Inside Korea’s First ‘Cancer ER’ Improve Your ED’s Front Door Experience Peter Cameron on Building EM in Qatar Sweden: EPs Prove Superior at Finding PE EMERGENCY PHYSICIANS INTERNATIONAL
ISSUE 9
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FALL 2012
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WWW.EPIJOURNAL.COM
WORTH THE FIGHT How Raed Arafat, the adopted father of Romanian EMS, made emergency medicine an issue worth taking to the streets. // page 7 by judith tintinalli & terrence mulligan
“Emergency care is the right of any citizen and the duty of the state to provide.”
-raed arafat
“hands off smurd!” Romanians take to the streets in support of the country’s national emergency care system research from italy – Avoid harmful radiation by
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EDITOR’S DESK
A New Wave of Collaboration
T
his August I attended the 9th Annual New York Symposium on International Emergency Medicine, held at the stately New York Academy of Medicine and Lenox Hill Hospital. The meeting highlighted international emergency medicine fellowships, which it is gratifying to see have grown and proliferated in recent years, expanding their activities around the globe. There are now over 32 U.S.-based international EM fellowships and there are programs in Canada, Australia, the Netherlands, and South Africa. Each fellowship is unique in its focus, ranging from disaster preparedness to emergency medicine education to pre-hospital training. The Society for Academic Emergency Medicine (SAEM) and EPI Journal both keep updated listings of the fellowship programs on their web sites, so go online if you’d like more specific information on the structure and contacts for any specific fellowship. Over the past year a number of international EM fellowship directors have gotten together to form the International EM Fellowship Consortium (IEMFC). The Consortium’s admittedly lofty goals are to link and coordinate all the International EM Fellowship programs, share information and project development, and provide a linked and comprehensive application service for prospective applicants. The IEMFC has established an official website: www.iemfellowships.com. Currently, the site houses information for potential candidates applying to IEM fellowships and serves as a way for senior residents to submit their applications. In the near future, the consortium site will display information regarding work being done by each program, allowing for individuals looking to aid in international work to search by type of project, location or institution. It will also allow programs to post international opportunities, and there will be a communication area to inquire about projects or to collaborate for funding opportunities. I very much encourage any International EM Fellowship directors who have not yet joined the IEMFC to do so, as being a member of this Consortium should have significant benefits for your program. It is crucial that the IEMFC facilitate fellowship programs sharing information about their projects and activities as the potential for multiple programs to collaborate on and share projects is huge. Even if you are not associated with an International EM Fellowship but are interested in global health activities, the IEMFC could be a good way to find a fun and rewarding project to support. Also, if your institution does not have an International EM Fellowship but you are interested in starting one, I would very much encourage you to proceed. There is a large and growing number of extremely talented applicants seeking these programs. Plus, having an International EM Fellowship has been shown to be a major attractant for EM residency program applicants. If you’re not sure how to go about starting an International Fellowship program, just contact the IEMFC. I am looking forward very much to seeing the further successes of the fellowship programs in providing EM specialty and training development throughout the world. I would also like to encourage all the fellowship programs to let us at EPI know about your activities so we can help publicize them and facilitate global collaborations.
C. James Holliman, MD, FACEP, FIFEM editorial director
The Consortium’s admittedly lofty goals are to link and coordinate all the International EM Fellowship programs, share information and project development, and provide a linked and comprehensive application service for prospective applicants. Learn more at www.iemfellowships.com
Inside Korea’s First ‘Cancer ER’ Improve Your ED’s Front Door Experience Peter Cameron: Building EM in Qatar Sweden: EPs Superior at Diagnosing PE EMERGENCY PHYSICIANS INTERNATIONAL
ISSUE 9
.
FALL 2012
.
WWW.EPIJOURNAL.COM
WORTH THE FIGHT How Raed Arafat, the adopted father of Romanian EMS, made emergency medicine an issue worth taking to the streets. // page 8 by judith tintinalli & terry mulligan
“Emergency care is the right of any citizen and the duty of the state to provide.”
-raed arafat
“hands off smurd!” Romanians take to the streets in support of the country’s national emergency care system research from italy – Avoid harmful radiation and use ultrasound first with suspected pediatric pneumonia
ABOUT EPI With a quarterly print and digital distribution and an online network of more than 1,700 members, EPI is the new hub connecting global emergency care, sparking dialogue and creating a space for new collaborations. Find copies of the print magazine at international EM conferences around the world, or read it online at www.epijournal.com
www.epijournal.com
3
LETTER FROM THE PUBLISHER
Symplur Times
W
hen Irish president Michael Higgins opened the International Conference on Emergency Medicine in June, it marked an historic occasion. I’m not talking about Higgins being the first head of state to address the biennial meeting (read Andy Neill’s account on page 30). Or that with 2,800 attendees, it was the biggest ICEM ever. This meeting broke ground in a more subtle way – one most properly expressed in 140 characters or less: ICEM 2012 was the “most-tweeted” emergency medicine conference in history. Over the course of the events in Dublin, a stealthy band of smartphone-carrying, WiFiconnected physicians took to Twitter and wove a behind-the-scenes dialogue into a “virtual conference” that extended the reach of the meeting to the far corners of the world. “@AndyNeill your commitment to meaty tweets is bringing #ICEM2012 all the way to an ill-timed family holiday in Cornwall!” wrote one physician who couldn’t make the meeting. Now, “tweeting” during a conference isn’t new; what is new is reaching critical mass. According to web elder statesmen Mike Cadogan, ICEM may have been the “most-tweeted” medical conference ever. To get an idea of the scale and scope of the ICEM digital conversation we turn to a new web site called Symplur, which, among other things, aggregates data on healthcare hashtags. (For the uninitiated, a hashtag is a code that is included in a twitter post which makes that entry searchable by theme.) The hashtag #ICEM2012 was viewed 3.5 million times (the number of tweets multiplied by the number of followers for each tweet). There were nearly 5,000 tweets posted using the hashtag by a total of 476 people. You might be thinking: Who cares what people are “tweeting.” It’s unedited, uncurated and about as far from peer reviewed as you can get. This may be true, but the democratic nature of the web means that when an app like Twitter is harnessed for good, it can spread free, educational material incredibly far, incredibly quickly. The critical mass reached at ICEM doesn’t represent an inherent quality of material, but a massive potential for shared knowledge. Whether you’re in Cornwall or the Corn Islands, you’re now just a browser click away from contributing to a global medical dialogue. And Twitter is just the beginning. According to Life in the Fast Lane, there are now 130 emergency medicine/critical care blogs and podcasts, hailing from 17 countries. They say two heads are better than one. Social media says, “I’ll take your two and raise you 2,000.” And when it comes to tackling the next generation of global emergency medicine challenges, collaboration is more than a good idea – it’s absolutely essential.
Logan Plaster Publisher
publisher LOGAN PLASTER logan@epijournal.com Follow on Twitter @EPIJournal editorial director C. JAMES HOLLIMAN, MD executive editors PETER CAMERON, MD TERRY MULLIGAN, DO, MPH LEE WALLIS, MD MARK PLASTER, MD editorial interns DR. RASHMI SHARMA REBECCA CORDER PEREL BERAL regional corespondents CONRAD BUCKLE, MD MARCIO RODRIGUES, MD CARLOS RISSA, MD KATRIN HRUSKA, MD SUBROTO DAS, MD MOHAMED AL-ASFOOR, MD JIRAPORN SRI-ON, MD editorial advisors ARIF ALPER CEVIK, MD KATE DOUGLASS, MD HAYWOOD HALL, MD CHAK-WAH KAM, MD GREG LARKIN, MD PROF. DONGPILL LEE SAM-BEOM LEE, MD ALBERTO MACHADO, MD JORGE OTERO, MD print advertising LOGAN PLASTER logan@epijournal.com
on the web
CONNECT WITH INTERNATIONAL COLLEAGUES ON EMERGENCY MEDICINE’S LARGEST PROFESSIONAL NETWORK
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Fall 2012 // Emergency Physicians International
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THE MARKETPLACE
The 2nd Global Network Conference on Emergency Medicine Dubai UAE 2 - 6 May, 2013
African Conference on Emergency Medicine Accra International Conference Centre, Ghana 30 October to 1 November 2012 www.afcem2012.com Please support Adopt-aDelegate (AFEM’s peer sponsorship project); more details online Register an donate online www.afcem2012.com
Pre-Conference Workshops Empowering Life Support Protocols with ABCDE Ultrasound Resuscitation Simulation Learning in Emergency Medicine Advanced Paediatric Emergency Care Metabolism: Acid-base, O2, Fluids and Electrolyte Disorders Interpretation ECG Non Invasive Ventilation Difficult Airway Management Disaster Medicine: Improvised Explosive Devices Emergency Department Administration Conference Sessions Intensive Care Trauma Cardiovascular Disaster Medicine Ultrasound Pediatric Metabolic Toxicology Sepsis Pre-Hospital Administration
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EVENT CALENDAR 11/12–10/13
12 MONTHS OF INTERNATIONAL EM CONFERENCES
NOVEMBER 2nd ACEM Congress // Bogota, Colombia
November 9 – 11, 2012 www.acemcolombia.com/home/en/ congress-2012.html
4th World Congress in Emergency Medicine // Mayan Riviera, Mexico November 15-17, 2012 www.urgenciasmexico.org
14th Annual Conference for Society for Emergency Medicine in India // New Delhi, India
5th Danish Emergency Medicine Conference 2013 // Denmark April 18 – 19, 2013 www.akutmedicin.org
Manchester Critical Care // Manchester, UK April 25-26, 2013 www.critcaresymposium.co.uk
MAY
The First European Congress on Pediatric Resuscitation and Emergency Medicine // Ghent, Belgium May 2 – 3, 2013 www.prem2013.be/
The Second Global Network Conference on Emergency Medicine // Dubai, UAE May 2-6, 2013 www.emergencymedicineme.com
SAE Conference // Buenos Aires, Argentina May, 2013 www.emergencias.org
IN THIS ISSUE www.epijournal.com
03 | Editor’s Letter 04 | Publisher’s Letter 07 | Profile: Raed Arafat How the father of Romanian EMS made emergency medicine worth fighting for
10 | Research The PE Test: EM Efficacy in Sweden
11 | Ultrasound Update Italy: Ultrasound first with suspected pediatric pneumonia
13 | Curious Cases An unusual case of fish poisoning seen during a stint in the Caribbean
14 | Pediatrics IFEM finalizes Pediatric road map
Source
November 16-18, 2012 www.semi.org.in
SAEM Annual Meeting // Atlanta, Georgia, USA
FEBRUARY/2013
May 15-19, 2013 www.saem.org
Poll: What is the state of emergency pediatrics in your country/region?
