Mental Health in Post-Quake Haiti EM Comes of Age in Slovenia A Swede’s Brooklyn Observership
EMERGENCY PHYSICIANS INTERNATIONAL
Hong Kong Undergraduate education at a crucial crossroads
south korea Looking outward while
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EM Development Reports from
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the 8th Annual NY Symposium on
INterNAtIoNAl emergeNcY medIcINe
“Global Collaborations in Emergency Medicine”
August 17 – 18, 2011 lenox Hill Hospital New York city gueSt SpeAkerS: Joe O’Neill, MD Founder of PEPFAR Sandra Schneider, MD President of ACEP Peter Cameron, MD President of IFEM Lee Wallis, MD President of EMSSA & AFEM Robert Bristow, MD Columbia University
RSVP to: ifemconference2011@gmail.com or call (516) 562-1223
Latha Stead, MD University of Florida
CouRSE DiRECtoRS:
plus . . . Chairs of IEM Sections for ACEP, SAEM, AAEM, ACOEP, CAEP, ACEM and EuSEM
Kumar Alagappan, MD Sassan Naderi, MD Terrence Mulligan, DO, MPH John Acerra, MD, MPH
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topIcS: Lessons Learned from 15 years of IEM collaboration Rebuilding in Haiti, Japan and Africa
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Editor’s Desk
A New Wave of Collaboration
W
e are all too aware of the deadly tidal waves which have struck the Pacific Rim nations in recent years. But there is another tidal wave in the making, one worth celebrating. It is the wave of enthusiasm and support being shown for emergency medicine global health activities. This tidal wave grew greatly (although it has not peaked) at the 2011 Society for Academic Emergency Medicine (SAEM) Annual Meeting in Boston, Massachusetts. For the first time, there were multiple didactic and research abstract presentations on international EM and global health each day of the conference. Several sessions featured research from international participants. On the final day of the conference, Drs. Ian Martin, Michael Runyon, and Bob Hoffman presented comprehensive rationale, planning, and operational advice for conducting international clinical rotations and receiving international medical students and physicians in clinical and observational rotations in the U.S. Their advice was the most comprehensive and practical I have heard on this subject to date. If your institution is uncertain about the value or practical operation of international clinical electives, you should contact them to make this presentation at your institution. A key component to the tidal shift taking place was the announcement at the SAEM conference that the Global Emergency Medicine Academy (GEMA) was approved by the SAEM Board of Directors. As an official SAEM academy, GEMA (led at this time by Dr. Ian Martin) now can receive administrative and financial support from SAEM to lead global EM academic activities. Also of note for the international community was the decision by SAEM and its journal Academic Emergency Medicine (AEM) to dedicate its 2013 “Consensus Conference” to the subject of global emergency medicine. The AEM Consensus Conference is held for one full day each year immediately preceding the SAEM Annual Meeting, and its topics each year have been on key issues in academic EM. The fact that this conference will now recognize and publicize the value and importance of global EM as an academic endeavor, and help lay out a long term research agenda, is a huge step in the right direction. Beyond academic support, global emergency medicine is now even getting administrative support. I met an amazing number of people at the conference who have been designated by their institutions to be “Directors of Global Health Programs.” It is so gratifying to see this administrative recognition, even at many departments of emergency medicine which are not located at university hospitals. Finally, the tide of support has swelled because of the huge number of medical students, EM residents, and EM faculty who want to make global EM a major focus of their careers. These are young, but incredibly capable individuals. One example is the strong leadership within the Emergency Medicine Residents Association (EMRA) International Committee, which has already developed a number of resources (rotations list, practical travel guidebook,etc.) for EM residents and students to carry out international activities. And I should also mention the wonderful interorganization cooperation which exists between the leaders of SAEM’s GEMA, the American College of Emergency Physicians International Section, the EMRA International Committee, and the International Federation of EM (IFEM). Leaders of each of these organizations are developing overlapping collaborations and freely sharing information and resources related to global EM development. On a personal note, after all my years of struggle to push recognition of global EM as an academic discipline and an important career experience for medical students and residents, it is incredibly gratifying to see these things come to fruition. Let’s keep this wave rolling!
C. James Holliman, MD, FACEP, FIFEM editorial director
‘‘
I should mention the wonderful inter-organization cooperation which exists between the leaders of SAEM’s GEMA, the American College of Emergency Physicians International Section, the EMRA International Committee, and the International Federation for Emergency Medicine (IFEM). Leaders of each of these organizations are developing overlapping collaborations and freely sharing information and resources related to global EM development.
MSF in embattled Ivory Coast Peter Cameron’s IFEM Rundown Common Laryngoscopy Mistakes
EMERGENCY PHYSICIANS INTERNATIONAL
the south america issue a r g e n t i n a An in-depth dossier from the ‘land of contrast’
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c o l o m b i a
A young EM society gains national recognition
EM Development Reports from
CroatIa south afrICa & japan Issue 3 sprIng 2011 epinternational.ning.com
About EPI With a circulation of 8,000 (quarterly) and an online network of more than 900 members, EPI is the new hub for global emergency care, sparking dialogue and creating a space for new collaborations. Find copies of the print magazine at international EM conferences around the world, or read it online at epinternational.ning.com
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3
Letter from the publisher
The Power of the Healer
“N
o group of physicians sits with as much potential political power today as emergency doctors. Why? We are the central hub of clinical decision-making.” There are plenty of medical specialists – even emergency physicians themselves – who would debate this statement, written in a recent editorial by Dr. Greg Henry, a past president of the American College of Emergency Physicians. While the specialty of emergency medicine makes undeniable progress on every continent, it still struggles to carve out its place in the medical establishment. From Colombia to France to Thailand, EPs cite a “lack of recognition” as one of their chief challenges (see page 14 for our global survey). But it is not to top-down, administrative power that Dr. Henry refers. He is not speaking of positions of prestige, flashy titles or high salaries. Rather, he points to the fact that emergency physicians hold a kind of soft power that is earned the old fashioned way, through a round-theclock work ethic and a singular focus on patient care. “The only real power emergency medicine has is that we can do things for others, keeping the patients as our central focus,” writes Dr. Henry. “This is the key. When you use power for you, you lose it; when you use it for the cause, you gain it.” In other words, at its best, the ED is a place with the sole agenda of healing, where politics and personal gain is set aside. In this issue, our writers demonstrate this power in action, like the power in being the first on the scene. As Dr. Peter Cameron writes in this month’s Grand Rounds (page 35), “There is good evidence that if patients can get the right diagnosis and treatment at the start of a hospital stay, the total length of stay is less and complications are less.” In a similar way, EPs are often the first to disaster zones, and as such have the ability to guide future care. As Dr. Tyler Jorgensen writes (page 28), a trip to post-earthquake Haiti revealed large numbers of unmet psychological health needs. This analysis by EPs was able to guide planning for future medical groups. By focusing on how to best treat a patient, regardless of condition, community status or ability to pay, EPs wield a power that is quite different than that of political activists, politicians or hospital administrators; different and perhaps greater. And as the work done by the men and women highlighted in this issue show, it is difficult to argue against an agenda of healing.
publisher Logan Plaster Logan@Plasterpub.com editorial director C. James Holliman, MD executive editors Peter Cameron, MD Terry Mulligan, do, mph Mark Plaster, MD associate editor LONNIE STOLTZFOOS regional corespondents Conrad buckle, md Marcio Rodrigues, MD CARLOS ARREOLA-RISA, md Katrin Hruska, 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 advertising Michelle rucks mrucks@epmonthly.com 5 College Avenue Annapolis, MD 21401
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3 | Editor’s Desk 7 | Event Calendar 32 | IEM Fellowship Directory
EMERGENCY PHYSICIANS INTERNATIONAL www.epinternational.ning.com
8 | Clinical p Where’s the fluid? Test your skills with this issue’s bedside ultrasound case study. 9 | Opinion Dr. Alberto Machado, the president of ALACED, on sharing the burden of diagnostic error. 10 | In The Field { Health indicators are reaching emergency levels, says Gedi Mohamed, the director of the general hospital at Kenya’s Dagahaley refugee camp. 12 | Interview EPI sits down with Prof. Stefek Grmec, a leader within the Slovenian Society for Emergency Medicine (SSEM). 35 | Grand Rounds Dr. Peter Cameron on why emergency physicians need to embrace the role – and title – of “specialist.”
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Source 14 | Dispatches “What is the greatest challenge emergency medicine faces in your country?” 16 | Botswana New residency could be a foretaste of EM developments in the sub-Saharan nation. 18 | South Korea A strong national EM organization is looking outward while honing standards and systemic shortfalls at home. 20 | India The recent INTEM conference in Ahmadabad showcased EM perspectives from the Indian subcontinent
Advertiser Directory: IFEM-NYC Symposium 2 The Morgan Lens 5 EMS: A Practical Global Guidebook 11 The T-Ring 17 IEDLI Leadership Institute 21 EM in the Developing World 22 The Mediterranean Emergency Medicine Congress 27 EMS China Conference 31 GE Healthcare Ultrasound 36
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Summer 2011 // Emergency Physicians International
28
Features 23 | Hong Kong: Education at a Crossroads In Hong Kong’s only undergraduate emergency medicine training ground, instructors struggle to recruit amidst an exam-based culture 25 | Transatlantic: All or Nothing A Swedish emergency physician on an observership in New York City reflects on the differences in care between the two developed nations. 28 | Haiti: Beyond the Physical p Addressing acute mental health needs in the disaster zone.
