the intuition experience garners. If a seasoned EM physician’s insight suggests that central nervous system imaging is merited despite a negative CHCT rule, the patient should definitely be scanned. If the clinician’s gestalt is that no significant intracranial injury exists, concern about the medical-legal implications of the rare (0.6% neurosurgically significant – all detected by the CHCT Rule) clinically significant injury should not drive decision making. Practicing knee-jerk, counterintuitive, defensive medicine drives up the cost of health care for everyone and negates the value of clinical expertise.
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T
he Canadians have demonstrated a unique expertise in developing evidence-based rules that make sense. However, as a risk manager, board member of our group’s risk retention group and a practicing emergency physician, clinical application is where the rubber meets the road. At journal club, this is an academic discussion. In the ED, we need to make certain we are practicing safe, appropriate and efficient, risk-averse emergency medicine. Which would you prefer to do? Avoid a lawsuit and all the fun this will add to your life for 18 months; or use an evidence-based guideline to convince a jury of laypersons why it was OK to miss a small subdural. We could have an academic discussion. However, how does that help the average doc working a shift? Many research-oriented discussions focus on the quality of the research. Unfortunately, they fall short with how or if the included recommendations should be implemented clinically and how to do so. For most of us, this is not an academic discussion. It’s a matter of how to get through the next shift, practicing high quality emergency medicine, avoiding a lawsuit, walking away with some sense of gratification for the care we provide. The issues I have with the Canadian CT Head rule are a lack of external validity, the exclusion of “clinically unimportant” lesions and the use of a utilization reduction tool that may result in missed intracranial injuries. External validity is key. Can the study results be reproduced elsewhere, or is it only valid in the environment in which the original study was conducted. In example, an excellent head CT rule was studied at Louisiana State University (LSU) in 2000. It reduced CT utilization without any additional missed injuries. Unfortunately, attempts to reproduce the same results in other environments have been unsuccessful. Thus, rendering application of their rule to LSU only. Some might say that the Canadian CT head rule has stood the test of external validity. Well, the devil is in the details. Boyle, et al., British investigators, noted a substantial increase in utilization of CTs, without any additional benefit. In Australia, the New Orleans criteria and the Canadian CT head rule were tested. Neither performed well. Rosengren, et al., from down under, reported that if the high-risk Canadian criteria were utilized, 74% of the nor-
The issues I have with the Canadian CT Head rule are a lack of external validity, the exclusion of “clinically unimportant” lesions and the use of a utilization reduction tool that may result in missed intracranial injuries.
pro
con
While the CHCT rule has not been demonstrated cost-effective or widely acceptable, ...no US legal literature demonstrates appropriate use of the CHCT rule missing a clinically significant, successfully litigated intracranial injury. The clinically insignificant CT findings represent the central argument against the CHCT rule. Dr. Klauer has argued that if one of these injuries is missed by one physician only to be found by another physician, a lawyer will portray the patient as a major corporate CEO if only the first physician had ordered the scan even if few surgeons in the world would intervene on the injury. If detecting any abnormality regardless of the cost to the individual or society is top priority, recognize that a brain injury can exist despite a normal head CT. If we are to take a fully defensive posture and toss the evidence out with the tort reform, should we not order more sensitive head injury tests such as MRI, PET scans, serum biomarkers, and formal cognitive testing before any of these patients leave the ED? Most EM physicians would not advocate this extreme viewpoint, but what distinguishes unnecessary head CT ordering from other unnecessary brain injury testing? Tort reform is past due to alleviate counterintuitive over-testing. Intracranial injuries, missed or recognized, often have devastating results for individuals and families. The CHCT rule, or future worthy substitutes, ought to continue to be the focus of research until cost-effectiveness and acceptability can be demonstrated. If physicians are being legally persecuted for appropriately applying these rules, the case details and testimony should be reported in venues such as EP Monthly. Lacking an effective alternative, cost-conscious, evidence-based physicians are left with two choices: augmenting clinical decision making with the CHCT rule or substituting best-evidence practice for uniform testing of all head injury victims at tremendous cost to society with no proven benefit to the individual patient. Christopher Carpenter, MD, is an Assistant Professor at Washington University School of Medicine.
vClinical Update In 2009 trial, prediction rule safely stratifies children with minor head injuries, gauging which need CT
K
uppermann, et al., published an excellent article in 2009. This study helped to address the question of which children with “minor head injury” require a CT scan and in which patients can a CT be safely be avoided. 42,412 children, younger than age 18 yrs, with a GCS of 14 or 15 were studied in 25 North American Emergency Departments. Both groups included derivation and validation populations. The patients were divided into two subcategories, less than 2 years and 2 to 18 years.