18th World Congress on Disaster and Emergency Medicine // Manchester, UK
18 | Nicaragua
19th Annual AAEM Scientific Assembly // Las Vegas, USA February 9-13, 2013 www.aaem.org
MARCH
33rd International Symposium on Intensive Care and Emergency Medicine // Brussels, Belgium March 19 – 22, 2013 www.intensive.org/index.asp
APRIL
4th Central European Emergency Medicine Congress // Wroclaw-Karpacz, Poland April 17 – 20, 2013 www.ceem2013.org
May 28 – 31, 2013 www.wcdem2013.org
SEPTEMBER
Mediterranean EM Conference // Marseilles, France September 7 – 11, 2013 www.memc2013.org
OCTOBER
The American College of Emergency Physicians Scientific Assembly // Seattle, USA October 14 – 17, 2013 www.acep.org
16 | Dispatches
20 | Mexico 21 | Society News: AFEM 22 | Ethiopia
Reports 26 | Inside Korea’s Cancer ER Asan Medical Center’s new facility has improved care while lowering costs
30 | ICEM Observations Opening remarks by Irish president Michael Higgins, plus a photo essay
32 | Design: First Impressions Manuel Hernandez on how EDs need to rethink their “entry strategy”
35 | Hypertension in Belize A group studies patient perceptions of HTN in this developing nation.
LIST YOUR NEXT INTERNATIONAL EVENT FOR FREE ON THE EPI NETWORK – WWW.EPIJOURNAL.COM/EVENTS
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Fall 2012 // Emergency Physicians International
38 | Grand Rounds IFEM President Peter Cameron on his new post in Qatar, and on the unique challenges of building an EM system from the ground up.
PROFILE
Romania’s Adopted EM Champion Last January, emergency medicine icon Raed Arafat resigned from his post in the Romanian Ministry of Health, sparking unprecedented public protests in defense of Romania’s emergency care system. by judith tintinalli, md
& terry mulligan, do
I
n January, 2012, Dr. Raed Arafat resigned his position as Under Secretary of State of the Romanian Ministry of Health, a position he had held since 2007. An emergency physician born in Damascus, Arafat stepped down because he opposed the government’s attempt to privatize and commercialize Romania’s emergency care system. What happened next was unprecedented, not only for the world of emergency medicine, but for healthcare politics worldwide. Thousands of Romanian citizens took to the streets of Bucharest, demonstrating in support of Dr. Arafat and SMURD, the emergency care system he’d created for Romania. It is safe to say that never before has a leader in emergency medicine been so appreciated by his countrymen. “He simply hypnotised us with his words,” wrote Alexandra Mihai on his blog Al Hayat wa Dounia Newspaper. “Dr. Arafat is a hero, a big treasure that God sent to the Romanian people”(1). Government protesters carrying signs in support of Arafat set fires and threw stones, and police responded with tear gas and water cannons. President Traian Basescu berated Dr. Arafat’s principles and policies on national television. Protests and citizen dissatisfaction grew stronger – so strong that Prime Minister Emil Boc resigned for the sake of Romania’s stability. **************** What kind of emergency physician could inspire a nation to protest in such a way? Arafat’s story begins in 1965. Born in Damascus, he grew up in Nablus, the West Bank, and by age 14 had mastered the only book in the Nablus library on emergency care: ‘First Aid Without Panic’. “It was a passion,” he says, recalling that even in high school he was setting up first aid teams. Arafat fixed his sights on medicine and enrolled in medical school at the University of Medicine and Pharmacy in Cluj Napoca, in the Carpathian mountains of Romania. Romania was part of the Eastern Bloc until 1989, and 50 years of political and
economic ties to Palestine made it a comfortable choice. Arafat was also admitted to a school in the United States, but his parents hid it from him, afraid that if he left, he’d never return. In his 3rd year of medical school, a leading faculty surgeon encouraged Arafat’s interest in emergency care and he was soon teaching first aid and splinting techniques to medical students. Arafat then chose a residency in anesthesia and critical care (the closest option to emergency medicine at the time) at the Targu-Mures University of Medicine and focused his clinical and administrative energies on emergency care. In 1990, Dr. Arafat created the Serviciul Mobil de Urgenta, Reanimare si Descarcerare (SMURD) – or the Mobile Emergency Service for Resuscitation and Extrication – in Targu Mures. This service, modeled on systems from Edinburgh, became the first mobile intensive care unit in Romania. This first ‘unit’ consisted simply of a used Opel Kadette equipped with a defibrillator and resuscitation equipment, purchased in Germany with help of the German Red Cross. Within a year of SMURD’s creation, Arafat’s leadership in emergency care in Romania was well recognized. Before the development of SMURD, Romanian nurses and doctors worked on ambulances but lacked formal training in the principles of emergency care. Dr. Arafat used his skills in anesthesia and critical care to educate pre-hospital providers in
intubation, ventilation, and cardiac resuscitation. As the reputation of the Targu Mures unit grew, so did the system, with new ambulances, monitors, and resuscitation equipment. In 1991 the unit became a joint venture between the Mures Fire Brigade as first responders, and the Mures County Emergency Hospital, fueled by the belief that “emergency care was something for everyone, and daily emergency care also includes disaster preparedness.” Many, if not most, worked as volunteers during this time. In developing these new concepts, Arafat moved quickly, following the adage that it’s better to ask for forgiveness than permission. In the end, having earned the gratification of his countrymen, neither were required. The result of SMURD was that a whole new set of patients was getting resuscitated pre-hospital and making it to the hospital for care. However, when they did, there was no ‘emergency department’ or ‘emergency room’ in which to manage emergent cases after the initial resuscitation. As was the usual practice at that time, patients were placed in a ‘specialist’s room’ based on the organ system affected. So, in 1993, with direct support of the Royal Infirmary of Edinburgh led by Dr. Keith Little and Head Nurse Margaret White, a surgeon’s changing room in Targu Mures was partitioned as a ‘resuscitation room’. In the first year, the mortality in the emergency reception area, where the new resuscitation room was placed, dropped by 50%. Ideas were turning into reality for Arafat, and relatively quickly. In 1994, the Emergency Service of the Royal Hospital of Edinburgh, with support from the BBC, provided a modular building to serve as an emergency room, and placed it in front of the hospital entrance. At the beginning, developing emergency medicine in Targu Mures was challenging because the physicians didn’t understand what Dr. Arafat and his colleagues were trying to do. But before long, whenever there was an emergency somewhere in the hospital – be it a difficult IV, an intubation or defibrillation – a call would come to the emergency department and the team would come running to save the day. It wasn’t long until the emergency department staff became recognized experts in critical cases, followed closely by the hospital’s appreciation at their ability to handle noncritical cases as well. Support for Arafat’s work came pouring in from every corners, from the local community to the ministry of the interior to emergency physicians around the globe. Eventually even the World Bank and the Romanian Ministry of Health took notice. Thanks to the support of the Royal Infirmary of Edinburgh, the Soros Foundation, and the Rotary Club, additional emergency departments were established in 1997 and 1998 in three major cities. Starting in 2007, the www.epijournal.com
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PROFILE
//
On an international level we have to wake everybody up [to the fact] that emergency care needs government, funding, WHO, national groups, to look at emergency cases as a problem that needs to be tackled in the next years. If you don’t have an emergency care system, you don’t have access 24/7 to these problems. -raed arafat
(L) Dr. Arafat signs papers at the Romanian Ministry of Health during an interview with EPI executive editor Terrance Mulligan (R) Dr. Arafat attends the inauguration of a new EMS dispatcher at the Floreasca Emergency Hospital in Bucharest
REFERENCES (1) Alexandra Mihai, ‘Dr Raed Arafat, our Romanian Hero’, Personality of the Month on June 23, 2010, Al Hayat wa Dounia Newspaper). (2) Hartley, Joel, First Aid Without Panic. 1975 Hart Publishing Company Inc; Popular Library Edition May, 1977)
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World Bank funded a national Romanian project to create even more emergency departments. Perhaps most impressive, however, was the community support: citizens raised $100,000 in 1998 to purchase a fully functioning intensive care ambulance. When faced with a government request for VAT of $60,000, citizens signed a petition opposing the VAT because the ambulance had been bought by the Romanian people. This led to the cancellation of the tax for that particular ambulance by a government decree. What started in 1990 with a used Opel Kadett is today a national emergency care system with 63 emergency departments throughout Romania, standardized by care as levels 1, 2, or 3. There are five national helicopters jointly managed by the Ministry of the Interior (police pilots) and EDs, for medical evacuation. Communication is well integrated between fire, ambulances and emergency departments. There is a national emergency phone number (1-1-2) and there’s training for paramedics and nurses. Between 1993 and 1999, 3-year emergency medicine residencies were expanded to 5 years. In 2011, there were nearly 3,500,000 ED visits in Romania and about 2,400,000 ambulance visits out of a population of 20 million. Arafat contributes the development in part to his role as Undersecretary of State, saying, “The solution for you is to work from top down not down up… Any country who puts a person at this level and gives him the power to do this, the emergency system will develop much faster than if it just developed spontaneously, department by department.” In 2005, Dr. Arafat went beyond building emergency departments and became instrumental in the writing of legislation mandating prehospital, disaster and emergency care as the right of any citizen and the duty of the state to provide. It was Arafat’s opinion that emergency care could not be left in the hands of the local community or insurance companies; it is the issue of the state. In Romania, though EDs are part of the hospital, they are linked directly to the Ministry of Health and are funded directly by the state budget and not from insurance. That said, Dr. Arafat is careful to distinguish policy from politics. He views himself as a technical person in emergency care, not a politician. But as a technical person with a powerful political appointment, Dr. Arafat is able to implement system change on a larger scale. As he says, “Emergency care should be looked at how it is delivered on a regional and national level, not as a local level. It is not just a medical system, it is the national safety and security system of any country. It is much more than medicine, it is how your system is developed so that you can take care of everyday and special situations,
Fall 2012 // Emergency Physicians International
Raed Arafat’s Principles for Developing an Emergency Care System Interview by Terrance Mulligan, DO 1. Emergency care is not just a medical system. It is the national safety and security system of a country. It is much more than medicine. It is how your system takes care of everyday and special situations, like mass casualty incidents. 2. To start an emergency system, you must build up the specialty. You cannot have an EM system without EM physician specialists, paramedics and nurses. 3. Planning is very important. Start with pilot projects, as much to see what to do as what NOT to do. It is hard to escape from mistakes. 4. Adapt to your country. Learn to take the good things from others and adapt them. You can’t develop an emergency care system by copy and paste. 5. Start with basic things. Train lots of first responders rather than developing lots of intensive care units. We started in Romania with intensive care units because we had to show rapid change. Today I start with first responders and then move up to more advanced units. 6. Emergency care needs government and national funding. Emergency care is not just trauma, but needs to manage infectious disease, cardiac, and respiratory problems which are growing everywhere.