EVENT CALENDAR 08/11–7/12
TWELVE MONTHS OF i nte r n a t i on a l E M c onfe r en c es
AUGUST
The IFEM-NYC Symposium on International Emergency Medicine // New York City, USA Join speakers like PEPFAR’s Joe O’Neill for this gathering about global collaborations. Plus, meet the directors of IEM fellowship programs. August 17 – 18, 2011 www.ifem.cc
SEPTEMBER
Sixth Mediterranean Emergency Medicine Congress // Kos, Greece Come to Greece for this biennial event hosted by EuSEM, AAEM and HeSEM. September 10 – 14, 2011 www.emcongress.org/2011
Caribbean Emergency Care Conference // Willemstad, Curaçao Hosted by: Netherlands Antilles Foundation for Clinical Higher Education (NASKHO) September 19 – 24, 2011 E-mail: info@naskho.org www.caribbeanemergency.org
CEM Conference 2011 // Gatehead, United Kingdom Hosted by: The College of Emergency Medicine September 21 – 23, 2011 www.collemergencymed.ac.uk
III Brazilian Congress of Emergency Medicine // São Paulo, Brazil The Brazilian Association for Emergency Medicine and São Paulo University, School of Medicine will host this congress. September 22 – 25, 2011 www.abramede.com.br
The European Trauma Course // Verona, Italy
Emergency Medicine in the Developing World // Cape Town, South Africa
The European Trauma Course (ETC) has been developed to teach a system of care for managing trauma patients that is pragmatic, reflecting the reality of emergency medicine throughout Europe. September 22 – 24, 2011 www.erc.edu
All aspects of emergency care will be covered in the scientific and educational plenaries of this biennial, regional African conference. November 15 – 17, 2011 www.emssa2011.co.za
28th ACEM Annual Scientific Meeting // Sydney, Australia
OCTOBER
Hosted by: Australasian College for Emergency Medicine November 20 – 24, 2011 www.acem.org.nz
24th ESICM Annual Congress // Berlin, Germany Hosted by: European Socieety of Intensive Care Medicine October 1 – 5, 2011 www.esicm.org
January/2012
Retrieval // Glasgow, Scotland The conference will focus on the full spectrum of prehospital, transfer and retrieval medicine, applicable to medical, paramedical and nursing staff. October 6 – 7, 2011 www.emrs.scot.nhs.uk
The American College of Emergency Physicians (ACEP) Scientific Assembly // San Francisco, USA The largest emergency medicine meeting in the world, ACEP’s scientific assembly will bring together the best EM educators in the United States with a large and active international interest group. October 15 – 18, 2011 www.ACEP.org
IAEM Annual Scientific Meeting 2011 // Limerick, Ireland
Hosted by: Israeli Ministry of Health and the Home Front Command January 15 – 19, 2012 https://event.pwizard.com/ipred2012
The 1st Middle East Emergency Medicine Conference // Dubai, UAE For information, email: conference@uae.messefrankfurt.ae January, 17 – 19, 2012
MARCH
32nd International Symposium on Intensive Care and Emergency Medicine // Brussels, Belgium August 17 – 18, 2011 www.intensive.org
Hosted by: Irish Association for Emergency Medicine October 20 – 22, 2011 www.emergencymedicine.ie
JUNE
ICEM 2012 // Dublin, Ireland
NOVEMBER
Symposium on Quality and Safety in Emergency Care // London, England CEM and IFEM unite to bring together this first-of-its-kind symposium, held at the British Museum November 15 – 16, 2011 www.ifem.cc
List your next international event for free on the EPI Network
Second Israeli Int’l Conference on Healthcare System Preparedness & Response to Emergencies & Disasters // Tel Aviv, Israel
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Join speakers like Peter Cameron, Lee Wallis and Abdel Bellou for this gathering about global collaborations. Plus, meet the directors of IEM fellowship programs. August 17 – 18, 2011 www.ifem.cc
w w w. e p i n t e r n a t i o n a l . n i n g . c o m
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CLINICAL
l Parasternal long axis view of the heart
Where’s the Fluid? A bedside ultrasound case study by Teresa Wu, MD, Lauren Maeda, MD & Brady Pregerson, MD
Y This case study originally appeared in Emergency Physicians Monthly. Find more ultrasound review articles at www.epmonthly.com
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our dejected resident walks away from the patient’s bed to peek at the portable chest X-ray that was just taken. “I can’t believe I missed that airway!” she says. “I haven’t had that happen in years!” You reiterate how difficult the airway was, and you compliment her on changing her approach between attempts. “You know, Richard Branson once said, ‘Opportunities are like buses…there’s always another one coming’,” you say. “Why don’t you go see what the EMS call is all about?” Sure enough, the local flight crew is bringing in a 52-year-old male in respiratory distress. He is tachypneic and tachycardic and they are having a hard time getting a history from him. He was initially hypotensive, but his blood pressure has responded well to the liter of normal saline that they just infused. You have five minutes to get everything prepared. In gearing up for a potentially tricky resuscitation, your once dejected resident is now full of energy. She organizes the troops, assigns roles, double checks all of her airway equipment, and prepares the ultrasound machine. The patient arrives a few minutes later and requires intubation. Like a pro, your superstar senior slides an 8.0 mm endotracheal tube gently through the vocal cords. As the RT’s hook the patient up to capnography, your resident attempts to auscultate for
Summer 2011 // Emergency Physicians International
bilateral breath sounds. “Something’s not right here,” she says. “I can’t hear any breath sounds on the left. I can’t even hear his heart sounds on that side.” Before you can even open your mouth to make the suggestion, she reaches for the ultrasound probe and begins scanning the patient’s chest. With the phased array transducer, your resident takes a quick look at the patient’s heart in the parasternal long axis (above). She throws a quick smile your way, and says, “Looks like he’s going to need another procedure.” She obtains a few more views to confirm her findings and scurries off to grab the requisite supplies.
What do you see on the parasternal long axis view of the heart (above)? What procedure does this patient need? see page 30 for case conclusion
Alberto Machado, MD
OPINION
President of ALACED
Sharing the Burden of Diagnostic Error In Latin America, emergency physicians have become scapegoats, inordinately burdened with the weight of diagnostic errors which are often caused by systemic problems.
T
ime flies in emergency medicine. The moment that we make decisions, the state of the patient changes, directly influencing our prognosis. No other field has the gravity of dependence between decisions and time. Emergency physicians make decisions almost the entire time from the beginning of their shift until the end, many of which are influenced by external factors beyond their expertise. In the famous Argentine tango Cambalache there is a line that says, “You’re all the same whether you be a priest, a mattress, king of clubs, a cad, a tramp…” This sentiment, born out of Argentina’s “Decada Infame” can be felt in today’s globalized world, in which many companies confuse labor positions with performance roles which directly impact their products and results. But the workforce is not black and white. It is full of nuance and variation. A product manager of a screw factory manages and administers resources and processes to obtain a specific type of screw that meets the need of the company that will use them. This role is different from that of a customer service manager, which in turn is quite different from providing a service to someone with an acute pathological disease. The real problem comes when we put the focus, across the spectrum, on the end product. A properly-made screw is not the same as an emergency physician making a correct diagnosis, even though we may find similarities in work processes. So how does the EP make the correct diagnosis? The general method used by the EP begins with assessing the initial complaint of the patient, the signs and symptoms, history, examination, physical examination and results of additional tests (imaging, laboratory, etc...). Each of these items should be internalized and metabolized by the EP who then produces the final product that provides us the “early diagnosis”. If we interpret that the results of addi-
tional studies are correct, the final diagnosis will be 100% the responsibility of the emergency physician. At the biological level, when an enzyme acts on its substratum it obtains the product that produces that enzyme. In industry, if we put a certain amount of molten iron in a machine that produces screws, the end product will be as many screws as can be produced from the amount of iron that was put in. In emergency medicine the formula is: reason for visit + signs + symptoms + history + physical + examination + results of further studies x EP = correct diagnosis. Is it that simple? What if the diagnosis is wrong? Where does the responsibility lie? Currently, the fingers point directly at the emergency physician, whether rightly or no. “The EP misinterpreted the outcome of the additional studies,” they might say. Or “The EP did not request the proper test,” or “The EP did not conduct a thorough Q/A with the patient.” “The EP did not complete a physical examination.” “The EP underestimated the symptoms.” The question is, why does the blame for diagnostic error fall solely on the emergency physician? In my experience, it is because this is a simple way to maintain the status quo. That is to say, the organization can continue as usual as if nothing had happened, because it has already identified the person responsible for the error. And if errors continue to happen, by identifying the one person responsi-
//
The overload of patients in the ER, coupled with the shortage of resources, leaves the EP more exposed and isolated than you’d leave a sweeper on a football field.
ble, the organization remains intact, and those in positions of leadership are preserved and protected. In the face of this system, what is the basic responsibility of the EP? Without doubt, it is to be properly trained and knowledgeable. Having a proper training and foundation in their specialty, in addition to a substantial number of years in practice, are what solidifies the abilities of the EP and enables them to adequately cope with and serve patients in the emergency department. Perhaps more interesting is the question, “What is not the direct responsibility of EP?” Here is a partial list to think about: q Work hours q Time to eat and go to the bathroom q The number of doctors, nurses, administrators and technicians working alongside the EP. q The number of patients who you are attending to at the same time q The time you can devote to each patient q Having all the elements for appropriate care q The work environment, where we attend to patients Is it appropriate? q The permanent removal of violent patients and relatives Especially in Latin America, the overload of patients in the ER, coupled with the shortage of resources, leaves the EP more exposed and more isolated than you would leave a sweeper on a football field. Continually, organizations attribute diagnostic error as the fault of the EP, because it is easier and cheaper for everyone. Except, of course, for the emergency physicians picking up the pieces. Without going into the perceived quality, only taking into account the Donabedian 2 triad – “structure, processes and outcomes” – a negative result cannot be solely the responsibility of a single element (EP) but is more likely related to the structure and especially to a specific process. But to see that the problem is much deeper, and that the implication of seeing this would re-engineer processes, is something threatening to directors because it involves making changes and an increased workload, possibly showing mistakes in management that previously were hidden. Obviously, the EP is not a machine nor can he or she work as such, in the same way that diagnostic errors are not 100% the responsibility of physician error. Understanding this, physicians need to lobby for changes to be made in the processes so that the burden of diagnostic errors are shared among all responsible parties.
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in the field
kenya
Health Indicators at Emergency Levels
u Dr. Gedi Mohamed is director of the general hospital at Dagahaley refugee camp, near Dadaab in northeastern Kenya. He is the first Kenyan Somali doctor to work in the camp since Doctors Without Borders/ Médecins Sans Frontières (MSF) took over health care there, and he believes that the linguistic and cultural links he shares with his predominantly Somali patients make a huge difference to the success of his work.
I
n recent months, the hospital has come under increasing pressure as thousands of new refugees have continued to arrive from Somalia in need of medical care. Like the camps themselves—which were built to hold 90,000 people, but are now “home” to more than 350,000, not including those huddled in makeshift tents in the surrounding desert—the hospital is struggling to keep up with demand. Last week, MSF opened an extra 60-bed ward to accommodate all the sick and malnourished children. Here, Dr Gedi describes what brought him to Dadaab, and how MSF is coping with the current crisis: “I was born 130 kilometers [81 miles] north of Dadaab, in the town of Wajir. My family are Kenyan Somalis. My parents are just ordinary people, but my grandmother educated me, my cousin—who was a pharmacist in Nairobi—encouraged me to do medicine, and my brother paid all of my fees. With this support from my family, I went to Uganda, to Makerere, the oldest university in East Africa, where I studied medicine and surgery for five years. This was followed by a year at the hospital in Embu, in central Kenya, which I can honestly say was the hardest year of my life. But that’s what made me who I am, and it was good preparation for working in Dadaab. When I first came to work for MSF, in early 2010, I was the first Somali doctor in the hospital. In fact, at one point I was the only doctor in the hospital. Now we have eight. In that first year I was completely overwhelmed by the amount of work. At that time, MSF was just starting up its surgical program, and as I specialized in surgery, I decided to stay on. I’ve been director of Dagahaley hospital since September. Working in Dadaab is incredibly challenging. The environment is very harsh, and we work hard. We take just two days’ holiday a month. On the other hand, the result of what we do is visible, and every day you get to help someone. When I go to the market, people are constantly coming up to thank me and to say ‘I was your patient.’ That is the satisfaction that keeps us going. I can’t imagine I’ll ever achieve more in my career than what I’m doing here, in terms both of helping patients and the special relationship I have with them. Ninety-eight percent of the camp’s population comes from Somalia. As I’m a Somali speaker, patients can come and talk straight to me. If you have a translator, you lose so much that is important. But it’s about far more than simply having a language in common. I understand the culture, the religion, the environment they’re in. I can
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Summer 2011 // Emergency Physicians International
relate directly to them. If there are issues around giving care—if a patient is refusing treatment, for example—I can explain it from a religious perspective. Our shared culture makes it easier for me, and for the patients too. The challenges that the hospital faces are different for the two populations—the long-term refugees and the new arrivals. They both have different experiences and expectations and need to receive different health education messages. In Somalia, health care has been a victim of the civil war. The new arrivals have no experience of conventional medical care, so we have to explain very clearly what is going on. We have to convince people that certain critical conditions are treatable, and that, if they will just give us time, the patient doesn’t have to die. They have a very different perception of health compared to someone who has lived in the camp for 20 years. But our current challenge has less to do with perception than sheer numbers, as we try to deal with the thousands of new refugees who are arriving each month. Until recently, bed occupancy in the hospital was at about 80 percent, but now we are seeing occupancy rates of 110 percent. This is having a big impact on the quality of care provided, as staff who previously did a ward round for 20 patients are now doing ward rounds for twice that number. Last month there were 308 deliveries in the maternity ward – double what it was a year ago – and the numbers of sick and malnourished children are rising steeply. Right now we have 80 severely malnourished children with medical complications in the inpatient feeding center, and 782 children with malnutrition receiving outpatient care. We have just opened a temporary extension to the feeding center, with 60 beds, to accommodate the overspill from the wards, and have taken on more staff. Outside the hospital, in our five primary care health posts, extra staff have also been brought in, while a new health post opened in March to cater specifically to the needs of the new arrivals. I can say that health indicators are now at an emergency level.