mal scans could have been avoided, and the one patient requiring “neurosurgical intervention” would have been identified. However, with addition of the medium-risk (2 additional) criteria were used, only a 46.7% reduction in scans would be noted. Unfortunately, two “clinically significant” abnormalities would have been missed. Their conclusion was that such studies have no applicability outside the environment in which they were developed. Hence, they lack external validity. I agree with them! If you feel external validity has been proven by these studies, conducted in Europe and Australia, how does that apply to apply to those of us practicing in the U.S.? When’s your next shift in Canada, England or Australia? A fundamental challenge applying the many utilization-driven guidelines, generated by Canadian researchers, to EDs in the United States is that our medical malpractice climate does not afford any forgiveness for medical error. The Canadian CT head rule was 92% sensitive for identifying traumatic neurosurgical lesions. CT utilization could have been reduced to 32%. Unfortunately, only 320 of the 348 patients with positive CT scans would have been identified. Stiell was proud to report that they did not miss any of the lesions requiring neurosurgical intervention. However, they don’t talk much about the 28 “clinically important” and “clinically unimportant” lesions the rule would have missed. In the malpractice climate in the United States, there is no such thing as a “clinically unimportant” intracranial injury. Any such miss is an opportunity for a lawsuit. If a claim is made, convincing a jury of laypersons that the lesion was “unimportant” will be nearly impossible. Furthermore, average defense costs will be at least $100,000, and that’s just to get you to your first day of trial. Great concept. But, it falls way short on practical application. Plaintiffs and jurors don’t commend a physician for reducing utilization and saving healthcare costs when they have an injured patient in front of them. I agree that we spend far too much on unnecessary tests in this country. However, until our legal system accepts misses in exchange for controlling costs, we can’t put ourselves at risk. Kevin Klauer, DO, is the Director of Quality and Clinical Education at EMP & the Director of the Center for Emergency Medicine Education
CTs were obtained in 14,969 (35.3%) patients, identifying clinically important traumatic brain injury (ciTBI) in 376 (0.9%) patients, 60 requiring neurosurgery. ciTBI was defined as, “death from traumatic brain injury, neurosurgery, intubation >24 h or hospital admission > 2 nights.” The prediction rule for children less than two years of age, “normal mental status, no scalp hematoma except frontal, no loss of consciousness or loss of consciousness for less than 5 s, non-severe injury mechanism, no palpable skull fracture and acting normally according to the parents,” had a negative predictive value of 100%. The prediction rule for the older group, 2 years and older, “normal mental status, no loss of consciousness, no vomiting, non-severe
injury mechanism, no signs of basilar skull fracture, and no severe headache,” yielded a negative predictive value of 99.95%. No neurosurgical lesions were missed in the validation groups. Although no decision rule is perfect, these validated prediction rules provide an excellent guideline with respect to identifying patients at very low risk for clinicallyimportant traumatic brain injuries and in which patients a head CT may be safely avoided. Kuppermann N., Identification of children at very low risk of clinically-important brain injuries after head trauma: a prospective cohort study. Lancet. 2009 Oct 3;374(9696):1160-70.
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DISASTER RELIEF
Haiti Earthquake
Aggressive Compassion
u Facing the Difficult Reality of Emergent Amputations by Dr. Greg Elder, MSF-USA’s Deputy Operations Manager
I
n the days following the earthquake in Haiti, I was asked in a CNN interview about the rescue of an 11-year-old girl who was partially trapped under a building. It was a compelling story: an innocent victim crying in pain, newly-arrived searchand-rescue teams racing against the clock in an apocalyptic cityscape, and an ethical dilemma over whether to risk the girl’s life by performing a crude amputation or attempting a slow rescue. It was an awkward question for a doctor to face on national television. I wondered if I was being asked to comment on the scene or to give a professional opinion on what should be done. Later in the day, I was dealing with the events ongoing at MSF’s centers in Port-au-Prince. Our hospitals had been damaged and staff members were missing. Our traumatized teams were struggling with the overwhelming numbers of patients flooding into the facilities they’d established where our trauma center once stood. Our emergency response team was plotting out our phased response strategy and calling high-level contacts in regional governments to request facilitation of our efforts. My mind drifted back to the little girl and I wondered if anything I’d said might have been construed as professional advice to amputate her leg and to move to the next case. Doctors are trained to make these decisions and to live with their consequences. As a doctor working for a humanitarian organization, I am buffered from the personal impact of such choic-
es. At headquarters level, patients can become abstract categories: victims, displaced, refugees, and so on. MSF conducts more than 8 million consultations a year in nearly 70 countries. That’s 8 million individual conversations between a health worker and a patient. They could happen under a tent in a mobile clinic in Darfur, at an
“
At headquarters level, patients can become abstract categories: victims, displaced, refugees, and so on. . . . from time to time, even for those of us at headquarters, one patient can alter that abstract relationship and make the decisions very real.