like mass casualty incidents.” These top-down views are not without their detractors, as the protests of this past January illustrate, but in Arafat’s words, “Change cannot be brought about without disturbing someone, but with determination and faith in your idea, everything can be surpassed.” (1) **************** After five days of rioting, President Basescu reversed his position, with a public declaration that Dr. Arafat’s concept of the delivery of emergency care – that it is a citizen right provided by the state – would not change. So Dr. Arafat returned to his position as Under Secretary to continue his work for the people, and by the people, and he continues in that capacity today. As he explains, “Emergency care is the right of any citizen and the duty of the state to provide. It is not to be left in the hands of the local community. It is the issue of the state.”
In an emergency, there’s no substitute for your time. :00
Seconds
Patient enters Emergency Department, eyes inflamed
:10
Seconds
No Time to Lose: Raed Arafat’s Rapid Rise 1990-1998 Worked as a volunteer emergency physician until he got Romanian citizenship. Was hired officially as the Chief Physician of the Emergency Department and SMURD in Mures County. Until then he worked under the mentorship of the head of the ICU at the hospital, initially as a resident, and then as a volunteer physician. 1991 Founding member and secretary general of the Romanian Society for Emergency and Disaster Medicine 1992-1998 Consultant of the Ministry of Health of Romania on emergency medicine 1992-1998 Served as consultant of the Ministry of Health of Romania 1998-2007 Chief Physician, Department of Emergency Medicine in the Targo Mures County Hospital
1999-2001 Technical expert for the World Bank program for implementation and integration of emergency medical services based upon the model of Targo Mures 2003 Granted the Knight of the Order of Merit by the President of Romania 2005 Served as national representative on emergency care for the Ministry of Health 2005 Officer of the Order of Merit, granted by the President of Romania
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2007-Present Served as Under Secretary of State at the Ministry of Health, responsible for emergency medicine and disaster preparedness
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RESEARCH
The PE Test: EM Efficacy in Sweden In a recent Swedish study, it was shown that emergency physicians are more accurate in detecting pulmonary embolism in the emergency department than internal medicine physicians.
Emergency physicians were significantly more likely to detect PE in the context of the emergency department:
emergency physicians
internal medicine physicians
by ulf martin schilling, dr. med
D
etecting the emergency of non-fulminant pulmonary embolism (PE) still is one of the major problems presenting to the emergency physician. Signs and symptoms of PE most often are discrete and non-specific. Non-invasive investigation and laboratory parameters can be misleading, and the final diagnosis often is stated by radiologic investigation. To help physicians to suspect PE several scoring systems have been developed. In Sweden, the use of the Wells score is emphasized by the national board of health.
Emergency medicine in Sweden still is a developing field of medicine and was recognized as late as 2008 as a subspecialty. Thus, most of the emergency physicans working at the emergency department still are residents under continuous education and the guards are shared by emergency physicians and physicians otherwise working at the different wards.
Objective Due to their specialisation in the field of emergency medicine, it could be suspected that emergency physicians might be better in detecting the otherwise discrete findings of pulmonary embolism in emergency patients. To confirm this hypothesis, a single center restrospective cohort-study was performed.
Methods During the three-month periods (March to May) 2007 and 2008 the findings in all patients undergoing pulmonary CTangiography at the emergency department of our university hospital were reviewed. The investigations were attributed to emergency physician (EP) or internal medicine physician (IP). Both negative and positive findings were evaluated, and the number of medical patients treated by the respective group were calculated according to the computerized triage system as each emergency physician signs for the patient he is treating.
10
Statistical analysis was performed by the Students-T-test, and probability levels of 5% were accepted as significant.
Results During March till May 2007, a total of 2847 patients attended for medical problems, 576 of which were treated by EP (20.23%). The rest of the patients (79.77%) were treated by IP. In March till May 2008, 2408 patients searched for medical problems and 625 (25.95%) were attended by EP. During this period, EPs ordered a total of 34 pulmonary CT in 2007 and 35 in 2008. 17.64% (2007) and 22.86% (2008) of these resulted in confirmation of the diagnosis of pulmonary embolism. IP ordered 77 (2007) and 64 (2008) pulmonary CTs during this period, resulting in 12.98% (2007) and 10.93% (2008) of positive findings, respectively. Calculating these numbers on the total of patients attended by the different groups, EPs ordered pulmonary CT for 5.9% (2007) resp. 5.6% (2008) of their patients, whilst IP performed CT-scans in 3.39% (2007) resp. 3.59% (2008) of their patients (p=0.0108). This means that EPs had a higher index of suspicion for the diagnosis of PE in the context of the emergency department (1.74 (2007) resp 1.56 (2008) vs 1.0 for the IP). For the total of patients attended at the emergency department, this resulted in
Fall 2012 // Emergency Physicians International
3.26 : 1
In 2008, the odds-ratio to have a positive finding on a pulmonary CT by an EP compared to an IP was 3.26.
positive findings for pulmonary CT in 1.04% (2007) and 1.28% (2008) for the EP, and in 0.43% (2007) and 0.39% (2008) for the IP (p<0.01). This means that emergency physicians are more accurate in detecting PE in the context of the emergency department. Thus, the odds-ratio to have a positive finding on a pulmonary CT by an EP compared to an IP was 2.43 in 2007 and 3.26 in 2008. The total percentage of positive findings for the hospital including the emergency department was 14.29% (2007) and 14.15% (2008) on a total of 259 resp 212 CT-scans, and excluding the emergency department 14.19% (2007) and 13.27% (2008) on 148 resp 113 CT-scans. No significant difference could be found between the positive findings for all the hospital compared to the EP (p=0.38) or IP (p=0.27).
Conclusion Emergency physicians seem to have a higher index of suspicion for PE than internal medicine physicians and are more accurate in detecting PE in the emergency department. Compared with the total of our university hospital, emergency physicians are at least comparable in diagnosing PE. EPI Editorial Note: To learn more about emergency medicine efficacy, read â&#x20AC;&#x153;The efficacy and value of emergency medicine: a supportive literature review,â&#x20AC;? written by, among others, EPI executive editors Jim Holliman, Terrence Mulligan, Peter Cameron and Lee Wallis.