MSF is a medical humanitarian organization that observes strict neutrality and impartiality in its operations. Its activities in Ivory Coast are funded exclusively by private donors, ensuring its complete independence. MSF is working in Abidjan, providing emergency medical assistance with the collaboration of the Ministry of Health in the Abobo Sud hospital. In the western part of the country, it is providing primary healthcare services and supports hospitals in Duékoué, Guiglo, and Bangolo.
DISASTER RELIEF
libya
Intensive Care in Zintan
u An MSF team has been working in the hospital of Zintan, a city in western Libya’s Nafusah Mountain region, since April 30. Pro-regime forces have been fighting anti-government rebels in this strategically important area for several weeks now, driving what some estimates say are more than 40,000 Libyans to seek refuge in Tunisia. In Zintan, the MSF team has been donating medical equipment and material, providing training to the medical staff, and supporting the hospital’s Intensive Care Unit. MSF’s intensive care doctor, Dr. Morten Rostrup, explains: What is MSF doing in Zintan at the moment? MSF’s medical team is currently supporting the hospital with personnel (an MSF emergency coordinator nurse and an MSF intensive care doctor), medical equipment, and medicines. The team has been training the medical personnel and taking part in the organization of the mass casualty response of the hospital. Since the beginning of May, around 100 war-wounded have been admitted in the hospital following clashes between pro-regime troops and the insurgency. Casualties from both camps are treated in the hospital. An experienced trauma/war surgeon and an operating theater and intensive care unit nurse will reinforce the team in coming days. The surgeon will be in charge of the emergency response, in addition to the supervision of the medical personnel, and will take part in the clinical work, the referral, and the triage of patients, while the nurse will be in charge of the emergency room and will assist in the clinical work in the operating theater and the intensive care unit.
What type of wounds do you see as a result of conflict? Most patients have gunshot wounds and some are suffering from exposure to explosions with shrapnel wounds. We have had numerous abdominal traumas, some of them severe with internal bleedings and perforations of the intestines. We have also had some chest injuries due to gunshots, head injuries, and numerous fractures due to bullets.
Are the medical facilities able to cope? The medical personnel has been able to cope, but there is a need for more specialists. For the past two weeks, we have been working with the hospital staff in order to improve the response to mass casualties. We are currently reorganizing the Intensive Care Unit in order to better cope with the influx of patients. The arrival of the trauma/war surgeon will reinforce the system we have put in place.
What is the current situation in the city and surrounding areas? The situation is calm now, but shelling has been ongoing in Zintan. Many families have fled to Tunisia over the past couple of weeks, while some have recently started coming back. Still, some people continue to seek refuge in caves in the city due to shelling. There is general lack of food diversity, most of the shops are closed, but there is water and electricity. We have not yet been able to do any assessment outside the city, but we are concerned about the lack of access to health care in neighboring cities.
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INTERVIEW
EM Comes of Age in Slovenia With international conferences and newly-trained specialists, Slovenia’s fledgling EM society looks to take its place as an EM leader in central Europe. inverview By Matej Marinsek, MD
The Slovenian Society for Emergency Medicine (SSEM) was founded in 1995. With the execution of the 18th International Symposium on Emergency Medicine in Slovenia (June 15-18; Portoroz, Slovenia) and with the arrival of the first fully trained specialists in emergency medicine later this year, we can say that the Slovenian emergency medicine system is coming of age. On the eve of the symposium, Emergency Physicians International talked to Prof. Stefek Grmec, MD, PhD, a distinguished member of the SSEM.
EPI: ����������������������������������������������� The arrival of the first fully trained specialists in EM by the end of this year is very exciting news. How do you regard the execution of the residency program training? Prof Grmec: Overall, I think it was correct. With a start of a new specialty, there is, of course, a problem with finding appropriate trainers from other specialties. You know, the ones who understand the importance of the first minutes’ skills regarding their particular specialties. Once we found and attracted them, I think we were quite successful in getting the best of them “downstairs”. One thing I’m especially proud of is the integration of the emergency ultrasound training; we were both lucky and stubborn enough to become a part of the WINFOCUS family. Ultrasound courses are regular and the number of instructor candidates is high. The remaining goal of the residency training program is learning from teaching experiences abroad.
IN THE MIDDLE OF IT ALL: Slovenia lies in the middle of four major European geographic regions: the Alps, the Dinarides, the Pannonian Plain and the Mediterranean.
The recent decision of the EU to financially boost the construction of the regional emergency departments in Slovenia comes as a firm obligation for the Ministry of Health to direct the money appropriately and also speed up the whole process.
EPI: What do you expect from the first fully
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Prof Grmec: The first thing is staffing the emergency departments, and a firm engagement with the training process of the new generations of EM residents. Gradually, the selection of candidates with “teaching potential” should become a priority. EPI: How do you estimate the current position of emergency medicine as a specialty in Slovenia? Prof Grmec: It’s beginning to look healthier. EM has fought its way into the inner circle of basic specialties in Slovenia. The Ministry of Health, as well as hospitals, appreciate the benefits of having appropriately trained physicians. The number of residency program applicants regularly exceeds the available posts which is good for the selection of the best candidates.
EPI: How long have you been involved with the Slovenian Society for Emergency Medicine (SSEM)? What is your current position? Prof Grmec: I’ve been a member of SSEM for the last 12 years. For the past several years I’ve been in charge of the scientific research within the society. Regarding the 18th Symposium, I’m a member of the scientific committee. I am also the principal contributor to the core curriculum of the emergency medicine residency program in Slovenia.
trained emergency physicians?
Summer 2011 // Emergency Physicians International
EPI: The last two decades saw mainly the development of pre-hospital emergency medicine in Slovenia. What was (is?) the main obstacle in promoting faster development of the hospital-based emergency medicine system? Prof Grmec: I believe the summit of the pre-hospital emergency medicine system has already been reached. At a certain point it was probably necessary to start developing the whole system through a firm engagement with the primary care physicians. The problem now is that money is still canalized through the same pipeline and the receiving part of this flow, the pre-hospital system, has difficulties in understanding the necessity of redirecting the money to the hospitals where EDs are currently under the process of (re)construction. The whole thing is taking longer than we expected. Anyway, the recent decision of the EU to financially boost the construction of the regional emergency departments in Slovenia comes as a firm obligation for the Ministry of Health to direct the money appropriately and also speed up the whole process. EPI: Which one issue you would like to change as fast as possible? Prof Grmec: Internationalism of our residency program. EPI: Any final words? Prof Grmec: Despite problems with slow reorientation of the emergency medicine system from pre-hospital to hospital-based, the research in the field, especially in resuscitation, has always been strong. Last year, for example, we had a very successful “Resuscitation Summit on the Future of CPR” with cutting edge researchers from all over the world in Maribor. We are committed to keep up with the pace of the field.
source Firsthand reports of specialty development around the globe
dispatches 14 Botswana 16 South korea 18 india 20
The Seoul financial district in the Republic of Korea South Korea report on page 18
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SOURCE // DISPATCHES READER-SUBMITTED UPDATES FROM WEST TO EAST
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Q. What is the greatest challenge emergency medicine faces in your country? _______________________
1 UNITED STATES “Health care reform. Lack of insurance for many patients. ---------“Providing a wide variety of services that have nothing to do with emergency medicine.” ---------“Overcrowding, cost, aging population, too few physicians.” _______________________
2 COLOMBIA “In Colombia this is a new specialty with less than 200 EPs (including residents) working in the 3 most important cities. The most challenging
14
issue is the recognition of the administrators and directors of the importance of EPs.” ---------“Cultural things like political corruption, lack of financial support, hierarchies in organizations with power and games of power between specialties”
(70% of the time).”
_______________________
_______________________
3 BRAZIL “This is a Level III Public Hospital (Level I trauma), belonging to the University of Antioquia, with four critical care beds, almost 30 beds for observation, and 500 beds for hospitalization. There are 24-hour cath lab, intermediate care, ICU, and renal transplantation services. There are days in which the service is overcrowded
Summer 2011 // Emergency Physicians International
_______________________
4 PARAGUAY “We lack a formal speciality and we need more residencies.”
5 SWEDEN “Lack of interest and understanding for emergency medicine among doctors from other specialties.” ---------“The big question in Sweden this year is if we will get the basic specialty of EM. It is the first time in five years that the question is revisited by the legal bodies.”
_______________________
6 UNITED KINGDOM “Emergency airway still done by anaesthetics trainees. Limitation in terms of sedation (not using propofol, etc...). Space in the resus room. Number of staff (not enough EPs and ENs). Too much service prevision, not enough training” _______________________
7 SPAIN “The challenge is to have emergency medicine progress enough that it has a chance, like other specialities, without having to go out of our country.”
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“
The greatest challenges are government interference with the payment system, lack of data collection for QI and research, and the lack of EMRs for emergency departments” TURKEY 18 19 20 21
sub-specialty care (ie: neurosurgery) and there is currently no available residency training in Liberia. There is an on-going lack of all resources, from imaging to medications to laboratory support.”
for QI and research purposes. No EMRs for emergency departments.” ---------“Overcrowding, staff shortage, lack of primary care, lack of health insurance.”