HIV center in Malawi, or in a trauma hospital in Port-au-Prince. This is the measure of MSF’s human reach. This is the “human” in humanitarian. And, from time to time, even for those of us at headquarters, one patient can alter that abstract relationship and make the decisions very real. What could be the future of this little girl? What are the implications of my advice? Her leg was probably crushed. Pulling her out with her leg intact was unlikely. Reperfusion of her damaged limb could provoke crush syndrome and put her in mortal danger. Sepsis, gangrene, and tetanus are also risks. But amputating her leg
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would be only the first chapter. She would subsequently need intensive medical management —surgical debridement of her wound, fashioning of the stump, physiotherapy and planning for an artificial limb–that would require specialists and long-term follow-up care. She would need several new prostheses as she grows, and she will also almost certainly need psychological support to cope with the loss of her limb, the trauma and post-trauma of her experience, and the grief associated with losing friends and family. Services such as these were extremely limited in Haiti even before the earthquake (and almost wholly inaccessible if one didn’t have money). MSF set up Trinité hospital in 2005, when urban warfare was raging in Port-au-Prince. For the last two years, it’s been the capital’s sole trauma center, treating fewer war-wounded and rape victims but increasing numbers of people for motor vehicle, domestic, and workplace accidents. MSF also ran the city’s primary obstetric unit—providing obstetric care to some 25,000 pregnant women since 2006, almost 60 percent of whom were facing potentially life-threatening complications— while also providing primary and basic secondary health services in several city slums. On top of this girl’s short-term and longterm medical needs, one wonders how a young woman—possibly on her own, with a significant physical disability—will negotiate a crowded marketplace in a poor country that still lacks meaningful social safety nets despite the billions that have been invested in development aid and a UN peacekeeping operation. The proposed amputation to save this girl’s life is a calculated surgical act, at once aggressive and compassionate. A similarly aggressive and targeted approach is needed for the long-overdue reconstruction of Haiti’s health system. If it can be done, this young woman might not have to bear the burden of her collapsed house for the rest of her life
Originally from New Zealand, Dr. Greg Elder (middle, in Sudan) is MSF-USA’s Deputy Operations Manager. Photo by Caroline Livio/MSF
DISASTER RELIEF
Haiti Earthquake
8 Things I Learned in Haiti
Last January, the world watched as a massive earthquake hit Port-au-Prince, Haiti, virtually leveling the city and the surrounding towns. It is estimated that almost a quarter million people died in the initial quake and the ensuing medical disaster. I was privileged to be one of hundreds of emergency physicians who responded by going to Haiti to treat the thousands of injured. I encountered physicians like myself from all over the world. As we labored together to relieve the suffering, we learned a few things about international disaster response. by Mark Plaster, MD
Problem: People need help in the immediate hours and days after and event. However, big organizations take days if not weeks to respond. Emergency physicians need to be prepared to respond quickly to maximize their impact. As soon as I saw the scale of disaster in Haiti I, like many others, knew I wanted to respond. Being a part of the US Navy’s Rapid Response Team, I assumed we would be some of the first in country. But it took over a week to work through the government bureaucracy. Eventually I gave up on going through the military and joined an NGO (non-governmental organization) called Team Rubicon. The first team members had already been in country over a week. Lesson learned: If you want to be able to respond in the first wave of relief, have a relationship with a team of like-minded individuals or an organization that is ready to respond on a moment’s notice. Problem: With infrastructure gone, wouldbe rescuers can be a drain on scarce local supplies if not self sustaining. Obtaining medical supplies in country, especially narcotics, may be impossible. Team Rubicon was made up of former military doctors, nurses, paramedics and firefighters, all with an ‘expeditionary mentality’. As such, team members were responsible for providing our own tents, food, and medical equipment. Most of the Team Rubicon members were able to obtain supplies on short notice through the medical facilities where they worked, but these supplies were quickly exhausted and had to be obtained from the scarce local supply. A second team was able to resupply by contacting large suppliers, but only after a lag period. Lesson learned: While most equipment and personal gear can be stockpiled for use on a moment’s notice, medicines, especially narcotics must be obtained at the last minute. Have a predetermined supply line for meds that can be tapped quickly and maintained. Time is of the es-
introduction from the country’s own embassy in the US. This is where affiliating with a larger organization might be helpful. One of the Team Rubicon members had recently worked with the United Nations. Those contacts proved invaluable.