ULTRASOUND
Italy: Ultrasound First with Pediatric Pneumonia Ultrasound now allows physicians to forego harmful radiation when scanning for pneumonia in children by dr. alfredo barillari
T
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he diagnosis of pneumonia in children relies on physical examination, blood tests and chest X-rays. These methods have a low accuracy in the adult population that is even lower in the critically ill1. A systematic review of the utility of the clinical examination in diagnosing community-acquired pneumonia concluded that there were no combinations of the history and physical examination that could reliably confirm or refute the presence of pneumonia. The chest radiograph has been used as the reference standard for the diagnosis of pneumonia in most studies on adult patients. Nevertheless, technical limitations in the interpretation of chest radiograph of patients with possible pneumonia are well documented2. The reliability of this test is limited by significant interobserver and intraobserver variability in interpretation3. The chest X-ray is the most commonly used imaging tool in pneumonia because of availability and an excellent cost-benefit ratio. Computed tomography is mandatory in unresolved cases or when complications of pneumonia are suspected4. Current estimates indicate that a single CT scan will result in a lethal malignant transformation at least once in every 3,000 adult studies and that this rate may exceed 1 in 500 for children. Thoughtless and indiscriminate imaging of extremely low-risk patients becomes an ethical problem, as does imaging that is primarily obtained to protect the clinicians5. One in 1,250 adult patients, after being exposed to 15 mSv of radiation from a panscan (computed tomography of the head, neck, chest, abdomen and pelvis), will die from cancer. Children have 10 times the sensitivity to radiation, and the mortality approaches and possibly exceeds that of a laparotomy for a negative appendectomy6. These limitations along with the risk of ionizing radiations, mandate the search for a safe diagnostic tool for patients with suspected pneumonia. Enter portable bedside
ultrasound. Lung scan using ultrasound can be adopted as a simple and non-invasive method for evaluating children with pneumonia. It is easy to perform at the bedside, allows close follow-up and avoids the use of ionizing radiation7.
Scanning Technique Neonates and infants are best imaged with a high resolution 5-10 MHz lineararray transducer; children and adolescents may require a 2-4 or 4-7 MHz sector or linear-array transducer. Transternal, parasternal and intercostal approaches are good for imaging of the lung, pleura and anterior mediastinum. In the subxyphoid and transdiaphragmatic approaches the liver is used as an acoustic window for evaluating juxtaphrenic paravertebral lesions. Suprasternal and supraclavicular approaches facilitate evaluation of the upper mediastinum and lung apices. Ultrasound is performed in the supine, prone or decubitus position. Images are obtained in the transverse, longitudinal, and inclined transverse or inclined longitudinal planes to maximize demonstration of the lesion8.
Normal Findings Ultrasonsonography has been underused or often ignored as a diagnostic tool in the chest, especially in the lung , because air and the bony thorax were traditionally considered an obstacle to transmission of the
01 The bat sign: two adjacent ribs and their shadows resemble the wings, the pleural line in the middle resembles the body of the bat 02 “A” lines and pleural line
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ultrasound beam. However, since ultrasound has been gaining recognition as a highly useful tool in the evaluation of pleural lesions, its role in imaging of the lung and extracardiac mediastinum has expanded and its usefulness has been recognized1,8. The normal paediatric lung picture does not differ from that of the adult lung. The superficial layers of the thorax consist of subcutaneous tissues and muscles. The ribs, on longitudinal scan, appear as curvilinear structures associated with posterior acoustic shadowing. The pleura appears as a regular echogenic line (pleural line) moving continuously during respirations. Pleural movement has been described as the “lung sliding” sign. The amplitude of the lung sliding is minimal at the apices and maximal at the bases. Lung sliding can be objectified and documented with M-mode. The ribs and the pleural line, in the longitudinal view, outline a characteristic pattern, the “bat sign” (Fig. 1). Beyond the pleura-lung interface, the lung is air-filled and does not allow further visualization of normal lung parenchyma. However the large change in acoustic impedance at the pleura-lung interface results in horizontal parallel artifacts below the pleural
REFERENCES 1. Lichtenstein, et al: Ultrasound in the management of thoracic disease. Crit Care Med 2007; 35 (5 suppl.): S250-61 2. Basi, et al: Patients admitted to hospital with suspected pneumonia and normal chest radiographs: epidemiology, microbiology, and outcomes. Am J Med 2004; Sept 1, 117: 305-311 3. Katz, et al: Radiology of pneumonia. Clin Chest Med 1999; Sept 20 (3): 549-563 4. Sharmar, et al: Radiological imaging in pneumonia: recent innovations. Curr Opin Pulm Med 2007; 13: 159-169
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ULTRASOUND 03 Comet tail or B line arising from the pleural line 04 Consolidation with branching air bronchograms 05 Atelectasis with parallel air bronchograms 06 Pleural effusion with atelectatic lung
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line. Those artifacts have been termed “A lines” (Fig. 2). Vertically-oriented “comet-tail” artifacts arising from the pleural line, also called “B lines”, are absent in the normal lung. They arise from the pleural line, are well defined, reach the lower edge of the screen, erase A lines and move with lung sliding1,7. The presence of B lines, or comet-tails, is related to pathological findings and results from the fluid-rich subpleural interlobular septae, which are surrounded by air and identify an alveolar-interstitial syndrome (Fig. 3). 
pattern of anechoic or hypoechoic tubular structures within consolidated lung. Demonstration of fluid-filled bronchi, an appearance termed a sonographic or mucous bronchogram, is a specific indicator of pulmonary parenchymal consolidation, equivalent to the air bronchogram1, 10. Sonographic or air fluid bronchograms may not be visible, particularly in the peripheral lung. In this case color flow US demonstrates the normally branching pattern of pulmonary vessels in consolidated lung5. Pathological processes that involve the pleura and manifest as fluid collections, are ideal for imaging with US because of their acoustic properties. The different types of pleural effusion depend on the nature of the fluid collection: serous, purulent, hemorrhagic or chylous. Serous fluid is usually a transudate, and purulent fluid is an exudate or empyema. At ultrasound, pleural fluid may be characterized as a simple effusion, a complicated effusion or fibrothorax (pleural thickening or fibrosis). A simple effusion (Fig. 6) appears as a clear anechoic or cloudy hypoechoic fluid with or without swirling particles. A complicated effusion appears as a septated or multiloculated, hypoechoic fluid, partitioned by fibrin strands, with no clear demarcation between the lung and the pleural components. Fibrothorax appears as a thickened, echogenic rind of pleural plaque8.
Pathological Findings
The airless lung is similar in echogenicity and echotexture to the liver and spleen. Within the solid-appearing area of echogenicity, multiple bright dot-like and branching linear structures are found. These findings represent air in the bronchi and scattered residual air in alveoli within the consolidated or atelectatic lung. This appearance is termed a sonographic air bronchograms (Fig.4). In consolidation the lung volume is increased by fluid or tissue, but the bronchi are spared and retain their normal branching pattern. In atelectasis, overall lung volume is decreased; supplying bronchi of the involved lung can be crowded together in very close apposition in one plane, appearing as parallel-running bright lines (Fig. 5). Occasionally when the bronchial tree is filled with fluid rather than air, as in mucoid impaction, US may demonstrate a branching
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5. Mower, et al: Radiation doses among blunt trauma patients: assessing risks and benefits of computed tomographic imaging. Ann Emerg Med 2008; Aug 52 (2.): 99-100 6. Snyder, et al: Whole-body imaging in blunt multisystem trauma patients who were never examined. Ann Emerg Med 2008; Aug 52 (2.): 101-103 7. Copetti R, Cattarossi L. Ultrasound diagnosis of pneumonia in children. Radiol Med 2008, 113: 190-198 8. Ok H, Woo S K, Min J K, Jun Y J. US in the diagnosis of pediatric chest diseases. RadioGraphics 2000, 20: 653-671
CURIOUS CASES
NO FLY ZONE: The Haitians have found an ingenious way to test for Ciguatera. Lay the fish out; if the flies stay off, they know the fish is toxic and throw it out.
‘Bad Fish’ Gets Even Worse Working in an ED in the Caribbean, an unusual case of fish poisoning turns quickly into an emergency by keith a. raymond, md
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try to get paid for my vacations, and I have found locums positions in exotic locations are a good way to accomplish this. Like you, I love the Caribbean, and sipping an umbrella drink at the end of a long day watching a sunset sounds just about right. Especially after the day I had. I usually get off work, go scuba diving, take an afternoon nap, and then
go down to where the fishermen are selling their catch of the day off the ponga boats. I pick out a grouper and go grill it before the next night shift. It’s frustrating when I must see them in the emergency department, and they are sick as dogs from what they ate. It also makes me a bit nervous as I might be next. So when he came in with a heart rate of thirty and hypotensive, I knew there was trouble out at sea. He was a Haitian in his mid-thirties, but years of sun damage and poverty made him appear a lot older than his stated age. His GCS was 10/15, and he was stuporous. His wife was panicked racing around the gurney and jabbering patois.
We hooked him up to monitors and were amazed by the readouts. I prepared him for intubation, as the cold chill ran down my spine. Dropping into ACLS mode, I gave him Atropine 0.5 mg, and the response was dramatic. His heart rate rose into the 80’s and his blood pressure normalized, and he woke up, sat up in bed, and wondered how he got to the ED. His wife fell silent and looked at me with awe. It was like a miracle. He looked at me and said, ‘Bad Fish.’ He had known fish poisoning before, but not like this. The Haitians have found a way to test for Ciguatera that is quite ingenious. They lay the fish out, and if the flies stay off, they know the fish is toxic and throw it out.