_______________________
_______________________
except if they are totally idealistic. Lack of funding precludes opening sufficient residency slots so that we can advance towards 24/7 coverage by EPs.” _______________________
11 GHANA “It is a new discipline in Ghana so there is the difficulty with the basic principle. There is the problem of seeing patients first and then calling on other specialties to take over the management of the patient. Also, patients remain in the emergency area for several days waiting for space on the main wards.” _______________________
12 _______________________
8 FRANCE “Recognition of a 4-year sub-specialty in France.” _______________________
9 NETHERLANDS “Convincing other specialties we bring a more structural and developed approach to EM.” _______________________
10 LIBERIA “The greatest operational challenge is the lack of experienced clinical attendings to teach at the bedside of the teaching hospitals and at the Medical School. The greatest clinical challenge is the absence of specialty physicians for cases that require
ITALY “Building a bigger ED in Florence.” ---------“The greatest operational or clinical challenge faced by emergency medicine in Italy are overcrowding and a shortage of money. Also, there is a decreasing number of emergency physicians.” _______________________
13 BULGARIA “Emergency medicine should be a specialty with the same authority as the rest of the specialties in our country. We must create our own rules, using world experience.” _______________________
14 TURKEY “Government interference with payment system. Lack of data collection
15 YEMEN “Lack of will of the local people to improve the situation.” _______________________
16 BAHRAIN “Salmaniya Medical Complex is the only public hospital with an international standard. The training structure is such that most senior physicians are from different specialties who had certification and training from UK and Ireland. There is still not support for EM as a specialty although residency training in EM was established for Arab Board of Medical Specialty by American and Canadian Board certified physicians in EM from Bahrain, Saudi Arabia and Qatar in 2000. Many of our doctors are now board certified physicians who are struggling together for better rights. Another challenge that we are facing is the waiting time which is more than 1 year for the fellowship training in countries where EM is well recognised.” _______________________
17 ISRAEL “Israel has EM as a specialty. However, work conditions and pay scales cause difficulty in attracting high-quality young physicians,
18 THAILAND “Organization and support.” _______________________
19 SOUTH KOREA “The most serious problem may be the burden of work. Residents work 24 hours on and 24 hours off for four years. After finishing the residency, those who work in a university hospital have to work from 8:00 am to 6:00 pm (from Monday to Friday), and we take turns, 24hrs/day, during the weekend and holidays. Crowding is also a concern. Our hospital is the largest one in Korea (2,700 beds). There are more than 300 visits/day to ER and lack of inpatient rooms for patients.” _______________________
20 NEW ZEALAND “Brain drain; the New Zealanders leave to practice in Australia or the UK where the pay is better.” _______________________
21 GUAM “Lack of physician oversight within the hospital. Non-insured from outer islands.”
source
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A medical officer writes on the patient tracking board which was introduced by University of Botswana faculty. Prior to this system, no patient tracking system existed in the department.
emergency medicine residency to-do list
Botswana
A new EM residency gives a foretaste of positive developments in the sub-Saharan nation by Andrew Kestler, MD
I
n January 2011, Botswana became the 4th Sub-Saharan African country (following South Africa, Ghana, and Tanzania) to offer emergency medicine post-graduate training. Four new residents, all Batswana (citizens of Botswana), began their training at Princess Marina Hospital, the main government referral hospital in the capital, Gaborone. Since last year, another emergency physician has joined our staff at the University of Botswana (UB), swelling our emergency medicine ranks to 3 (2 from the US, 1 from Australia). Although we are stretched thin between clinical, didactic, and administrative commitments, our staff-to-resident ratio still manages to make our South African colleagues envious. The rest of the medical school continues to grow, having expanded from a staff of 5 to 40 in just two years. The second intake into the undergraduate medical program (MBBS) occurred in August 2010 with 48 students, up from 36 the previous year. On the post-graduate side, anesthesia, family medicine, and public health launched programs in 2011, following internal medicine and pediatrics. Surgery and obstetrics & gynecology are scheduled to
16
come online in 2012 or 2013. With some luck, we will move from our temporary warehouse into the new School of Medicine building in August this year. The University Hospital under construction is slated to open in 2013. The UB Emergency Medicine Residency is a 4-year Masters of Medicine (M Med) program. The rotations include about 2.5 years of emergency department time, and 1.5 years of off-service rotations, including medicine, pediatrics, anesthesia, and critical care. Thirdyear residents will spend approximately six months abroad for exposure to high-tech emergency departments and intensive care units. Based on discussions in progress, the time abroad is most likely to be in Australia or South Africa. We have partnered with the College of Emergency Medicine of South Africa to enable our residents to sit their Part 1 and Part 2 examinations necessary for emergency medicine specialist certification. Botswana is a vast but sparsely populated country of 2 million people, and it is unlikely that we will ever have to train more than six residents per year. Given the low volume of emergencies in most rural facilities, we project that our graduates will initially work clinically
Summer 2011 // Emergency Physicians International
----------------------Launch emergency ultrasound curriculum ----------Become accredited as a resuscitation training center for our own residents and others ----------Interview for our second class of residents ----------Prepare our residents for the Part 1 examination ----------Arrange for offservice rotations
in the urban centers of Gabarone and Francistown, and in the larger district hospitals of Maun and Mahalapye. In smaller facilities, we expect our graduates to play an important role as medical directors and emergency care trainers for the generalist medical officers. Needless to say we have plenty to do over the coming year related to the residency: 1) Launch our emergency ultrasound curriculum; 2) become accredited as a resuscitation training center for our own residents and others; 3) interview for our second class of residents; 4) prepare our residents for the Part 1 examination; 5) arrange for off-service rotations; and much, much more. Beyond the residency, we are in the final stages of getting a multi-disciplinary trauma research centre off the ground and finalizing the emergency medicine curriculum for 3rd-year medical students. We are also advising the Ministry of Health on the development of a pre-hospital care and emergency care policy, and are occasionally called to give input on disaster management issues. For example, we’ve been asked to advise on how to screen the Batswana returning from Japan for radioactivity exposure. Clinically, the Princess Marina Hospital serves a population which by Western standards would be considered unusually young and sick. Trauma and AIDS complications largely affect those between the ages of 20 of 50. We admit between 30%-50% of our patients, of whom at least 1 to 2 per day are suffering from septic shock. To add to the challenge, laboratory results are not available in real time, the CT is often down, and we sometimes run out of IV fluid and other basic medications and supplies. Botswana remains blissfully safe and stable, and the economy is rebounding as the global demand for diamonds picks up again. When not at work, there is much do: the closest game reserves are only 30 minutes away, and many others are within a three hours radius. Interested in working in Botswana? We have three full-time positions to fill, and we welcome residents and attending physicians who want to visit. Our recommended minimum stay is six weeks for those who want to share in the clinical work. Please write: Andrew.kestler@mopipi.ub.bw.
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source
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In the Republic of Korea, there are 7.1 hospital beds and 1.6 physicians per 1,000 people. Life expectancy at birth is about 78 years.
south Korea
A strong national EM organization looks outward while honing standards and addressing shortfalls at home. by Sam Beom Lee, MD
T
here are now over 100 emergency medical centers and emergency medicine residency programs in Korea. All university hospitals, and most regional and local emergency medical centers, have their own residency programs. Residents are required to undergo four years of residency training before taking the national board examination, which includes a written and case-slide exam. Emergency medical systems in Korea are divided and classified by their size, facilities, and functions. There are several levels of administration, from a national to more regional scope. The National Emergency Medical Center (NEMC) (www.nemc.or.kr) was established in 2001 and performs in accordance with duties assigned by the Minister for Health, Welfare and Family Affairs. The NEMC is responsible for coordinating regional EM centers,
18
supporting medical care in case of accidents and natural disasters, training EM technicians and related staff, developing policy, evaluating and supporting EM facilities, and ultimately improving the quality of EM services. Next in the organizational chain are approximately 16 Regional Emergency Medical Centers (REMC). One REMC could be appointed to each metropolitan city or province. Such an appointment would take into consideration the distribution of medical infrastructure, demographics, and population density. The REMC treats emergency patients, supports EM services in disasters, educates and trains regional EM staff, and coordinates any special tasks delegated by the Minister of Health and Welfare. Finally, at the community level there are Local Emergency Medical Centers (LEMCs). LEMCs operate within general hospitals to provide care for serious emergency cases.
Summer 2011 // Emergency Physicians International
upcoming events
A joint conference with the American Academy of Emergency Medicine (AAEM), the PanPacific Emergency Medicine Congress (PEMC) will be held in October 2012 in Seoul, Korea. www.pemc2012.org
The Governor or the Mayor may establish an LEMC according to the Act 30 of the Emergency Medical Service Law. In metropolitan and major cities there may be one center per 1 million people; in provinces, one center per 0.5 million people. There are 109 designated and operating LEMCs nationally. LEMCs are always on standby with staff on duty equipped to care for emergency patients. LEMCs provide more than one specialist in charge of internal medicine, surgery, pediatrics, obstetrics and gynecology, and anesthesiology. Mayors and magistrates may designate Local Emergency Medical Facilities (LEMF) among hospitals or clinics as well. As of 2009, approximately 325 LEMFs were designated and operated nationally to treat non-serious emergency patients. The Minister for Health, Welfare and Family Affairs also assigns Specialized Care Centers among general hospitals, with the approval of governors and mayors, for patients with trauma, burns, or poisoning. Speed and appropriate EM services are critical factors in a patientâ&#x20AC;&#x2122;s ultimate outcome. The Emergency Medical Information Center (EMIC) has been separated from the emergency rescue service, which is reached by calling 1-1-9. Calling the EMIC at 1-3-3-9 provides real-time information, including hospital information. This takes some of the burden off of 1-1-9 rescue by assisting EMS to treat patients quickly, collecting real-time information on hospital settings, and giving patients information to choose an appropriate hospital (see figure 1). The Korea Times reported recently that more than 13,000 foreigners have called EMIC in Seoul since the systemâ&#x20AC;&#x2122;s inception in May 2008. The foreign callers, the majority of whom were English speakers, mostly inquired about which hospitals were available to foreign nationals. Medical consultations and first aid inquiries accounted for 11% and 2.4% of calls, respectively, from foreigners. The EMIC in Seoul currently provides information in English, Japanese, and Chinese, with plans to expand services to Vietnamese and Mongolian speakers in August 2011. (www.koreatimes.co.kr) Growth Pains So far the most visible difficulties in Korean
The most visible difficulties in EM stem from ED overcrowding, owing largely to long inpatient stays and insufficient numbers of ED nurses and doctors. There are not enough beds to accommodate the rapid rate of admissions of both acute and non-emergency patients. These problems will probably need to be addressed by strengthening the function of local medical clinics and by adopting an ED triage system to collect the true emergency patients, shortening the inpatient stays to ensure that there are enough beds for those with the greatest needs. figure 1. The EMIC call system augments the emergency 1-1-9 system by gathering and disseminating critical real-time data.
Pre-hospital Care
Hospital Care
branches of the Korean Society of EM
call 1-3-3-9 on scene first responder
EMS Request
EMS Facility B
Inter-facility ambulance
Ambulance Dispatch
1-3-3-9 EMIC
EMS Facility A EM Specialist Hospital treatment Medical direction
On scene treatment EMT
Transportation patient information provide on-themove treatment
EM the Korea stem from ED overcrowding, owing largely to long inpatient stays and insufficient numbers of ED nurses and doctors. There are many patients in large regional and local emergency medical centers in Korea and not enough beds to accommodate the rapid rate of admissionsâ&#x20AC;&#x201D; of both acute and non-emergency patients. These problems will probably need to be addressed by modifying the medical delivery systems in Korea, by strengthening the function of local medical clinics, and by adopting an ED triage system to collect the true emergency patients, shortening
the inpatient stays to ensure that there are enough beds for those with the greatest needs. As the EM specialty continues to develop, much work remains to establish and train clinicians in the additional subspecialties including, but not limited to, resuscitation, toxicology, traumatology, critical care medicine, disaster medicine, EMSS, emergency airway management, emergency imaging, trauma/injury epidemiology and prevention, simulation-based medical education, and medical informatics.
Conclusion Continuing efforts are underway to increase the international reach and exposure of the Korean Society of Emergency Medicine. Establishing Korean EMSS, more regional trauma and critical care centers, and introducing new ED systems in hospitals are required to improve ED management in Korea. There are now plans to introduce the OSCE (Emergency Skill Examination) to the national board examination of EM in the future, which was already added to the Korean Doctor License Examination in 2009.