Mark Plaster, MD (R), rides through downtown Port-au-Prince with Brother Jim Boynton sence, but have a plan for a rapid resupply. Problem: Regardless of how thoroughly you plan, teams who travel light will have need of purchasing goods and services in country where banks may not be functioning. So cash will have to be carried. This can present a security issue. Daily expenditures for the entire team could reach $1000. Carrying that much cash, sleeping outdoors or in an unsecured environment can be a real risk. Team Rubicon, being made up a mostly former military had planned for and was prepared for such. But this might escape the planning of a naive and trusting group. Lesson learned: Team members must have access to and be willing to carry large sums of cash. You must also reserve cash and a plan for getting home. Problem: Getting the necessary paperwork for admission to a country takes more than having a good heart and desire to help. Haiti was a unique situation in that the government was virtually disabled. The initial teams were able to come into the country with little more than a letter from an official source in the US, far short of a visa. Other countries, however will likely keep national border security tight even in times of disaster. Medical teams must be prepared with current passports and letters of
Lesson learned: Have current passports for all members. Have a list of contacts for countries to which you are willing to travel, who can provide the needed documents on an expedited timeline. Consider obtaining some type of affiliation with widely recognized world relief organizations. Problem: Who is your first contact once you arrive at ground zero? By chance, Team Rubicon had a contact with a Jesuit mission in Port-au- Prince. Jim Boynton, a Jesuit brother affiliated with the mission proved invaluable to the group. Other physicians who went to help had contacts with other religious and benevolent organizations. Having a local contact that can be trusted in absolutely imperative. Lacking such a connection, precious time would have been wasted with a multitude of team sustainment issues. Since the mission was secure and set up with its own power, water, and internet access, the team was free to immediately begin providing much needed care. Lesson learned: Build a list of contacts for places you are willing to go. The more information the better as communication may be limited in a disaster. Religious NGOs are good contacts for this. They commonly have the trust of the locals and basic facilities from which to work. Problem: What happens when you out run your referral base? A disaster, by definition, is where the resources are overwhelmed. Emergency physicians who expect to refer serious cases on to other specialists may find that there are none, or that they are overwhelmed. In the case of Haiti, first responders found themselves handling crush injuries and
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DISASTER RELIEF
Haiti Earthquake
© Julie Rémy / MSF
open fractures with no hope of immediate followup by surgeons. Many field amputations were performed by physicians who had never done such procedures. Even when orthopedic surgeons began arriving they were quickly overwhelmed and soon out of orthopedic appliances. When the USNS COMFORT arrived on station, there were 1200 patients waiting to be air lifted to tertiary care. Needless to say it didn’t happen over night. Lesson learned: Especially for physicians from the developed world where practices are limited to speciality practice, go back to the basics and re-learn how to give basic care to anything. Plan on bringing supplies to clean wounds, splint the worst kinds of open fractures, provide prophylactic antibiotic coverage, and pain control for several days. Then develop priorities for handling once secondary help begins to arrive. If you want to help in a disaster, spend some time with your local general surgeons and orthopedic surgeons brushing up on basic wound and fracture care. If you haven’t already mastered the skill, learn regional anesthesia. And be prepared to step out of your first area of expertise to apply skills that you may know but seldom practice.
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Problem: How do I keep from making enemies of the locals? Physicians from the developed world can seem arrogant and condescending to the locals, especially local health care providers. Decisions, ostensibly made in the patients best interest, can fail to take into account the social situation of the patient and the local medical providers. Health care workers from the ‘outside’ can even be seen as an affront and ultimately resisted. In the case of Haiti, because some early physicians who spoke no Creole, simply did what they thought right and amputated crushed limbs without consulting anyone, patients became afraid to seek care. To make matters worse, many from our group, being former military, had very functional military clothing. But wearing it made us look like we were foreign invaders. I found that by wearing scrub tops, or a lab coat, even dirty ones, I was seen as a doctor, a universal symbol and given respect and assistance. Most situations were resolved with better communications. But these situations could have been avoided by taking time with each patient and bringing in the local medical providers, at whatever level, whenever possible.
Summer 2010 // Emergency Physicians International
Lesson learned: Regardless of the situation, don’t allow yourself to get caught up with the thought that you can do anything just because it’s a disaster. Consider your appearance. Communicate with the patients and local medical providers. People still require communication. Laws still apply. You are still a foreigner. Problem: How do you know when to go home? It was clear from the first day that the needs of Haiti would go on for a long time. But there was a definite time when it seemed that the larger organizations were in place, doing good work, and the immediate crisis was moving into a longer phase. Even though we knew that there would be a second wave of medical issues related to infection, malnutrition, and other issues, we had to face the fact that the time for our little group of emergency care givers was over. Leaving Haiti was like walking out of the ER with the waiting room still full. You just have to trust the next shift. Lesson learned: Coming full circle, you have to remind yourself that the EM portion of a disaster gives way to others with more assets.
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INTERVIEW
ACADEMICS second-by-second process of ambulance arrival, clerical registration, handover, prioritisation, documentation, and movement to ED cubicle is very different everywhere! Why??
The Future of the Federation wfrom page 11
AHA and other orgnaisations have long established track records. We just need to link in with these groups. Bodiwala: IFEM’s definition of emergency medicine is on the web. Many countries have adopted that definition broadly. Whilst its purpose is clearly defined, I would remind that it does include prehospital care. IFEM does and hopes to continue to collaborate with these organisations too.