Ciguatera toxin accumulates in predator fish such as red snapper, grouper, Spanish mackerel, and sea bass that eat reef fish. The reef fish graze on the coral and pick up dinoflagellates that are toxin producing most often during spring and fall. Once a human eats the infected predator fish they fall ill in a matter of hours. The toxin is essentially undetectable being odorless, tasteless, and heat resistant, and is therefore impervious to most cooking. The typical and most common symptoms are nausea, vomiting, diarrhea, muscle pain, numbness and tingling. However, in the severe cases, like in our fisherman, the toxin affects the sodium channels in the cardiac and skeletal muscles, as well as the vasculature causing serious sinus bradycardia and hypotension, with resulting paralysis, heart, and respiratory failure. Mild symptoms are treated with IV fluids, diphenhydramine, and other supportive measures. Severe symptoms, in addition to the above, are treated with Atropine. In his case, the patient was given Atropine as often as every 30 minutes to alleviate the toxic effects on the heart and vasculature, while his liver metabolized and eliminated it. He required frequent doses, usually hourly, which decreased over the next three days. He left the Hospital smiling, and as a bonus I didn’t have to pay for my fish for the rest of the time I was in the Caribbean!
SHARE YOUR CURIOUS CASES: When you come upon a case that grabs your attention – be it bizarre, rare or humorous – share it here. Cases should be 500 words or less, and photos are encouraged. Email cases to Logan@EPIJournal.com
ULTRASOUND Discussion Interpretation of the location and nature of an area of increased opacity on chest radiographs is sometimes problematic, particularly in young infants with varied configurations of the thymus, and differentiation between pulmonary, pleural, and mediastinal lesions is not always easy. Ionizing radiations can damage genetic information and induce malignant transformation of biological tissues. The risk of transformation depends on the dose of radiation, the vulnerability of the exposed tissue to the effects of the ionizing radiation, and the time that has elapsed since exposure. The risk of malignant transformation increases as a function of time from exposure. Radiated tissues do not recover from the transforming effect of a single exposure but retain the genetic damage in perpetuity. In this regard, diagnostic
imaging carries an irreversible lifetime risk that is particularly important among younger patients, especially those with actively dividing somatic cells5. Ultrasound imaging offers several advantages over traditional radiographic techniques: it is noninvasive, painless, and involves minimal contact. Emergency ultrasound studies can be performed at the patient’s bedside, avoiding the transfer of a potentially unstable patient to the radiology suite. It does not require the patient to remain motionless and it does not use ionizing radiation. Ultrasound is an ideal modality for serial examinations in rapidly evolving disease processes without concerns about cumulative radiation side effects.
REFERENCES CONT’D 9. Picano, et al: Ultrasound lung comets: a clinically useful sign of extravascular lung water. J Am Soc Echocardiography 2006; 19 (3): 356-632 10. Chen L, Baker M D. Novel applications of ultrasound in pediatric emergency medicine. Pediatric Emergency Care 2007, 23: 115-126
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PEDIATRICS
IFEM Finalizes Pediatric Road Map Last year, pediatric emergency medicine experts from around the world came together to form the first international guidelines document for the care of children in emergency departments. by dr. simon chu, plus an interview with dr. ffion davies [blue]
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n 2011, the International Federation of Emergency Medicine (IFEM) commissioned a paediatric special interest group, as part of the clinical practice committee, to create a standards of care document for the care of children in emergency departments. The reason for creating a standards document is to aid clinicians and managers around the world on supplying resources to enable emergency departments to deliver good paediatric emergency care. There are similar documents in the UK and USA, with resultant benefits of improved paediatric emergency care in those countries. The thought was that an international document would have a similar effect when used in other countries. Peter Cameron came over to the UK on a sabbatical. While he was visiting us I showed him what we call “the red book” which is a UK document that is a set of standards for pediatric emergency care. It was very successful because emergency pediatrics is an emerging sub-specialty of emergency medicine. It was at that stage where we’re still trying to draw the pediatricians and emergency guys together, and when a lot of hospitals still didn’t have particularly good facilities for children. Big teaching hospitals are fine, but outside of that, children were getting a bad deal and we had enough evidence to prove it. The UK document – and a similar one created in the USA – seemed to be successful in drawing a line in the sand and saying, “Listen, this is what you should be doing.” It helped the nurses and the doctors go to their boss, their management, and say, “Look, this is what we should be doing. We’re not doing it well enough at the moment.” Equally, the standards help with patient expectations as people ask, “what should our hospital be delivering?” So Peter came along and I showed him the red book because I had been chair of the committee that wrote the 2007 version. I told him how successful it had been, and he said, Why don’t we do an international version for IFEM? The special interest group has members
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from 7 countries around the world, including Argentina, Australia, Israel, Singapore, South Africa, UK and USA. The clinical practice committee chaired by Dr. Lee Wallis set up a pediatric special interest group. I then networked around the world to make sure we had representatives from each area who were well known in their field. We looked for people with specific emergency pediatric care experience but also with enough knowledge of international affairs that they would look at it not just from the point of view from their own hospitals, but with a global perspective. We were fortunate to get people with national and international reputations to join the effort, and we’ve basically been working as a special interest group ever since. From this, the challenge to produce a document which had value for resource rich and resource poor countries, with different cultures and health practices, was encountered but successfully resolved. Having a global perspective was easier than we expected. For instance, when we said it is an EP’s role to pick up on signs of child abuse and act on it, we had to recognize that around the world people have
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different degrees of tolerance. However, people told us that even in places where child abuse is rife, such as in Cape Town, there is a desire to declare it as unacceptable and have the doctor intervene. So we can stake our claims about child abuse and not cause controversy. It might be harder to achieve in Cape Town than in L.A. but the message stands true. The same was true about child-friendly care. We said that children should be protected from the sights and sounds of the adult ED as much as possible. Some of us do that already and have done it for years, and other people are finding that really hard because the kids get lumped in with the adults. But the principle remains, and that is our standard. I think whether a standard is lofty, or something you already do, or is something that will be debated at the local level, it is still the standard. Now we did give caveats. If you are running an out-patient clinic and you shut the doors at night and streams of people come from across the desert with donkey and cart and you have to wait all night for the doors to open and you’re seeing kids amongst everyone and everything else, that is not an emergency department. That is not an ER and that is not what these standards are for. At the African conference in Cape Town, we said, Look, this is all very well if you have this and that equipment, but if you’re in the middle of the bush and you aren’t actually an emergency department, these standards aren’t for you. If we tried to incorporate the little shack in the bush scenario or a tiny rural hospital, then we’d have a ridiculous set of standards. All in all, I was amazed how translatable the standards were without going so bland we weren’t saying anything useful. The document has 19 chapters which cover a wide range of topics, and not all purely about medicine. There are clinical topics including models of initial assessments in children, resuscitation and stabilization, and particular topics where we can be advocates of paediatric health, such as in child protection and in adolescent medicine. There are topics about service delivery, including appropriate staffing of EDs, child and family-centered care, supply of equipment and drugs for children, working within a health network, quality improvement systems, and supporting this with appropriate information management systems. Finally, there are topics to do with education and training, including staff training, research and academic emergency medicine training. This document has a wider scope and is more inclusive than those published previously in the USA and the UK. We have chapters on childbirth, adolescent care, child protection and pre-hospital, as well as a QA section and a staffing/training section. Basically there are 19 chapters, each being 3-4 pages, with recommendations at the end. It’s very, very concise so it should be user-friendly. The content is written with an international feel, avoiding regional terminology when possible. We’ve had to make sure that everything we say can be applied to every country as much as possible. All chapters are finished with a list of essential and desirable recommendations. Essential recommendations are those which we feel all international emergency departments should be able to deliver. Desirable recommendations are those which we fell all international emergency departments should strive to deliver, but this is based on continued on page 25
RISKY LEISURE
Steps descend to the edge of an active volcano. Will Nicaragua see a rise in eco-tourism injuries? Report on page 18
SOURCE FIRSTHAND REPORTS OF EM SPECIALTY DEVELOPMENT AROUND THE GLOBE
DISPATCHES 16 NICARAGUA 18 MEXICO 20 SOCIETY NEWS 21 ETHIOPIA 22
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SOURCE // DISPATCHES READER-SUBMITTED UPDATES FROM WEST TO EAST
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Q. What is the state of emergency pediatrics in your country/region? ______________________
01 UNITED STATES “Midwest USA - In our region, pediatricians mainly run the pediatric emergency departments in the community with fellowship-trained attendings at the academic centers.” -Benjamin Leacock ______________________
02 MEXICO “Fortunately, during recent years, most of the country has witnessed a major effort to improve the emergency care of pediatric victims. In the prehospital arena, the technicians have received special training and equipment to offer better care. In the hospitals they have specially desig-
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nated areas for pediatric victims.” -Carlos Arreola-Risa ______________________
03 COSTA RICA “Our emergency pediatric care is done by pediatricians. We do not have a pediatric emergency fellowship, but we have two pediatric emergency physicians. We are working to train fellows in pediatric emergency medicine.” -Mario Umaña ______________________
04 COLOMBIA “The pediatric emergency department at La Misericordia Hospital (Bogota) is a quality hospital for children; technology and warmth
Fall 2012 // Emergency Physicians International
Fall 2012 // Emergency Physicians International
define the service.” -José Navarro ______________________
05 ECUADOR “Pediatric emergency care service is conducted by a cadre of physicians highly-trained in disciplines of resuscitation and trauma care.” -Guillermo Perez Chagerben ______________________
06 DOMINICAN REPUBLIC “Pediatric emergency care in the Dominican Republic is evolving. We are moving past having an on-call pediatrician in charge of the ER, to having emergency resident and full pediatrician coverage in the emergency room. We are aiming to have
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emergency physicians in the pediatric ER with a fellow in peds 24/7.” -Pablo Smester ______________________
07 BRAZIL “Brazil has two emergency residency programs working with poor support. Unfortunately, the specialty is not recognized by the Brazilian board of specialities as an independent area. This is a major problem for the Brazilian Association of Emergency Medicine (Abramede), as it makes it almost impossible for the medical schools to open new programs. It also makes the area of emergency medicine less attractive as a career.” -Leonardo Lucena Borges ______________________
08 SWEDEN “PEM is becoming a defined competency based on the European
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their departments compared with the general ER. Although this is useful, there is still a struggle for subspecialty care due to the limited amount of tertiary centers and specialists.” -Adan Atriham ______________________
11 SPAIN “I think it needs improvement because in some emergency rooms there are pediatricians but in others, family physicians or general practitioners. The children require a different kind of attention in the ED that is not always met.” -Ana Navio ______________________