Samnam Yeongnam Daegyeong Chungcheong -------Several branch societies are divided by research projects, including: The Korean Emergency Airway Management Society, Korea Emergency Procedures Research Society, Korean Society of Emergency Imaging Study Group, and the EMS Forum. -------Other associated societies are: Korean resuscitation society, Traumatology society, Clinical toxicology society, and medical simulation in healthcare
www.epinternational.ning.com
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Students from the All India Institute of Medical Sciences (AIIMS) educate residents of Delhi about mosquito-borne illnesses. India Today has consistently ranked AIIMS as India’s top medical college.
in the splash of color and indulged in banquets with the best Ahmadabad had to offer. A visit to the Ashram where Mahatma Gandhi planned the nonviolent movement that brought India independence, and shopping for Gujarat’s fabled patola or bandhej (tie and dye) fabrics completed the cultural experience. All in all, INTEM 2010 was another educational, social and cultural success for SEMI and its mission to advance emergency medicine in India. Planning is now underway for the 13th annual INTEM to be held in November 2011.
Ambulance right of way
india
The recent INTEM conference in Ahmadabad showcased EM perspectives from the Indian subcontinent by Bob Suter, MD
A
mazing India was in full display at the 12th International Emergency Medicine (INTEM) Conference of Society for Emergency Medicine in India (SEMI) meeting, held last fall in Ahmadabad, in the state of Gujarat. The five-day conference and pre-conference workshops, which drew over 400 delegates, was organized for SEMI by the Lifeline Foundation, best known for pioneering the implementation of the unified emergency telephone number (“1-0-8”; see sidebar) in each Indian state as well as the development of EMSIndia, the first publication in India dedicated to EMS. The theme of the meeting was “Advancing Emergency Medicine in South Asia” and so Gujarat, which in 2007 became the first state to have an EMS Act, creating a statewide EMS system, and Ahmadabad , which has started a MD in EM, was an appropriate venue. EM in India has arguably seen more changes in the last year and a half than it has seen in the last 12 years. Bringing together 70 top
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tier speakers from the U.K., U.S., Australia, Singapore, and others, INTEM 2010 really showcased recent lessons learnt in India. With the South Asia focus, the conference was also an opportunity for India, Sri Lanka, Bangladesh, Nepal and Bhutan to learn and gain from all that is happenings around them. Of significance, this was probably the first INTEM conference where the Indian subcontinent’s perspective on emergency medicine was featured, rather than merely replicating Western ideas. The program focused on a few key statistics: 639,455 Indians die annually of cardiac emergencies (2006, WHO), 142,309 lives are claimed in road accidents (2008), 21 million children under five die due to lack of treatment (State of World’s Children 2008) and 24,775 Indians lose their lives due to various forms of animal, insect, and reptile bites (NCRB reports, 2001). In addition to the high quality conference sessions, attendees enjoyed the Garba, Gujarat’s traditional folk dance and participated
Summer 2011 // Emergency Physicians International
Ambulances in Delhi continue to get stuck in traffic, even when carrying emergency patients. That could begin to change, however, with a new state policy – and police focus – on catching offenders. Drivers who do not pull to the extreme left of the road when emergency vehicles are approaching will be fined Rs 100.
source: EMS INDIA
India Works to Establish National Emergency Call Number
I
ndia has kicked off the process of establishing a single national emergency call number, like 9-1-1 in the USA, 0-0-0 in Australia and 1-1-2 in the European Union. Basic services like police, medical emergency, fire, airline and rail enquiry‚ even municipal helplines‚ are being planned to be made available through the number. The actual number has yet to be determined. The single number is aimed to provide citizens direct access to counselling helplines and government departments such as education, health, transport, municipality and public distribution. According to media reports‚ a pilot project in five states – Orissa, Tamil Nadu, Assam, Rajasthan and Madhya Pradesh – has been rolled out. The five departments each are connected to a single state number. Based on the results of the pilot, a blueprint for connecting all departments across India through a national number will be prepared. The pilot project will be completed by December 31, 2011. The need for a single emergency number is based on the fact that more often than not, municipal and critical health helplines in hospitals are found unattended and not everyone can access the internet for critical service numbers. According to EMS expert Ravi Krishna, Director of “Dial 1298 for Ambulance,” though the concept is good, it is imperative for the government to keep non-emergency control rooms separate, lest they block critical calls. In the United States, the emergency service operates on the N11 mode, where N stands for any number between two and nine. -EMS India
Who Helps the Injured When There’s No Prehospital Care? A randomized survey from a level I trauma center in Mumbai There is extremely limited EMS service in Mumbai. The typical trauma patient is male, latetwenties, and poorer. Prehospital care is associated most with:
ODDS RATIO*
Government ambulance transport
10.83
Traffic Injuries
2.3
And least associated with: Arriving at a trauma center by taxi
0.54
Railway accident victims
0.41
REFERENCE: Roy N, Murlidhar V, Chowdhury R, et al. When there are no emergency medical services-prehospital care for the injured in Mumbai, India. Prehosp Disaster Med. 2010;25:145-151.
*n=170 People with injuries are usually assisted by: Police
89.7%
Good Samaritan
43.5%
Taxi
39.3%
International Emergency Department Leadership Institute 24-28 October, 2011 Boston, Massachusetts, USA As the number of interdisciplinary emergency departments grows internationally, where can ED leaders acquire the administrative skills they need to build and sustain successful emergency departments?
LOGO
The International Emergency Department Leadership Institute (IEDLI) was created by Harvard Medical School faculty and other international experts in order to provide ED leaders with the skills and knowledge they need to successfully operate emergency departments in any part of the world. In this one-week course of over 35 hours of interactive lectures and workshops, leaders will explore strategies to: • Establish the ED’s role within the hospital • Improve efficiency and control costs • Decrease overcrowding • Develop quality improvement programs • Educate and motivate ED doctors and nurses • Develop an emergency medicine training program • Form a strong administrative structure This program is designed for doctors, nurses and administrators.
Early registration discounts end July 1! www.IEDLI.org Advanced Program for IEDLI alumni 26-28 October, 2011 The International Emergency Department Leadership Institute is a collaboration between Harvard Medical Faculty Physicians at BIDMC and Brigham and Women’s Hospital. 21 www.epinternational.ning.com
The Third biennial
Emergency Medicine In the Developing World Conference
Isixeko Sasekapa, uMzantsi Afrika
Cape Town, South Africa 15 to 17 November 2011
Molweni basebenzi becandelo lenkonzo ezingxamisekileyo
Greetings Emergency Medicine Workers
Join us in the Mother City for a truly African conference experience Scientific content Paediatrics to Psychiatry, Toxicology to Trauma Pre-conference workshops: 14 November 2011 Cardiology, Ultrasound, Airway, Nursing, Disaster and Paediatrics Venue Cape Town International Convention Centre Call for Abstracts Abstracts may now be submitted through the website www.emssa2011.co.za. Abstract submission will close on 1 September 2011.
Visit us on www.emssa2011.co.za for more details
R Report: Hong Kong
Education at a Crossroads In Hong Kong’s only undergraduate emergency medicine training ground, instructors struggle to recruit within an exam-based culture. by Abraham Wai, MD
W
hen the International Federation of Emergency Medicine (IFEM) published its first undergraduate emergency medicine syllabus in 2009, it established the framework on how emergency medicine contributes to medical school education. In Hong Kong, the only medical school with an academic emergency department is the Chinese University of Hong Kong (CUHK), which is housed in the Prince of Wales Hospital, a 1400-bed teaching hospital. Emergency medicine teaching is delivered in different settings, including an acute medicine course for final year medical students, in conjunction with staff from the intensive care unit, and an emergency medicine clerkship in the emergency department. Our medical school implemented a new curriculum 10 years ago, in line with the goals of Tomorrow’s Doctor, a series of medical education guidelines created by the UK General Medical Council in 1993. The amount of fact-heavy teaching was significantly reduced and Selected Study Modules – which allow students to develop their own topical interest through small-group teaching (4-6 students) – was introduced. Emergency medicine topics, such as chest pain and major trauma, have
been popular among students over the years. However, after 10 years the curriculum is as fact-heavy as the previous one because the sheer amount of material and skills that students need to learn before their graduation have increased tremendously with the advancement of medical care in Hong Kong and the expansion of medical knowledge globally. As a relatively new clerkship (although 15 years old already), the heavy workload of medical students has been considered. There is a general belief among the academic staff in Hong Kong medical schools that students learn only the topics that would be examined in their final examination. In response to such attitudes, examination questions become an important tool to drive students to learn extensively in every clerkship. In Hong Kong there is a tendency for different specialties to use their own postgraduate examination questions for medical students. Obviously this becomes a vicious cycle that students read selectively to pass their assessments because the syllabus is huge and teachers set a wider curriculum to push students to read extensively. Emergency medicine essentially overlaps with most of the specialties in terms of knowledge. To avoid overloading our medical students,
h Busy emergency departments (top) have been identified as a barrier to quality teaching in emergency medicine. The author (second from left) meets students from different years to hear their concerns and share his own experiences.
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R Hong Kong
a symptom-based curriculum has been implemented in the emergency medicine clerkship. Students are exposed to patients with an undifferentiated spectrum of conditions so that they can integrate what they have learnt in other clerkships with a small number of didactic tutorials on specialised topics such as toxicology and trauma resuscitation. However, in view of test-focused learning attitudes, if students are not assessed appropriately they may lose their motivation to see patients and to learn. Or they will be overloaded because they are going to sit for extra assessment. Studentsâ&#x20AC;&#x2122; perceptions on the quality and quantity of emergency medicine teaching during their undergraduate study is very important because this is probably their only opportunity to learn about our specialty and we are in the position to attract quality graduates to join us. Insufficient direct teaching may be regarded as a lack of training opportunities in emergency medicine, leading to a potential loss of trainees. As we all know, emergency departments are overcrowded globally and our patients are valuable learning resources for our students. However, students need our guidance to effectively learn in our unique environment and we should develop strategies to ensure and maximise student participation during the clerkship. It is a great challenge to strike a reasonable balance between teaching (both undergraduate and postgraduate) and patient care, especially when the comparatively low medical staffing levels in Hong Kong are taken into consideration. Looking into the future, to provide quality undergraduate teaching we have to expand the size of the teaching team, in order to avoid any sacrifice on service. This year to meet our teaching objectives we introduced an informal written scenario-based quiz, in addition to a logbook, with coverage of all topics relevant to acute medicine, in line with the medical school final examination. Our students have had a very positive response to these initiatives.
jThe new clinical block of Prince of Wales Hospital, opened in October 2010, housed the emergency department of the Chinese University of Hong Kong. fTwo medical students studying prehospital medicine as a subspecialty of emergency medicine.