+As per IFEM bylaws, only
one national society can be a full member of IFEM. How do you think IFEM should handle countries that have multiple, competing EM societies? Bodiwala: Usually there is no problem, but should there be a competition we will seek to have clarification from either the government health department or a national medical organisation looking after
+In your traveling around the
world, have you been surprised about an element of EM that was similar across borders? Cameron: This is a difficult question to answer as we subconsciously expect things to be the same! I guess it is mostly the enthusiasm and dedication of people working in emergency medicine, in whatever form, under very different and sometimes difficult circumstances. Bodiwala: I have found that wherever I went, a bunch of hospital and general practitioners wanting to either establish EMS or EM as a specialty which is profoundly encouraging.
+What about an element of em
that was surprisingly different from country to country? Cameron: One thing that has taken me a bit by surprise – even within my own country – is the variation in how we process patients on arrival at the hospital. When we look at other businesses with high volumes – banks/supermarkets etc., – there is a standard process for the initial interaction. In high risk areas, such as ours, this is even more important. However, the
46
Dr. Peter Cameron poses with students from the first official emergency medicine residency program in Brazil. all specialties to signify which one is the representative of emergency medicine.
+What if the rival societies
are extremely entrenched? What is the criteria for choosing a dominant player? Bodiwala: In my personal opinion (as there is no written bylaw on this specific matter) I would suggest to clarify from the Government which of the two or many EM societies is ‘recognised’ by them, which one do they communicate with and other medical admin authorities and which one has the ability to conduct examinations and issue certification. I would also suggest that two or more societies decide among themselves who should represent emergency medicine in the International Federation based on who represents EM on their national scene.
Summer 2010 // Emergency Physicians International
Should I Follow the Fellowship Road? wfrom page 12
of projects that different programs are implementing. For example, GWU recently completed an emergency medicine training program in Turkey in association with the Emergency Medicine Association of Turkey (EMAT). The program used a ‘training of trainers’ methodology to first design an educational curriculum in emergency medicine, then deliver this curriculum to more than 2500 general practitioners over two years. The most critical feature of this program that allowed its success was the strong partnership with EMAT. The physician leaders from this association provided the training programs throughout the country, and in doing so brought an educational benefit to a large number of practitioners. This project specifically targeted those physicians who are not formally trained in emergency medicine, but are practicing in most of the country. As Emergency Medicine develops into a specialty, this is a common problem that countries encounter. This educational model of ‘training of trainers’ was an effective method of distribution of important education in emergency medicine. At this point, to my knowledge, there are not any International EM Fellowship programs offered in countries other than the United States. Emergency medicine programs around the world often will offer various opportunities for ‘visiting fellowships’ for physicians to visit their institution and engage in an educational experience. The length and goals of such an experience are variable, and are determined specifically between the visiting faculty member and institution. If you are working to develop emergency medicine in your own country, the International Emergency Medicine Fellowship programs may represent good resources for potential collaboration. It is also important to realize that fellowship programs are not exclusively for physicians just finished with residency, or those interested in academic medicine. An IEM Fellowship is a great opportunity to gain a lot of experience in a relatively short time, which leads to a variety of career opportunities. While staying in academics is an option, past international fellows have gone on to careers in NGO’s, various governmental organizations such as the CDC, or careers in community practice with a self-defined element of international EM. Others have gone on to live full time in another country, working to develop the EM system there. Just remember the importance of choosing the right fellowship ‘fit’ in the beginning – your experience will help to define your future career opportunities. There is a great variety of fantastic work being done across the spectrum of international emergency medicine fellowships. This work is truly bringing better health care and education to many, many people throughout the entire world.
The IEM Fellowship Directory California