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syllabus as well as the existing Swedish EM curriculum and international guidelines published this summer. University hospital peds ED is led by an EM specialist. As EM becomes a basic speciality, no special training program for PEM is available yet.” -Pia Malmquist ______________________
09 DENMARK “Injuries and some of the surgical conditions go to the emergency department. Other pediatric patients go to the acute admission unit of the pediatric department.” -Dan Brun Petersen ______________________
10 UNITED KINGDOM “PEM in England is quite good – better than adult EM. Hospitals tend to ensure good staffing and equipment of the pediatric section of
Bosnia and Herzegovina “In big cities there is rapid response to emergencies but in rural parts it takes a long time to get to a doctor. Serious treatment for children happens in university hospitals or general hospitals. I think there is a place for improvement in the promptness of treatment through more education and new equipment.” -Gordana Vujic ______________________
13 EGYPT “The Emergency Medicine (EM) speciality in Egypt started in the early 1980’s but the progress was very slow, producing few EM specialists. Pediatric EM specialists are even more scarce. Currently, pediatric emergency care is carried out by general EM Physicians/Specialists.” -Hany Ebeid ______________________
14 SOUTH AFRICA “The speciality of paediatric emergency medicine is about to be recognised in South Africa. This will give doctors the opportunity to pursue a career in this much-needed discipline. The Emergency Medicine Society of South Africa plans to launch a paediatric emergency care
subgroup later this year in order to coordinate the efforts and raise the profile of excellence in paediatric emergencies.” -Melanie Stander ______________________
15 ETHIOPIA “In Ethiopia the overall emergency facilities are lacking. Pediatric emergency doesn’t stand alone. Most pediatric emergencies are handled by nurses and general practitioners and small number are handled by general pediatricians. There is emergency pediatric training and 3-4 hospitals with pediatric ICU’s in the country. Emergency medications and equipments are deficient.” -Bereket Tessema ______________________
16 SUDAN “The pediatric emergency care in Sudan is run mainly by pediatric specialists. We are planning to involve our emergency medicine residents in pediatric A&E soon.” -Hussain Abdelgadir ______________________
17 BAHRAIN “On average, we manage 100 pediatric cases a day and commonly manage neonatal sepsis, accidental injuries and ingestion, respiratory emergencies, Sickle Cell Disease with complications and seasonal illnesses. Our pediatric room has 10 beds, each with its own monitor. Unstable cases are managed in a common resuscitation room. We need more subspecialty trained PEM in toxicology and trauma” -Munawar Alhoda ______________________
18 INDIA “Pediatric emergencies are not differentiated from adult emergencies in our region (West Bengal) barring one renowned institute, known as Institute of Child Health, and few government setups. There are a few
co-ops where the hospital is motherand-child based and has some pediatric emergency capabilities.” -Saptarshi Saha ______________________
19 Czech Republic “The only Paediatric Emergency Department is in a university hospital in Motol in Prague. The hospital is the largest one in Czech Republic and Paediatric hospital within this University hospital provides superspecialised care, not only for CR, but also for the region.” -Jana Seblova ______________________
20 IRAQ “We have no specified pediatric emergency specialty, but we have a pediatric emergency department within pediatric hospitals. A few pediatric doctors conduct a training course in PALS (Pediatric Advanced Life Support).” -Shakir Katea ______________________
21 SAUDI ARABIA “Paediatric Emergency care in Saudi Arabia is highly developed in a few specialized hospitals where there are emergency medicine board training programs. However these constitute nine centers out of more than 150 hospitals providing daily healthcare to the paediatric population. We need to graduate more paediatric EM fellows in the future to improve care, standards and protocols.” -Ahmed A. Shammah AlGhamdi ______________________
22 PAKISTAN “Paediatric emergency medicine is still not recognized as a speciality in Pakistan. We’re still striving to make paediatricians realize that it is a separate entity.” -Jabeen Fayyaz
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SOURCE
Medical Student Hannah Watson, Dr. Ramon Millan and Dr. Francis Arauz review a radiograph in the emergency department at Lenin Fonseca Hospital in Managua
3.7 Physicians per 10,000 people
NICARAGUA
The Central American state takes steps towards emergency medicine development through a collaboration with Brown University by robert partridge, kimberly pringle, john foggle, hannah janeway, rebeca herrera, martha bendaña and david bouslough
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ordered by the Atlantic and Pacific Oceans, Nicaragua is the second largest Central American state. It is also the second poorest in the hemisphere (after Haiti) and has the smallest population. Its 6 million citizens have emerged from a decade of civil war in the 1980’s into a period of stability over the past 20 years. The economy primarily relies on agriculture, but textile exports and tourism are also important. Nicaragua is home to numerous active volcanoes, and has faced many natural disasters in the past 40 years, including the 1972 earthquake, which killed more than 10,000 people, primarily in the capital Managua, and Hurricane Mitch in 1998. Emergency medicine has undergone rapid development in Nicaragua and the delivery of healthcare has improved over the past two decades. The unified health system that was created after the civil war emphasized improved access to medical services through
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the institution of a national network of more than 350 local primary care health clinics, disease prevention and vaccination programs, along with an increase in health care spending. In addition, the number of students entering medical schools annually has jumped more than five-fold, and the number of hospitals nationally reached 24 in 2006. As a result, there have been significant improvements in the number of preventable and transmittable diseases over the past three decades. The leading causes of morbidity and mortality are now non-communicable diseases (cardiovascular disease, diabetes, trauma, cancer) which have replaced communicable diseases such as respiratory disease, diarrhea, malnutrition as leading causes of death. Deaths from infectious diseases are down by 50% since 1996. But despite these positive changes, the vast majority of the health care budget is allocated to urban areas, primarily Managua, and the system remains understaffed, under-equipped, and
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Most Common Illnesses bacterial diarrhea hepatitis A typhoid fever dengue fever malaria leptospirosis 22.86 Deaths per 1000 live births. Ranked #137 in infant mortality $1,126 The GDP per capita, in US dollars. Nicaragua is the 2nd poorest country in the western hemisphere $284 Million (USD) Foreign direct investment in Nicaragua in the EM diplomate program. Source: CIA World Fact Book
under-funded. Nicaragua’s physician workforce is sparse, with an average of 3.7 physicians per 10,000 members of the population, one of the lowest in the western hemisphere. Significant inequities in access to health care services, and therefore, health outcomes overall, exist between rural and urban areas of Nicaragua. Much of the burden of poor health outcomes is borne by the 40-50% of the population who reside in the rural sector. Emergency medicine in Nicaragua was first recognized in the early 1990s when the Ministry of Health, because of increasing morbidity and mortality due to trauma and other treatable diseases, declared that emergency services and critical care development was its highest priority. Emergency departments were established at Roberto Calderón and Lenin Fonseca Hospitals, Managua’s two main public hospitals, with designated space, equipment, and hiring of full-time emergency physicians who had been trained in other specialties. The first emergency medicine residency program was established in Nicaragua in a small private hospital, Hospital Bautista, in 1992. Since that time two other university-based emergency medicine residency programs have been established in Managua at Roberto Calderón and Lenin Fonseca. The first of these public hospital-based emergency medicine residency programs was established in 1998 and graduated its first class in 2001. The Universidad Nacional Autónoma de Nicaragua, (UNAN) serves as an umbrella organization for the three residency programs in Nicaragua. Although the residencies at Roberto Calderon and Lenin Fonseca Hospitals are considered separate, the residents rotate at both hospitals and have a friendly relationship. A total of sixty-nine residents have now graduated from the three EM programs. Three of these EM-trained physicians remain at Roberto Calderón as core training faculty, and two remain at Lenin Fonseca. Currently, there are 13 residents at Roberto Calderón and 11 residents at Lenin Fonseca in-training within the three classes; the most recent academic year began in April 2012. Residents rotate at more than three adult hospitals, including Roberto Calderón, Lenin Fonseca, and the Women’s Hospital. Bertha Calderóne. Residents also rotate
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at one of two pediatric hospitals, including Hospital Manuel Jesus de Rivera: “La Mascota”, at an ophthalmologic hospital, Centro Nacional de Oftalmología, and at the psychiatric hospital Hospital José Dolores Fletes. Resident training is structured, but residents must be proactive and self-directed in their learning. Triage and diagnostic work-ups are usually performed by EM residents, and some procedures, especially intubations, are frequently performed by EM physicians. However, other procedures, such as chest tubes, are more commonly performed by surgery residents with EM residents performing the procedure only on occasion. Ultrasound, although available, is performed only by radiologists. In general, EM residents are exceptionally self-driven and proactive in identifying barriers to and deficiencies within their education and advocating for improvement. They note a continued struggle in earning the respect of their medical and surgical colleagues, and strive to establish credibility and respect for specialty of emergency medicine in Nicaragua. Nicaragua is in need of well-trained physicians with a broad skill-set that will allow improved access of care for all, from the pediatric population suffering from preventable causes of illness such as dehydration and infectious diseases (including malaria, dengue fever, leptospirosis and HIV/AIDS), to the adolescent population at increased risk of traumatic injury, to the adult population bearing the burden of the sequelae of non-communicable disease. The specialtytrained emergency physician has the ability not only to contribute immediately to the urgent healthcare needs of the Nicaraguan population, but also to train future providers in the field and make a contribution to a needed physician workforce. By mutual agreement, the two EM
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01 Dr. Francis Arauz and Dr. Ramon Millan examine a patient in the sala de choque at Lenin Fonseca Hospital 02 Dr. John Foggle teaches residents and medical students at Roberto Calderon Hospital
residency programs in Managua and the EM residency program at the Warren Alpert Medical School at Brown University have formalized an institutional relationship to promote clinical care, education, EM residency curriculum and programming guidance and academic development in Nicaragua. Specific areas of concentration include: • Formal International Emergency Medicine Resident Electives in Managua, Nicaragua • Medical student exchange programs between UNAN and Brown • EM faculty exchange • EM / Trauma / ATLS in Low-Resource Settings • ACLS in Low-Resource Settings • Pediatric Intensive Care • Tropical Infectious Disease (Malaria, Dengue, Leptospirosis) • AIDS-Defining Illnesses • In March, a group of seven EM faculty and residents, as well as Brown University medical students, traveled to Nicaragua to give a series of lectures in emergency medicine, as well as perform both clinical services and clinical teaching at the largest hospitals in Managua. This faculty exchange will
continue in October 2012 when Nicaraguan EM faculty visit Brown after attending the ACEP Scientific Assembly. Improvement in acute trauma management has been identified by Nicaraguan EM leaders as a component of emergency medicine training and practice that will have a significant impact in improving individual patient care and public health. An upcoming step in the collaboration with UNAN will be a one week adult and pediatric trauma course tailored specifically to Nicaraguan needs and resources. This will be taught in Managua by both UNAN and Brown faculty and residents to emergency medical providers practicing in urban and rural Nicaragua. The collaboration of the established EM residency programs in Nicaragua and the Department of Emergency Medicine at Brown University is based on mutual learning through exchange of students, residents and faculty. This program seeks to advance the specialty of emergency medicine at both locations through education, research, patient care and academic development.