A&E service in Hong Kong
Actual for 2009/10
Estimate for 2010/11
Number of attendances
2,214,422
2,243,000
Number of attendances per 1,000 population
316
316
Number of first attendances for: Triage I
19,457
19,700
triage II
33,153
32,900
Triage III
621,006
632,800
Cost per A&E attendance: $800 (HKD) Charge rate per A&E attendance: $100 for HK residents; $500 for non-locals
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Summer 2011 // Emergency Physicians International
R Report Transatlantic
All or Nothing A Swedish emergency physician on an observership in New York City reflects on the differences in care between the two developed nations. by Patrik Soderberg, MD
T
hanks to the Swedish Society of Emergency Medicine (SWESEM) and EMED EX I had the opportunity to spend two weeks at SUNY Downstate and Kings County Hospital in Brooklyn, New York. I am one of the first specialists in emergency medicine in Sweden, where EM has been a supra speciality since 2006. I am the resident program director at Södersjukhuset, the largest emergency room in Scandinavia, which is in the process of starting up a residency program in emergency medicine. On visiting New York, I was first struck by the setting. I have been to New York City a couple of times before – even to Brooklyn in the 90s – but the taxi ride from Newark Airport to Flatbush in Brooklyn left me with mixed feelings. We drove over giant bridges, saw the Manhattan skyline, got lost in Brooklyn, had a malfunctioning GPS, and then I was finally dropped off at the residents halls at SUNY Downstate. All in all, it felt less like the world’s monetary center and more like, “Is it safe to go outside?” The few people I saw on the streets looked like gang members from some film. When I walked the neighborhood that first night, I walked quickly, found some fried chicken, and went straight back to my room. Phew! Later I realized the neighborhood was friendly but quite poor. I walked home in the middle of the night several times with no incident. The next day I met Mert, one of the attendings and a member of EMED EX. He managed to get me an ID, a small, very pink piece of paper that helped me to get passed the guards watching every entrance. This is quite different than in Sweden, where access to the hospital is free. You never need an ID to get in; everybody comes and goes, for better or worse. In Brooklyn, many men and women in uniforms stood at checkpoints all over the hospital. Most of the time they seemed unin-
h Kings County Hospital in Brooklyn, New York (top). f Dr. Patrik Soderberg
Opportunites for International Medical Students at the Kings County Emergency Department Fourth year medical students from international schools interested in the King’s County emergency medicine (EM) or EM/Internal Medicine Residency programs can apply to one of several elective rotations. The rotating student will work with the attending faculty as well as the current emergency medicine residents. Applicants must be in good academic standing at their parent school, must have their school’s approval to participate in the desired elective, and must have liability insurance coverage. for course descriptions of the rotations go to www.downstate.edu/emergency_medicine/fourthyear.html For more information, email visitstudent@downstate.edu
www.epinternational.ning.com
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R Transatlantic
terested in my badge, but now and then someone really stopped me to make sure that the pink piece of paper was valid. I had to wonder at the value. Was this a way to keep people employed? There were a lot of handshakes the first days. Everybody was very friendly and eager to help out. The United States is great in this aspect; people are largely easy going, talkative and open-minded. This came as a stark contrast to my visit to India a few years ago. On that trip, most doctors I met were very suspicious and not so keen on helping out. My two week visit went by fast. I attended meetings, lectures and spent some time at the ER. Patients are more or less the same in New York as they are in Sweden. Some diagnoses are more common here, but there are no major differences in how we treat the patients. The large difference is that in the United States, emergency physicians are responsible for everything that is happening in the emergency department. In Sweden, cardiologists are responsible for hearts, surgeons for surgery, and so on. The problem with this, of course, is that patients in the emergency department often don’t have a proper diagnosis when they present, or even after the workup, resulting in no speciality taking responsibility. It was also striking that in the United States an attending has to sign for every patient. I observed that the residents in the later years are very good at what they are doing. Much better than most of the doctors staffing my emergency department back home, and yet they are still not allowed to work independently. In Sweden it is common that doctors fresh out of medical school work alone in emergency departments. Of course, there is someone to call, but most patients are treated without consulting. Another thing I found interesting was the fear of malpractice, and the health insurance situation, which makes everything a little bit more complicated. A large portion of the population in the United States don’t have health insurance, and they are very reluctant to seek medical help because it is very expensive. I met a man who lost the distal part of a fingertip last winter in an accident. He went to the ER to get help. No operation, just some revision and wound dressing. The invoice was $8,000 dollars. An uninsured American friend asked me for advise regarding his heart. When I suggested he see a doctor and check his ECG, he said that it would be too expensive for him. He would rather wait and hope for the best. It would seem that in the United States, a lot of people don’t seek
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Summer 2011 // Emergency Physicians International
h An ambulance drives down a Brooklyn street near King’s County Hospital. f The Brooklyn Bridge, as seen from Manhattan.
medical help at all, or at least wait until the very last minute. On the other hand, those who seek medical help get every possible test and are signed off by a specialist to make sure that all the standards of medical care have been met. Right across the street from the hospital was a law office specializing in malpractice cases, further driving home that malpractice is something American doctors have to take into consideration every time they treat a patient. Back home I sometimes get tired of all patients seeking help for very insignificant problems. But at least I don’t have to send all of them through the CT or MRI scan and do an extensive work up. Medical care in Sweden is easy to access and cheap for the population. It’s true that we do provide a little less care – maybe sometimes too little. However, I think that some of the workup and follow up in New York is too much, at least when you consider the number of people who aren’t getting any medical care at all. For Swedish emergency medicine, I think the future looks bright. If we can get as skilled as the American specialists and practice in our environment without insurance companies, or fear of malpractice suits, I am confident we can bring the highest quality emergency care to our patients.
www.epinternational.ning.com
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ID In-Depth: HAITI
Beyond the Physical Addressing acute mental health needs in the disaster zone by Tyler Jorgensen, MD & Ian B.K. Martin, MD
“G
ive me a minute. Let’s wait to call the next patient.” I was trying to soak it all in, to take a mental snapshot. I was in Port-au-Prince, Haiti with a medical relief team in May 2010, four months after the earthquake. We had already seen dozens of patients that day in our make-shift clinic in a condemned school building, and we had many more to see. From the ceiling above fell a steady rain of paint chips that stuck to my sweatsoaked shirt and peppered the old school desk that served as my examination table. A 78-year-old blind man was walked out the door with antibiotics for a urinary tract infection, cellulitis, and tinea versicolor. He was arm-in-arm with his daughter, ready to make the trek back “home” to their tent city. A young woman had just limped into the clinic with a painful, roaring case of cellulitis on her thigh. She now sat on an old wooden bench getting intravenous (IV) antibiotics and fluids. At the far end of the room with another provider was a 12 year-old boy with untreated tetralogy of Fallot. He was essentially living his life in a constant “tet spell,” able to walk only short distances before having to squat to increase his venous return. His room air saturation hovered around 70 %, and his fingertips were blue. It was into this clinic that walked Marguerite, a 20-something young single female who had lost both of her parents in the earthquake. Her chief complaint of headache merited the appropriate clinical inspection. But when concerning etiologies of her symptoms were ruled out with a focused history and physical exam, there seemed to be a deep sadness and emotional withdrawal lingering just out of reach. “Would you like to talk to somebody a little bit more about the earthquake and everything you’ve been through?” An emphatic “Oui!” was her response. ***************** As an emergency medicine resident at the University of North Carolina-Chapel Hill, I was able to spend an elective rotation last spring in Haiti and to return to the region last fall during a vacation. I was one of several physicians on teams sent by a church-based, non-governmental organization (NGO). We ran medical clinics wherever we could—tent cities, orphanages, churches, old school buildings—and did what we could for all-comers. We treated infants, toddlers, young adults, pregnant mothers, and the elderly. We treated all the usual suspects—filariasis, malaria, dengue fever, parasitic enteritis, measles, otitis media, cellulitis, urinary tract infections, urethritis, cervicitis, fungal infections of all kinds, miliary tuberculosis, necrotic foot infections, myxedema, kidney stones, dehydration, malnutrition, and hypovolemic shock. We even saw a bowel perforation, a hip fracture, and a healthy smattering of minor and major trauma. As an emergency medicine resident, I loved the variety of acuity and pathology. But in all of our clinical settings, there was a significant cadre of patients whose acute care needs were psychological in nature. In all of our patient encounters, the earthquake was never far from anyone’s mind. The earthquake seemed to serve as the major time reference for most patients, the duration of a patient’s symptoms being often described as “since before the earthquake” or “ever since the earthquake”. Indeed, many patients we saw had mild somatic complaints, but after further questioning and examination seemed mostly just to be struggling with memories of the event, or adjusting to life in the aftermath. Again, our experience seemed similar to the 2004 tsunami, where Gupa-Sahir et al. found that 9.7% of their patients at a field hospital were presenting primarily for psychiatric illness1. Not only were our patients dealing with a large amount of post-traumatic stress,
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but our patients were struggling to live in a nightmarish reality. There were nursing mothers trying to raise their babies in 6x6-foot “tents” made of sticks and old bed sheets. There were children whose parents and siblings still lay somewhere beneath the rubble. There were young men and women, able-bodied, with no options for employment—left alone with their thoughts at night in the smoldering heat that gathered under their tarps. The psychopathology we encountered went well beyond patients being “just a bit shaken up.” We saw severe post-traumatic stress disorder (PTSD), anxiety disorder, major depressive disorder, bipolar disorder, and even previously undiagnosed psychosis. ***************** As we did our best in all settings to help patients cope, we employed different strategies at different sites. Following are three major observations that resulted: The first observation is that if you are planning a trip to a disaster area prior preparation is necessary to effectively address mental health emergencies. As emergency physicians, we are no strangers to caring for patients with mental health and behavioral emergencies, often without “backup.” In California, for instance, 51% of 243 emergency departments in a recent survey had no mental health specialist on-call2. Despite our experience, the care of the mental health patient in the disaster zone is likely to remain an uncomfortable proposition for the average emergency physician. So how can we better prepare to address the mental health needs of our patients? One way is to make sure your team composition includes personnel with expertise in the area. On our first team we had a minister-in-training with counseling experience. He was able to dedicate large amounts of time to one-on-one sessions with patients who seemed to be having a particularly rough go of it. On our second team served a physician who was trained in both psychiatry and family medicine. She served as an invaluable “consultant” within out clinic settings. We referred many patients to her. Not only did she spend lengthy one-on-one time with patients and their families, but she also provided coping-strategy sessions for groups of 6-10 Haitians at a time. An alternative, and perhaps more universally available, approach is for members
The psychopathology we encountered went well beyond patients being “just a bit shaken up.” We saw severe post-traumatic stress disorder (PTSD), anxiety disorder, major depressive disorder, bipolar disorder, and even previously undiagnosed psychosis.”
h Lines formed long before the daily clinics opened, and they got bigger each day. gAn orphan living in the rebuilt orphanage where the medical team held their clinic.