Harbor-UCLA/IMC Global Health Fellowship Regional Focus: Iraq and possible extension to Haiti Contact: Ross I. Donaldson, MD, MPH Harbor-UCLA Medical Center Department of Emergency Medicine 1000 West Carson Street, Box 21 Torrance, CA 90509 Length: 1-2 years Salary: Competitive Shifts: 5 per month Degree: MPH, DTMH available Number of Positions: 1 Deadline: November 1 ( (310) 222-3500 8 ross@rossdonaldson.com : www.emedharbor.edu/ Global.html Keck School of Medicine at the University of Southern California Contact: Billy Mallon, MD Department of Emergency Medicine 1200 North State Street Room 1011 Los Angeles, CA 90033 Fax: (323) 226-6454 Length: 1-2 years Salary: Competitive Shifts per week: 2 Advanced Degree: MPH, DTMH Number of Positions: 1 Deadline: December 1 ( (323) 226-6667 8 wkmallon@yahoo.com : www.cbooth.info UCLA-CIM International Medicine Fellowship Nicole Durden, Program Manager UCLA Medical Center Dept. of Emergency Medicine 924 Westwood Blvd., Ste 500 Los Angeles, CA 90024 Length: 1-2 years Salary: Competitive Shifts: 5 per month
Advanced Degree: MPH, PhD Number of Positions: 1 Deadline: December 1 ( (310) 794-3086 8 ndurden@mednet.ucla.edu : http://cim.ucla.edu
Connecticut
Yale University School of Medicine Regional Focus: Africa Contact: Simon Kotlyar, MD Department of Emergency Medicine 464 Congress Ave, Suite 260 New Haven, CT 06519-1315 Fax: 203-785-4580 Length: 2 years Number of Positions: 1 Salary: PGY level, MSc tuition, travel stipend, excellent benefits Shifts/hours per week: 0.5 FTE Advanced Degree: MS, London School of Hygiene and Tropical Medicine Deadline: December 1 ( (203) 785-4058 8 simon.kotlyar@yale.edu : medicine.yale.edu/ emergencymed/fellowships/ global/index.aspx
District of Columbia
George Washington University Regional Focus: India, Malawi, Egypt, El Salvador, Ethiopia, Peru Contact: Kate Douglass, MD 2150 Pennsylvania Avenue, NW, 2B-417 Washington, DC 20037 Fax: (202) 741-2921 Length: 2 years with MPH 1 year without MPH Salary: Highly competitive, including MPH tuition and generous CME Advanced Degree: MPH Number of Positions: 1-2 Deadline: November 15 ( (202) 741-2954 8 kdouglass@mfa.gwu.edu : www.gwemediem.com
Georgia
Emory University Contact: Scott Sasser, MD Department of Emergency Medicine 531 Asbury Circle - Annex Suite N - 340 Atlanta, GA 30322 Fax: 404-778-2630 Length: 2 years Number of Positions: 1 Salary: Instructor Shift / hours per week: Advanced Degree: Deadline: check with department ( (404) 778-5975 8 ssasser@emory.edu Medical College of Georgia Regional Focus: Peru, Bangkok Contact: Hartmut Gross, MD 1120 15th Street Augusta, Georgia 30912 Fax (706) 721-7718 Length: 1 year Salary: Competitive salary, benefits, CME, international travel funds Shifts per month: half-time EM clinical faculty position Advanced Degree: None Number of Positions: 1 ( Phone: (706) 721-4412 8 hgross@mail.mcg.edu : www.mcg.edu/ ems/residency/ internationalMedFellow.htm
Illinois
Cook County Hospital Contact: Jamil Bayram, MD & Robert Simon, MD Cook County Hospital, Rush University Medical Center, and Int’tl Medical Corps Dept. of EM 1653 W. Congress Parkway, 177 Murdock Chicago, IL 60612 Fax: (312) 942-4021 Length: 2 years (with MPH) Salary: Very competitive; benefits; tuition fees for the MPH; travel expenses and
stipends are provided Number of Positions: 1- 2 Deadline: Open ( (312) 942-4978 8 jamil_bayram@rush.edu University of Illinois at Chicago Contact: Janet Lin, MD, MPH Department of Emergency Medicine College of Medicine East Suite 469A 808 South Wood Street Chicago, IL 60612 Length: 2 years Salary: N/A Number of Positions: 1-2 Deadline: Open ( (312) 413-7393 8 jlin7@uic.edu
Maryland
The Johns Hopkins University Contact: Alexander Vu, DO Center for International Emergency, Disaster & Refugee Studies 1830 E. Monument Street, Suite 6-100 Baltimore, MD 21205 Fax: (410) 502-8881 Length: 2 years Salary: Competitive Number of Positions: 1-2 Advanced Degree: MPH Deadline: December ((410) 614-5665 8 avu3@jhmi.edu University of Maryland Regional Focus: China, Egypt, South Africa and Botswana Contact: Bob Corder, MD School of Medicine Division of EM 110 S. Paca Street, 6th Floor, Suite 200 Baltimore, MD 21201 Length: 2 years Salary: Competitive Number of Positions: 1 Advanced Degree: MPH Deadline: Open ( Phone: (410)328-8025 8 bobcorder@comcast.net
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The IEM Fellowship Directory massachusetts Harvard University / Beth Israel Deaconess Medical Center Contact: Philip D. Anderson, MD Department of EM One Deaconess Road W/CC -2 Boston, MA 02215 Length: 2 years Salary: Competitive, benefits, CME benefits and MPH tuition Positions: One Advanced Degree: MPH Deadline: December 1 ( (617) 754-2324 8 pdanders@bidmc.harvard.edu Harvard University / Brigham and Women’s Hospital Regional Focus: Various Contact: Stephanie Rosborough, MD Department of EM 75 Francis Street Boston, MA 02115 Length: 2 years Positions: One Salary: Competitive with excellent benefits Shifts/Week: 1-2 Advanced Degree: MPH Deadline: November 20 ( (617) 732-5813 8 iem@partners.org : www.brighamandwomens.org/ dihhp/iem
New York
Bellevue Hospital Center/ New York University School of Medicine Contact: Michael Mojica, MD Emergency Care Institute Room 345A Bellevue Hospital Center 27th Street and First Avenue New York, NY 10016 Length: 1 - 2 years Salary: Competitive No. of Positions: 1 ( (212) 562-8147 8 mojicm01@nyumc.org
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A dynamite victim gets emergency care in a Brazilian emergency department. Programs like Vanderbilt University’s International Emergency Medicine Fellowship focus on IEM work in South America.