Now Accepting ‘Source’ Reports for EPI Issue #10 EPI’s ‘Source’ section is your chance to let the world know how emergency medicine is developing in your country. Share your latest projects, political updates and regional research. No previous writing experience necessary. Submit Source Reports by emailing Logan Plaster: Logan@EPIJournal.com
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SOURCE
Private Health Insurance accounts for 4% of medical expenditure in Mexico. (Health Affairs Magazine)
//
MEXICO
The PACE program faces hurdles as it lobbies for emergency ultrasound training in Mexico by haywood hall, md
I
t takes very little to convince emergency specialists that emergency ultrasound is a valuable tool that needs to find wider application. We excitedly refer to it as the “new stethoscope” and physicians the world over are wowed by its potential. However, when it comes to bringing ultrasound to a developing health system – where resources are centrally determined and providers may have limited training – things get more complicated. Radiologists and other specialists, as well as hospitals administrators, are often resistant to having ultrasound in emergency departments. The reasons range from legitimate concerns about training levels to base turf wars. We have fought these battles in the United States (and it took decades), but they are just beginning to emerge in Mexico, where the ER provider is often the lowest person on the totem pole. At PACE, we have been successfully teaching FAST for the last 12 years, but it’s
20
just the beginning. For ultrasound to develop, you need equipment available as well as vision, and you need the vision to come from the top. To be truly successful, the Health Ministry will have to consciously adopt the vision and train their front line emergency physicians in emergency ultrasound and provide safe harbor for the use of this technology. In June, 2011, PACE took a solid step in this direction when it held an emergency ultrasound course called PACE SONO at the IFEM symposium in San Miguel de Allende. It was a translation of the successful Third Rock Ultrasound course. While this course seemed like a great success, when we tried to get the program ported to the IMSS system (the largest provider of medical care in Mexico) it was blocked by a hospital that had every reason to adopt it. The facility had a flagship emergency medicine program in Mexico City and their radiologist was double boarded in emergency medicine. In rural
Fall 2012 // Emergency Physicians International
We have fought these battles in the United States (and it took decades), but they are just beginning to emerge in Mexico, where the ER provider is often the lowest person on the totem pole.
hospitals, there is even less tolerance and less capacity, so the barriers are even higher. The PACE program’s next strategy is to continue to teach Ultrasound wherever we can – wherever there is support – but at the more fundamental FAST level. One key for the future will be for the “stethoscope for the 21st century” idea to begin stick at the medical school level. Then, when doctors graduate as general physicians (and begin to practice at that level, as most do) they can be minted as GP sonographers. By doing this, we will “desensitize” the system to the use of the technology. And this is a charge that can, and should, be led by emergency physicians. That way, when critics finally acknowledge the efficacy of point-of-care ultrasound use by general practitioners, the doors will swing open for emergency physicians and for clinical ultrasound in general. It is not immediately rewarding to take such a long view, but I believe that it is essential to have an impact at the systems level. To encourage emergency ultrasound in developing systems, we need to show the decision makers at the highest levels that implementation can provide the increased efficiency in terms of patient outcomes, safety and optimal use of workforce. At the same time, we must doggedly seek to understand the system at hand – what worked in the United States or in the UK might not work in Mexico. What is the profile of the provider? Can a GP in an ED put a central line in with confidence? Will the system allow it? If global EM experts are episodically dropping in to “help” without being sensitive to the context, they will only be able to superficially expose providers to the technology. While this has a place, it is not necessarily high impact. Clinicians will always be interested in technological advances, but to be successful, there has to be a fundamental basis for culture change. What data will the Ultrasound missionary have in hand to convince the authorities? In our situation, we’ve decided that one positive step is to find a medical school that is willing to train all of their graduates in ultrasound, and then change the game. This is what we are attempting to do at the University of Celaya School of Medicine in Mexico. A ray of light in this ongoing struggle continued on page 25
SOCIETY NEWS
The Africa Desk News from the African Federation for Emergency Medicine (AFEM) by lee wallis, md
E
mergency care is slowly but surely getting onto the radar of governments and other stakeholders in the region, with several recent noteworthy developments to bring to your attention. In Ethiopia, the Black Lion Emergency Department continues its successful collaboration with the university of Wisconsin and Toronto University, with its first class of residents making excellent progress through their training. The Ministry of Health has recently invested in several hundred new ambulances, in addition to piloting bicycle ambulances in the rural regions, and is embarking on an ambitious plan to train 5000 EMTs in the coming years. The Ethiopian Society of Emergency Medicine Professionals was recently formed, and is hosting its first conference in Addis Ababa in early October (details are on the website: www.esemp.org). Excellent progress continues to be made in Uganda towards the development of the first EM residency programme. More details are available if you are keen to find out. The African Federation for Emergency Medicine hosts its first conference in Ghana in late October (www. acem2012.com); the first 120 locally trained EMTs will be attending, in proud recognition of the advances in prehospital care in that country. AFEM is also making great progress in the development of a one-year programme in emergency care, aimed at General Practitioners in the region. All content for the curriculum will be open source online. The first East Africa regional meeting on emergency medicine will be held on 3-4 December in Dar es Salaam, hosted by the Muhimbili Emergency Medical Department and supported by Abbott Fund Tanzania. The aim of the meeting is establish a regional federation for resourcesharing and coordination of emergency care efforts. Contact teri.reynolds@ucsf.edu for more information
Submit news from your emergency medicine society for publication. Email Logan@EPIJournal.com
www.epijournal.com
21
SOURCE
ETHIOPIA
Strengthening emergency medicine by building human and institutional capacity at Addis Ababa University/Tikur Anbessa Hospital by aklilu azazh, md; heidi busse, mph; peter rankin, bs, rn sisay teklu, md; janis tupesis, md; assefu woldetsadik, md ryan wubben, md; girma tefera, md
B
rought together by a shared concern about the challenges in delivering emergency medical services in Ethiopia, Addis Ababa University’s Tikur Anbessa Hospital (AAU/TAH), the University of Wisconsin-Madison (UW), and the non-profit diaspora organization People To People (P2P) formed a twinning partnership in the fall of 2009. Twinning partnerships are founded upon guiding principles that emphasize collaboration and relationshipbuilding. This partnership received a fiveyear grant from the United States President’s Emergency Plan for AIDS Relief (PEPFAR) and the U.S. Centers for Disease Control and Prevention (CDC/Ethiopia), administered by the American International Health Alliance (AIHA). The goal of this collaboration was to
June 2006: Formation of Emergency Medicine Task Force at AAU, with members representing all clinical departments.
22
Fall 2009: First group of EM Fellows conduct training at UW.