of the team to undergo training to prepare them for acute mental health conditions (e.g., depression, PTSD, etc.) they may encounter. While few disaster-relief medical teams will have actual mental health professionals on them, there is data from hurricanes Ike and Gustav to suggest that completion of a Psychological First Aid (PFA) course can give more confidence to team members who may be serving in a counseling role, particularly if they have no prior experience3. The second observation is that effective screening strategies likely lead to catching more patients with needs. We employed a broad spectrum of screening strategies in our clinical settings, with varying results. In our first clinic, we employed what I would call “hunch” screening. This is the traditional sort of screening, where a provider, after talking to a patient for a while, simply gets a “hunch” that there may be an acute mental health need that needs to be addressed. He can then refer the patient to dedicated personnel or change gears and further address the need himself. In subsequent clinics, we employed what could best be called a “universal” screening technique. All patients, while waiting to be seen, had to answer a four question questionnaire-- “Do you have desire to kill yourself or that you would die?” “Do you have panic attacks?” “Do you have flashbacks?” “Have you felt depressed for more than two weeks?” If a patient answered yes to any of these questions, he was triaged to see the psychiatrist on our team. When this strategy was employed, we saw a significant increase in the number of patients receiving mental health diagnoses and interventions. Yet another screening technique to consider is “promotional” screening. This would involve using radio broadcasts, paper fliers, or other forms of advertisement to announce to a community that mental health will be addressed at your clinic. While we did not employ this approach, we were told that patients would likely flock to our clinic due to the large unmet need within the country. (The emergency physician simply “dabbling” in mental health interventions out of necessity may not want to use a “promotional” screening strategy.) The final observation is that there are multiple therapeutic interventions that may be employed by the emergency physician for the patient with mental health needs. The first and easiest intervention is just letting patients talk about their experiences. In our clinics, there seemed to be great therapy in simply allowing our patients to talk for a while about their experience. For some patients, this was the first time they had the opportunity to verbalize their experiences, and their spirits seemed to lift a bit afterwards. Perhaps by being third parties, who did not actually live through the earthquake, we provided a neutral sounding board for their experiences they had not otherwise found. Another intervention that seemed effective, particularly of use in the post-disaster post-traumatic stress patient, was “eye movement desensitization and reprocessing,” or EMDR, training. This is an evidence-based and simple technique of selfrelaxation that can be taught in individual and group sessions4. After an EMDR training session, a patient can then teach this technique to other members of his
community. As with all interventions, cultural sensitivity is of utmost importance. Another mental health intervention is the use of medications. While most emergency physicians are wary of prescribing psychoactive medications, some consideration can be given to providing patients with a small supply of benzodiazepines or sleep aids to get through difficult nights. Choice of medications should be driven by local availability, provider preference, and cost—among other factors. Unfortunately, without long-term follow-up, it is hard to know if these interventions have all the desired effects we hope. Without a ready long-term supply of mental health resources, it becomes all the more important that our efforts work to rebuild families and communities. ************* I do not claim expertise in the area of disaster psychiatry, and I am not advocating that emergency physicians become experts in the field. But just as we come to the disaster zone prepared to care for major and minor trauma, infectious diseases, and dehydration, we should come prepared to encounter a significant amount of acute mental health needs. In reality, an emergency physician is far more likely than a mental health specialist to be in position in the disaster zone encountering patients with acute mental health needs. And while the services of fully-trained mental health specialists are invaluable, they are not likely to be universally available in the postdisaster period. As emergency physicians we pride ourselves on taking all-comers and doing what we can to help them. With this article I am simply suggesting that in our toolbox and on our packing list should be some resources to help our patients with acute mental health needs in the wake of disasters. (1) Guha-Sapir, Debarati, Willem Gijsbert Van Panhuis, Joel Lagoutte. Short communication: Patterns of chronic and acute diseases after natural disasters – a study from the International Committee of the Red Cross field hospital in Banda Aceh after the 2004 Indian Ocean tsunami. Tropical Medicine and International Health. 2007; 12: 1338-1341. (2) Menchine MD, Baraff LJ. On call physician specialist availability and higher level of care transfers in California emergency department. Acad Emerg Med. 2008; 15:329-36 (3) Allen B., Brymer M. J., Steinberg A. M., Vernberg E. M., Jacobs A., Speier A. H. and Pynoos R. S. 2010. Perceptions of psychological first aid among providers responding to Hurricanes (4) Gustav and Ike. Journal of Traumatic Stress, 23: 509–513. www.emdria.org. Eye Movement Desensitization and Reprocessing International Association
Special thanks to Dr. Jo Marturano, for her expertise, guidance, and most of all, her commitment to helping Haitians with mental health needs. www.epinternational.ning.com
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ABOUT THE AUTHORS
CLINICAL
Dx: Large Pleural Effusion continued from page 8continued from page 5
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 Teresa Wu is the EM Ultrasound Director and Co-Director for Simulation Based Training for the Maricopa Emergency Medicine Program in Phoenix, Arizona.
Y
our resident comes back into the room with a chest tube tray and Pleurovac in hand. On the parasternal long axis view of the heart you see a large collection of anechoic fluid near the heart. Because it is lying behind the descending aorta, you know that the fluid is in the patient’s lung and not around his heart (Figure 2). You help your resident prep the ultrasound machine so she can perform the procedure in a sterile fashion under dynamic ultrasound guidance. With your probe at T7 in the mid-axillary line, you and your resident visualize a large anechoic left pleural effusion above the diaphragm, cephalad to the spleen. You point out the hyperechoic visceral pleura floating in the pleural effusion so that your resident can avoid the lung parenchyma as she inserts the chest tube under ultrasound guidance (Figure 3). Your resident successfully drains a liter of pleural fluid from the patient’s thorax and his blood pressure begins to improve. You put in an order for a delayed second chest X-ray to evaluate for re-expansion pulmonary edema and you pat your resident on the back for a job well done. With her newfound confidence and the trusty ultrasound machine in tow, she heads out toward the chart rack to see what other opportunities lie ahead.
Figure 2: RV = Right Ventricle, LA = Left Atrium, Asc Aorta = Ascending Aorta, Ao = Descending Aorta
Editor’s Notes 1. Diagnostic ultrasound is 93% sensitive for pleural effusion (Lichenstein 2009) and sonographic evaluation of non-traumatic pleural effusions can change emergency physician treatment plans in 43% of cases (Tayal 2006) 2. Among other etiologies, pleural effusions can result from CHF, PE, ARDS, or pneumonia, and sonography can help distinguish each of these diagnoses (Volpicelli 2008, Copetti 2008) so don’t just focus on the effusion. 3. Ultrasound may someday play a role in timely out-of-hospital decision making by improving diagnostic accuracy (Lapostolle 2006). 4. Sonographic procedural guidance can enhance patient-safety in the hectic ED by reducing “wrong-sidedness” (Shapiro 2003) and by reducing iatrogenic pneumothorax (Feller-Kopman 2007) 5. Employing ultrasound in emergency practice can yield positive return-on-investment (i.e. become financially rewarding) within 5-years (Soremekun 2009).
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Figure 3: Lung parenchyma floating in a large pleural effusion
Summer 2011 // Emergency Physicians International
The IEM Fellowship Directory
global
The United States
IFEM Fellowship Regional Focus: Global Contact: Peter Cameron, MD 8peter.cameron@med.monash. edu.au
California
australia/ new zealand Australasian College of Emergency Medicine (ACEM) Regional Focus: Global, Australia, NZ & South Pacific Contact: Peter Cameron, MD 8peter.cameron@med.monash. edu.au and Gerard Oreilly 8oreillygerard@hotmail.com
canada University of Toronto / Canadian Association of Emergency Physicians (CAEP) Regional Focus: Global, Africa Contact: Valerie Krym 8v.krym@utoronto.ca
The netherlands The NVSHA (Dutch Society for Emergency Medicine) Contact Dr. Pieter van Driel 8vandrielpieter@hotmail.com Terry Mulligan, DO, MPH 8terrymulligan@yahoo.com Length: 1 to 2 years Number of positions: 1 or 2 Degrees: Subspecialty/Fellowship Status in Dutch EM System Deadline: Rolling. Currently open only to Dutch EPs ( +31 624 11 3566 : nvsha.nl
south africa South Africa: Univ. Cape Town / Stellenbosch Univ. / EM Society of South Africa (EMSSA) Regional Focus: Africa, South Africa Contact: Lee Wallis, MD 8leewallis@bvr.co.za
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Harbor-UCLA/IMC Global Health Fellowship Regional Focus: Iraq, Haiti and possibly others Contact: Ross I. Donaldson, MD, MPH, Harbor-UCLA Medical Center Department of EM 1000 West Carson Street, Box 21 Torrance, CA 90509 Length: 1-2 years Salary: Very Competitive Shifts: 5 per month Degree: MPH, DTMH available Positions: 1-2 Deadline: November 1 ( (310) 222-3500 8ross@rossdonaldson.com :www.emedharbor.edu/ Global.html :www.internationalmedicalcorps .org Keck School of Medicine at USC Regional Focus: Chile, Ghana, Mumbai, Thai-Myanmar border, British Guyana Contact: Billy Mallon, MD Department of EM 1200 North State Street Room 1011 Los Angeles, CA 90033 Fax: (323) 226-6454 Length: 1-2 years Salary: Competitive Shifts per week: 2 Degree: MPH, DTMH Positions: 1 Deadline: December 1 ( (323) 226-6667 8 wkmallon@yahoo.com : www.cbooth.info Loma Linda University Regional Focus: Vietnam, China, and Kenya Contact: Debbie Washke, MD Department of EM 11234 Anderson St,. RM A108 Loma Linda, CA 92354 Fax: (909) 558-0121 Length: 1-2 years Salary: About $80,000 Degree: MPH with 2-year program Positions: 1 Deadline: March 1 ( (909) 824-4344 8 dwashke@llu.edu
Summer 2011 // Emergency Physicians International
Stanford International Emergency Medicine Fellowship Contact: S.V. Mahadevan and Matthew Strehlow Stanford University 701 Welch Rd. Bldg C Palo Alto, CA 94304 Fax: 650 723-0121 Length: 1-2 years Positions: 1-2 Salary: Please contact Hours per week: approx. 15 Degree: MPH possible for 2 yr candidate Deadline: ACEP Scientific Assembly ( (650) 723-0063 8 jgalfin1@stanford.edu : emed.stanford.edu/fellowships/ international.html UCLA-CIM International Medicine Fellowship Contact: Nicole Durden, UCLA Medical Center Dept. of EM 924 Westwood Blvd., Ste 300 Los Angeles, CA 90024 Length: 1-2 years Salary: Competitive Shifts: 5 per month Degree: MPH, PhD Positions: 1 Deadline: October 15 ( (310) 794-3086 8ndurden@mednet.ucla.edu :http://cim.ucla.edu
Connecticut
Yale University School of Medicine Regional Focus: Africa Contact: Simon Kotlyar, MD Department of EM 464 Congress Ave, Suite 260 New Haven, CT 06519-1315 Fax: 203-785-4580 Length: 2 years Positions: 1 Salary: PGY level, MSc tuition, travel stipend, excellent benefits Shifts/hours per week: 0.5 FTE Degree: MS, London School of Hygiene and Tropical Medicine Deadline: December 1 ( (203) 785-4058 8simon.kotlyar@yale.edu :medicine.yale.edu/ emergencymed/fellowships/ global/index.aspx
Delaware
Christiana Care Health System Regional Focus: Africa Contact: Susan E. Thompson, DO Christiana Care Health Systems Dept. of EM Administration 4755 Ogletown-Stanton Road Newark, DE 19718 Length: 1 – 2 years Shifts: Between two and three 8- or 9-hour shifts/week Degree: MPH with 2-year program Deadline: November 15 ( (302) 733-3904 8susthompson@christianacare.org
District of Columbia
George Washington University Regional Focus: India, Malawi, Egypt, El Salvador, Ethiopia, Peru Contact: Kate Douglass, MD, MPH 2150 Pennsylvania Avenue, NW, 2B-417, Washington, DC 20037 Fax: (202) 741-2921 Length: 2 years (1 year possible under special circumstances) Salary: Highly competitive, MPH tuition and generous CME Degree: MPH Positions: 1-2 Deadline: November 15 ((202) 741-2954 8kdouglass@mfa.gwu.edu :www.gwemediem.com
florida
University of Florida College of Medicine - Jacksonville Contact: Elizabeth DeVos MD, MPH Department of EM 655 W 8th St Jacksonville, FL 32209 Deadline: Check with department ((904) 244-4405 8elizabeth.devos@jax.ufl.edu
Georgia
Emory University Contact: Scott Sasser, MD Department of EM 531 Asbury Circle - Annex Suite N - 340 Atlanta, GA 30322 Fax: 404-778-2630 Length: 2 years Positions: 1 Salary: Instructor
The IEM Fellowship Directory
Deadline: Check with department ((404) 778-5975 8ssasser@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, int’l travel funds Shifts per month: half-time EM clinical faculty position Degree: None Positions: 1 ( (706) 721-4412 8hgross@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 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 Positions: 1- 2 Deadline: Open ( (312) 942-4978 8 jamil_bayram@rush.edu Univ. of Illinois at Chicago Contact: Janet Lin, MD, MPH Department of EM, College of Medicine East Suite 469A 808 South Wood Street Chicago, IL 60612 Length: 2 years Salary: N/A Positions: 1-2 Deadline: Open ((312) 413-7393 8jlin7@uic.edu
Maryland
Johns Hopkins University Contact: Alexander Vu, DO, MPH
International Emergency Medicine Center for Public Health and Human Rights 5801 Smith Avenue, Suite 3220 Baltimore, MD 21212 Fax: (410) 502-8881 Length: 2 years Salary: Competitive Positions: 1-2 Degree: MPH Deadline: September 15 ((410) 735-6436 8avu3@jhmi.edu University of Maryland Regional Focus: China, Egypt, South Africa, Botswana, The Netherlands Contact: Veronica Pei, MD, MPH University of Maryland Department of Emergency Medicine 110 S. Paca Street, 6th Floor, Suite 200 Baltimore, MD 21201 Length: 2 years Salary: Competitive Positions: 1 Degree: MPH Deadline: Open ( Phone: (410)328-8025 8veronica.pei@gmail.com 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 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 Degree: MPH Deadline: November 20 ( (617) 732-5813 8 iem@partners.org : www.brighamandwomens.org/ dihhp/iem
minnesota
Regions Hospital Contact: Matthew Morgan, MD Regions Hospital Department of EM 640 Jackson St. St. Paul, MN 55104 Length: 2 years Degree: MS in development policy or certificate in tropical medicine ( (651) 254-3336 8matthew.w.morgan@ healthpartners.com :www.regionsem.org/ fellowships/internationalmedicine
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 Positions: 1 ( (212) 562-8147 8mojicm01@nyumc.org Kings County Hospital/SUNY Downstate College of Medicine Contact: Christina Bloem, MD SUNY Downstate Medical Center Department of EM 450 Clarkson Avenue Brooklyn, NY 11203 ( (718) 245-4790 8christina.bloem@downstate.edu New York - Presbyterian: The University Hospitals of Columbia and Cornell Regional Focus: Africa (Uganda, Tanzania, Kenya, Sudan, Ghana, Malawi, Sierra Leone); India, Sri Lanka, Montenegro, Dominican Republic, Burma; WHO in Geneva Contact: Rachel T.