New York - Presbyterian: The University Hospitals of Columbia and Cornell Regional Focus: Southern Asia, Kenya, Dominician Republic Contact: Rachel T. Moresky, MD Columbia University Medical Center - Center for EM 622 West 168th Street PH 1-137 New York, NY 10032 Length: 2 years Salary: Competitive No. of Positions: 2 Advanced Degree: MPH Deadline: December 1 ( (212) 305-2995 8 rtm2102@columbia.edu : www.nypemergency.org/ fellowships North Shore - Long Island Jewish Health System Contact: Sassan Naderi, MD Dept. of EM 270-05 76th Ave New Hyde Park, NY 11040 Length: 1 year No. of Positions: 1 - 2 Salary: $90,000 Hours per week: 18 Advanced Degree: N/A
Summer 2010 // Emergency Physicians International
Deadline: Rolling ( (718) 470-7501 8 snaderi@nshs.edu St. Luke’s Roosevelt Hospital Center - Global Health Fellowship Contact: John D. Cahill, MD Dept. of EM 1111 Amsterdam Avenue New York, NY 10025 Length: 2 years No. of Positions: 2 Salary: $87,000 Hours per week: 20 Advanced Degree: MPH optional Deadline: Rolling ( (212) 523-3330 8 applications@ slredglobalhealth.com : www.slredglobalhealth.com University of Rochester Medical Center Contact: David H. Adler, MD Dept. of EM 601 Elmwood Avenue Box 655 Rochester, NY 14642 Length: 2 years Salary: $80,000 - $100,000/ year depending on clinical
time; CME, benefits, 5k/year travel No. of Positions: 1 Advanced Degree: MPH, clinical investigation, or medical management Deadline: April 15 ( (585) 463-2945 8 david_adler@ urmc.rochester.edu
North carolina Duke International Emergency Medicine Fellowship/Global Health Residency Program Regional Focus: East Africa Contact: Charles J. Gerardo, MD Duke University, DUMC 3096 Durham, NC, 27710 Length: 2 years Number of Positions: 1 Salary: Competitive, including tuition for advanced degree Advanced Degree: MS in Global Health (MSc-GH) Deadline: November 1 ( 919-681-4458 8 gerar001@mc.duke.edu
photo by Márcio Rodrigues
4
The IEM Fellowship Directory Oregon Oregon Health & Science University - Global Health Fellowship Contact: Mohamud Daya, MD Oregon Health & Science University Dept. of EM 3181 SW Sam Jackson Park Road, CDW-EM Portland, OR, 97068 Length: 2 years No. of Positions: 1-2 Salary: PGY level, CME allowance, benefits Shifts per week: 1 Advanced Degree: Master’s or certificate options (tuition support provided) Deadline: Rolling ( (503) 494-8220 : www.emergencyresidency. com
Pennsylvania University of Pittsburgh Contact: Allan B. Wolfson, MD Dept. of EM 230 McKee Place, Ste. 500 Pittsburgh, PA 15213 Length: 2 years Salary: Negotiable
Shifts per week: Negotiable Advanced Degree: MPH offered from the University of Pittsburgh Graduate School of Public Health ( (412) 647-8265 8 wolfsonab@upmc.edu : affiliatedresidency. health.pitt.edu
tennessee
Vanderbilt University International Emergency Medicine Fellowship Regional Focus: South America Contact: Seth Wright, MD Vanderbilt University 703 Oxford House Nashville, TN, 37232 Length: 1-2 years No. of Positions: 2 Salary: $88,000 + excellent benefits, tuition, travel expenses Hours per week: 14.75 Advanced Degree: MPH, DTMH Deadline: Rolling ( (615) 936-0075 8 seth.wright@vanderbilt.edu : emergencymedicine. mc.vanderbilt.edu
zine by a new maga
Firs than d repo rts oF spec ialt y deve lopm ent aro und the glob e
including
bhutan turkey Colombia hong kong Vietnam a South afriC Panama korea SPain Croatia ghana Issue 1 // Summ
er 2010
//
epinternational.ni
University of Utah Regional Focus: Ghana, Thailand, India, Peru Contact: Eric Barton, MD Associate Professor Div. of Emergency Medicine 201 Presidents Circle Room 201 SLC, UT 84112 Length: 1 to 2 years Salary: competitive Number of positions: 1 or 2 Shifts: 7 per month/54 hours Advanced degrees: MPH Deadline: Rolling ( (801) 581-2730 8 erik.barton@hsc.utah.edu
Official EPI Article Reprints Available
EM DEvElopMEnT rEporTs FroM bE arounD ThE glo
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University of Texas Southwestern (Dallas-Parkland) Regional Focus: Mexico/Latin America Contact: Robert E. Suter, DO, MHA Div. Emergency Medicine UT Southwestern Medical
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// Emergency Physicia
Baylor College of Medicine / Texas Children’s Hospital Regional Focus: Various Contact: Charles G. Macias, MD, MPH Texas Children’s Hospital 6621 Fannin, MC 1-1481 Houston, TX, 77030 Length: 4 years (pediatrics trained); 3 years (EM trained) with Board eligibility in PEM at completion Salary: PGY level Number of Positions: 1 Clinical Hours per week: 32-40 Conferences/week: 4 hours, except PICU rotation Advanced Degrees: MPH, MEd, MS, MBA Deadline: August 31 through ERAS (apply for PEM Fellowship) ( (832) 824-5468 8 pwomack@ texaschildrenshospital.org