Moresky, MD, MPH Columbia University Medical Center - Center for EM 622 West 168th Street PH 1-137 New York, NY 10032 Length: 2 years Salary: Competitive Positions: 2 Degree: MPH Deadline: November 1 ( (212) 304 5745 8rtm2102@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 Positions: 1 - 2 Salary: $90,000 Hours per week: 18 Deadline: Rolling ( (718) 470-7501 8 snaderi@nshs.edu St. Luke’s Roosevelt Hospital Center - Global Health Fellowship Focus: HIV/TB/Tropical Contact: John D. Cahill, MD Dept. of EM 1111 Amsterdam Avenue New York, NY 10025 Length: 2 years Positions: 2 Salary: $87,000 Hours per week: 20 Degree: MPH optional Deadline: Rolling ( (212) 523-3330 8applications@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 Positions: 1 Degree: MPH, clinical investigation, or
www.epinternational.ning.com
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The IEM Fellowship Directory
medical management Deadline: April 15 ( (585) 463-2945 8david_adler@ :www.urmc.rochester.edu/ emergency-medicine/education/ international.cfm North carolina Duke International EM Fellowship/Global Health Residency Program Focuses: East Africa, Casualty department epidemiology, trauma epidemiology research, validation of trauma scoring in resource limited settings Contact: Charles J. Gerardo, MD Duke University, DUMC 3096 Durham, NC, 27710 Length: 2 years Positions: 1 Salary: Competitive, including tuition for advanced degree Degree: MS in Global Health (MSc-GH) Deadline: September 24 ( 919-681-4458 8 gerar001@mc.duke.edu : www.dukeglobalhealth.org :globalhealth.duke.edu Oregon Oregon Health & Science University - Global Health Fellowship Contact: Amy Marr, MD OHSU Dept. of EM 3181 SW Sam Jackson Park Road, CDW-EM Portland, OR, 97068 Length: 2 years Positions: 1-2 Salary: PGY level, CME
allowance, benefits Shifts per week: 1 Degree: Master’s or certificate options (tuition support provided) Deadline: Rolling ( (503) 494-8220 8 marra@ohsu.edu : 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 Degree: MPH offered from the University of Pittsburgh Graduate School of Public Health ( (412) 647-8265 8wolfsonab@upmc.edu : affiliatedresidency. health.pitt.edu
Rhode Island Rhode Island Hospital Regional Focus: Liberia, Rwanda, Uganda, Kenya, and Haiti Contact: Lawrence Proano, MD University EM Foundation 593 Eddy Street, Providence, RI 02903 Length: 2 years Salary: $87,500 Positions: 1-2 Hours per Week: 16 Degree: MPH from Brown University ( (401) 444-5826 8lproano@lifespan.org
tennessee
Vanderbilt University International EM Fellowship Regional Focus: South America Contact: Seth Wright, MD Vanderbilt University 703 Oxford House Nashville, TN, 37232 Length: 1-2 years Positions: 2 Salary: $92,000 + excellent benefits, tuition, travel expenses Hours per week: 14.75 Degree: MPH, DTMH Deadline: Rolling ( (615) 936-0075 8seth.wright@vanderbilt.edu : emergencymedicine. mc.vanderbilt.edu
texas 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 Positions: 1 Hours per week: 32-40 Conferences/week: 4 hours, except PICU rotation Degrees: MPH, MEd, MS, MBA Deadline: August 31 through ERAS (apply for PEM Fellowship) ( (832) 824-5468 8pwomack@ :texaschildrenshospital.org
University of Texas Southwestern (Dallas-Parkland) Regional Focus: Mexico/Latin America. Others negotiable. Contact: Robert E. Suter, DO, MHA Div. Emergency Medicine UT Southwestern Medical Center at Dallas 5323 Harry Hines Boulevard CS2.122 Dallas, TX, 75390-8579 Length: 2 years Salary: Competitive Positions: 4 Hours: 56 clinical hours/month Degrees: MPH Deadline: December 1 ( (214) 648-3916 8robert.suter @utsouthwestern.edu
utah University of Utah Regional Focus: Ghana, Thailand, India, Peru Contact: Erik Barton, MD, MS, MBA University of Utah Health Care 30 North 1900 East, Rm 1C26 Salt Lake City, UT 84132 Length: 1 to 2 years Salary: competitive Positions: 1 or 2 Shifts: 7 per month/54 hours Degrees: MPH Deadline: Rolling ( (801) 581-2417 8erik.barton@hsc.utah.edu
Have your fellowship listed in the most comprehensive global EM directory Send program description to info@plasterpub.com
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Summer 2011 // Emergency Physicians International
Grand Rounds
with peter cameron, MD
Embracing the Role of “Specialist” Modern health care systems depend on specially-trained physicians who know which care pathway is appropriate for a particular patient presenting with an undifferentiated emergency illness.
I
In my role as IFEM President I am often asked what emergency medicine is and what we specialize in. We are definitely generalists treating a wide range of illnesses with varying degrees of severity. But we are called “specialists” – so what is it that we specialize in? Our specialty is young and has grown partly in response to changes in the way healthcare is delivered. Modern healthcare needs highly trained physicians, at the front door of the hospital 24 hours per day. This is because we can actually save lives and decrease morbidity by early accurate treatment of many illnesses including trauma, cardiovascular disease and sepsis.
The days of waiting a few days for “the specialist” to appear and give a considered opinion are gone. Being on “the end of the phone” to sort out difficult patients, assumes that the treating doctor on the floor, can actually recognise the severity of the illness and has some idea of urgency and prioritization of treatment. A seriously injured or critically ill patient with an acute myocardial infarct or sepsis needs rapid assessment and resuscitation. It is not possible to have the full spectrum of medical specialists “on tap” every hour of the day in every hospital. Even if this were possible – it would be bad luck if a vascular surgeon assessed a patient when the patient was actually having a stroke or myocardial infarct! Most emergency physicians would claim the initial assessment and resuscitation of critically ill patients as a central component of their specialty. Other specialists might say that they are good at this as well, for example intensivists and anaesthetists interested in resuscitation. It is also worth noting that category 1 patients or resuscitation patients make up less than 1-2% of most ED presentations. So although we like resuscitation, we spend most of our time doing other things, like looking after elderly medical patients with ill-defined illnesses, drug addicts/overdoses, social problems and patients with “minor” injuries or illnesses. Is there anything “specialized” in looking after this fairly general group of patients? Over recent years, it has become apparent just how important our skills are to hospitals and health systems. There is good evidence that if patients can get the right diagnosis and treatment at the start of a hospital stay, the total length of stay is less and complications are less. Importantly, avoidance of admission can result in better use of hospital beds and avoid exposure to the “dangers” of hospital stay.
Apart from the obvious patient benefit, this is important to administrators in managing patient demand and flow through the hospital system. Virtually every health system is struggling with excess demand and limited resources to meet that demand. Looking at the hospital system through an industrial prism, it is clear that cheap and safe healthcare can only be delivered through standardization of care pathways. In emergency care, this requires highly trained physicians to ensure that patients are triaged accurately, resuscitated early, and placed in the right care pathway at the start of their stay. For patients being discharged from the ED, standard checks and assessments must be in place to ensure that the risk of short-term morbidity and mortality is low and follow up is adequate. For patients admitted to a ward, early referral for appropriate tests, subspecialty consultations and treatments will result in optimal outcomes. Being under the wrong specialist or in a specialty ward that is not related to the presenting medical problem is unsafe and inefficient. This is true for most specialty areas including cardiology, respiratory, surgery, orthopedic and stroke wards. Knowing which care pathway is appropriate for a particular patient presenting with an undifferentiated emergency illness requires specialized expertise. No other specialists are trained to perform these tasks for emergency patients. Modern healthcare depends on this skill. The present focus on patient safety and quality is an opportunity for our specialty. Lean thinking, six sigma, Process Improvements Teams, organizational reengineering are really conceptual frameworks for lazy hospital administrators to do the work that should be part of normal management practice within hospitals. Emergency medicine has the potential to lead the way in improving organizational structure and processes to improve outcomes for emergency patients at the same time as improving efficiency of care delivery. Our ability to work in teams, coordinate complex care in the setting of uncertainty, training in evidence based care and our general knowledge of how the health system works, makes us a vital part of any modern healthcare system. In fact you could argue that we are the system specialists! Dr. Cameron is the President of the International Federation for Emergency Medicine. www.ifem.cc
Over recent years, it has become apparent just how important our skills are to hospitals and health systems. There is good evidence that if patients can get the right diagnosis and treatment at the start of a hospital stay, the total length of stay is less and complications are less. Importantly, avoidance of admission can result in better use of hospital beds and avoid exposure to the “dangers” of hospital stay. www.epinternational.ning.com
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