Center at Dallas 5323 Harry Hines Boulevard CS2.122 Dallas, TX, 75390-8579 Length: 2 years Salary: Competitive Number of Positions: 4 Hours: 56 clinical hours/month Advanced Degrees: MPH Deadline: December 1 ( (214) 648-3916 8 robert.suter @utsouthwestern.edu
source
PHYSICIANS EMERGENCY AL INTERNATION
Summer 2010
texas
+
dispatches 16
The Future of IFEM
Bhutan 18
interview with turan key 21 bodiwala Drs. gautam viet er Cameron nam Pet24 and
colomB Netherlands ia 26 Could The EM be a template for hong kongt in Europe? 28 developmen
This past spring, Vietnam took a strong step towards greater EM development through a historic interna tional collaboration Details on page 26
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CASE STUDY
ABOUT THE AUTHORS Brady Pregerson manages a free online EM Ultrasound Image Library and is the editor of the Emergency Medicine Pocketbook series. For more information visit ERPocketBooks.com
Dx: Liver Abscess wfrom page 14
This image demonstrates a view of the right upper quadrant using the 2.5 MHz curvilinear probe just below the costal margin. The liver is moderately echoic and takes up most of the image. The abscess has an anechoic/hypoechoic center with a slightly hyperechoic surrounding rim. The diaphragm is very hyperechoic and separates the liver in the near field (top of image) from the lung in the far field (bottom left of image). The right kidney cannot be seen in this image, but is nearby.
continued from page 5
LIVER
* *
Liver abscesses may be caused by a variety of organisms. Pyogenic abscesses cause about 80% of cases and are often polymicrobial with E. coli or Klebsiella pneumonia being the primary pathogen. Entamoeba histolytica causes about 10% of cases and Candida albicans or another fungal organism is the usual cause in the remaining 10%. Treatment usually entails antimicrobials targeted at the suspected organism or organisms and drainage, often performed percutaneously. Your patient is admitted to the hospital overnight for antibiotics and antiparasitics. In the morning he is improved and is
*
abscess
* * Di
Teresa Wu is the EM Ultrasound Director and Co-Director for Simulation Based Training for the Maricopa Emergency Medicine Program in Phoenix, Arizona.
* *
*
ap
hr ag
m
discharged so that he can get himself to the closest urban hospital where they perform a
CT guided drainage of the abscess. The cultures grow out Klebsiella pneumoniae.
Pearls & Pitfalls for Imaging Liver Masses 1.
Liver Abscesses: Abscesses may be single or multiple. They are characterized by a hypoechoic fluid collection with a hyperechoic shaggy wall. Early on the abscess contents may be close in echogenicity to the liver parenchyma, but as the contents liquefy further, the fluid becomes hypoechoic or even anechoic.
2.
Hemangiomas: Hemangiomas are the most common primary tumor of the liver and are usually solitary. The are quite hyperechoic, often appearing bright white, and are also homogenous and well circumscribed.
50
3.
Metastases: Metastases may be single or multiple. They may be of similar echogenicity to the liver, but in a more heterogeneous pattern. Often liver metastases or primary liver masses are more echoic that the liver due to increased vascularity.
4.
Cysts: Liver cysts may be single or multiple. They are usually benign when they have thin walls and an anechoic fluid center. Posterior enhancement may be noted.
5.
Gallbladder Stones & Polyps: For a good case example see the November 2009
Summer 2010 // Emergency Physicians International
issue of Soundings or check it out at www.erpocketbooks.com
6.
During a focused bedside ultrasound, you may happen to come across a liver mass during the scan. The liver is an excellent acoustic window, so many bedside ultrasound applications will provide you with a great view of the liver parenchyma. Although EM physicians are not typically trained to make â&#x20AC;&#x153;formalâ&#x20AC;? interpretations of liver sonograms, it is useful to understand some hepatic ultrasound basics so that the appropriate management decisions can be made. When a
liver mass is discovered during a focused, bedside scan, explain to the patient the limitations of your scan, and ensure that appropriate, comprehensive imaging is arranged for a definitive diagnosis.
7.
Practice Makes Perfect: With bedside ultrasound there is no substitute for experience. The more ultrasounds you do, the better you will be able to differentiate abnormal from normal, even when you may not be sure exactly what the abnormality is.
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Summer 2010 // Emergency Physicians International
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