2008
Fall 2012 // Emergency Physicians International
Bi-directional Exchange Trips A series of technical exchanges based on the train-the-trainer model were conducted at AAU, with courses adapted to the Ethiopia setting. Trainings were designed for a range of health care workers, including residents, physicians, nurses, midwives, ambulance drivers, and community health workers. The courses were initially taught by trained emergency professionals from the U.S., while a cadre of local instructors was developed. Expansion of Local Workforce In order to increase and sustain local capacity to deliver emergency medical care and
Fall 2009-Present: UW and other US institutions conducted exchange trips to teach emergency modules at AAU.
Summer 2009: Twinning Partnership formed between AAU, the University of Wisconsin, and People To People.
2007
Off and Running: The Ethiopian Society of Emergency Medicine Professionals held its inaugural meeting this month in Addis Ababa. Learn more at esemp.org
Leadership Training and Development The partnership conducted a condensed competency-based EM Fellowship for four Ethiopian physicians and four nurses at the University of Wisconsin who would serve
Aug. 2008: First Emergency Services Unit established at AAU/Tikur Anbessa Hospital.
Oct. 2006: National consensus workshop on Emergency Medicine, held in Addis Ababa.
2006
enhance and strengthen emergency care at AAU/TAH by building institutional and human resource capacity, and by increasing the number of medical professionals trained to deliver emergency care. This collaboration was designed with the local setting and resources in mind, with active leadership from the Ethiopia diaspora. Given the successes achieved by this partnership, it may provide lessons for replicating to similar environments. The Ethiopia emergency medicine partnership followed a six-phase model to address the spectrum of emergency services:
as the leaders of the newly emerging AAU/ TAH emergency department. The curriculum was designed for experienced Ethiopian physicians and nurses to augment their practice and enhance their professional development. It incorporated elements of critical and trauma care, quality improvement, leadership, and management. The physicians and nurses were trained simultaneously at the UW to foster communication and teamwork. The physicians had more than five years of patient care experience and were all trained in specialties such as anesthesiology, internal medicine, surgery, obstetrics/ gynecology, and pediatrics. The nurses were experienced health care workers.
Feb. 2010: AAU launches Emergency Training Center and hosts EM Symposium. Graduate programs in EM approved by AAU Senate. Summer 2010: AAU’s Emergency Services Unit is converted to an ED Sept. 2010: First class of Emergency Medicine residents are started at AAU.
2009
2010
Oct. 2010: AAU Pediatric EM fellowship (for physicians and nurses) conducted at UW. Oct. 2010: University of Toronto conducts first exchange trip to AAU/ TAH.
2011
March 2012: Ethiopian Society of Emergency Medicine Professionals (ESEP) is formed. October 2012: CME Conference and ESEP Meeting to be held at AAU
2012
TWINNING: BUILDING THROUGH PARTNERSHIP 1. Build Partnership Collaborate with those who share principles, goals, and resources that complement each other
6. Disseminate Information Communicate results with partners and plan for sustainability
education, an emergency medicine training center (EMTC) was established at AAU in 2010. The EMTC provides instruction and certification in emergency courses, keeping health care workers’ skills up-to-date and expanding the trained workforce. It has trained over 2000 health care workers from TAH and hospitals from across the country.
3. Implement Program Develop calendar of exchanges, ID trainers, specify training objectives, and communicate
2. Develop a Work Plan Select priorities through a needs assessment, then craft a shared work plan and budget
5. Evaluate Results Assess trainings with multiple assessment tools and use results to inform ongoing program changes
4. Monitor Outcomes (Process, Impact) Keep records of activities; evaluate QI projects; review & update work plan
The AAU EMTC aims to gain international accreditation for some courses by Fall 2012. Graduate Education Programs Ethiopia’s first EM residency program was launched at AAU in September 2010. Five residents were enrolled in its first class. The curriculum was modeled after the UW
EM residency curriculum (goals, objectives, rotations, timeline), but was collaboratively and uniquely adapted to the local setting and practice. Additionally, a Masters in Nursing training program was established at AAU with 20 students enrolled in the first class. continued on page 24
Join the healthcare transformation of a nation
First class opportunity for specialist emergency physicians in Qatar Hamad Medical Corporation (HMC) is the premier provider of secondary and tertiary care in Qatar, and one of the leading healthcare providers in the Middle East. HMC manages eight highly specialized hospitals and is committed to providing high-standard services to the country’s growing population. We are expanding our team of clinical experts to facilitate greater knowledge transfer and ensure world-class, evidence based patient care. The Positions We are looking for senior and junior specialist emergency physicians to join our team at Hamad General Hospital. These posts are a first class opportunity to become involved in the transformation of our emergency department as a locum or longer term member of the team.
The Opportunity • Work in a high-volume, culturally diverse emergency department that sees up to 1500 patients a day • Treat a unique and interesting clinical case mix • Experience strong executive support within a great international team • Develop research and special skills The Package • Accommodation • Tax-free remuneration • Generous leave and other benefits for those appointed to substantive posts Visit us in the exhibition hall at the ACEP 2012 Scientific Assembly, Denver and the ACEM Annual Scientific Meeting, Hobart
For further details please contact: Professor Peter Cameron - Chair, Emergency Department at pcameron@hmc.org.qa or Dr. Don MacKechnie - Director of Emergency & Acute Medicine Transformation at dmackechnie@hmc.org.qa
www.epijournal.com
23
SOURCE: ETHIOPIA 3 continued
from page 23
Key Themes
Challenges
Successes
Knowledge Transfer and Shared Responsibility
• Communication (due to distance and time zones) and limited human capacity to cooperatively adapt trainings to Ethiopia setting meant that trainings were designed by Americans and not completely relevant. It took time and repetition of trainings before the knowledge and ownership was fully transferred.
• Identified Ethiopians to participate in “Training of Trainers” to build a local base of instructors. The fellows took leadership roles in designing and conducting trainings that were adapted to the Ethiopia setting. • Included non-physician health care workers in training & mentorship activities since responsibilities in the ED often fall to nurses and residents • Through trial and error, the partners learned how to better incorporate input from Ethiopian partners when designing trainings and curricula.
Engaging Multiple Partners and Stakeholders
• Institutional knowledge about past EM research projects and partnerships at AAU was not always recorded or communicated, which led to duplication of efforts. Communication among multiple institutional partners was challenging, especially as the participation level naturally ebbed and flowed.
• Utilized the diaspora community and their networks. • Collaborated with multiple international academic institutions to conduct trainings, residency program evaluation, and exchange ideas. • Conducted monthly conference calls. • Visited community EM services such as 911 Call Center and Fire Departments.
Professional Development Activities
• Ethiopia has a shortage of health care workers, and providing training could lead those trained to leave Ethiopia for a private hospital that paid more or offered better opportunities.
• Conducted workshops on clinical research for fellows and sought opportunities for collaborative research projects between Ethiopian and American colleagues to build professional capacity. • Identified global EM conferences for fellows and nurses to attend and/or present at. Improved local working conditions, environment, and salaries. • Built professional, peer-to-peer relationships.
Teamwork and Communication
• There is a clear hierarchy within the medical profession, not only in Ethiopia but also the U.S. This at times may have limited full participation of all team members.
• Emphasized teamwork and communication in hospital and pre-hospital settings, both in the fellowship curriculum and EM trainings. • Recruited diverse attendees, such as nurses, midwives, community health workers, residents, interns.
Cultural Exchange and Appreciation
• Language barriers • Social roles and customs • Gender roles
• Shared meals, social events, and visited cultural sites in both Ethiopia and Wisconsin, spending time together outside of the hospital to build understanding and friendships. • Worked to understand cultural differences, not necessarily change them.
Lessons Learned Through program evaluations and key informant interviews with program staff and trainees, key themes emerged that contributed to the partnership’s success. One of the fundamental principles of a twinning partnership is that information is mutually exchanged, whereby all partners communicate and priority is given to building relationships (process) rather than producing outcomes (product). This helps ensure that program efforts are sustainable and responsive to the
24
local context. Solutions implemented to ensure this is achieved include communication strategies, clear definition of roles, sufficient time for trust and peer relationships to be built, and recognition for individual accomplishments and shared successes. The Ethiopia EM twinning partnership will continue to take a systems approach to support emergency training, research, and infrastructure at AAU/TAH. This includes the EM residency program, a critical care fellowship, nurse training and empowerment,
Fall 2012 // Emergency Physicians International
pediatric emergency and critical care, quality improvement and leadership. The shortterm achievements of this twinning model suggest that long-term, collaborative partnerships can be effective in systems strengthening and components adapted to similar environments may achieve equal success.
MEXICO 3 continued
IFEM FINALIZES PEDIATRIC GUIDELINES
from page 20
has been the OB FAST Ultrasound Workshop in our Advanced Life Support for Obstetrics (ALSO) which we run in Mexico. It introduces the use of point-ofcare ultrasound in a health care arena that the Health Ministries consider very high priority: decreasing maternal mortality. PACE has trained over 5,000 people in Mexico in the ALSO program (and American Academy of Family Physicians program). Many of them have been general practitioners and we often include the popular OB FAST Ultrasound workshop. From this groundwork, physicians can develop other ultrasound skills. At the 1st IFEM Symposium on resuscitation in San Miguel de Allende Mexico held last June, the third Rock/ PACE SONO course was held and international faculty, such as Drs. Jeremy Smith and Long Tran (UTSW), Darryl Macias (UNM), and PACE Fellow David Price along with the Mexican EM leadership held a ground breaking course. PACE is providing these lectures on video in both languages through the EPI social media web site; these lectures can be used as a resource throughout the Spanish speaking world. EM ultrasound will inevitably find its place in the sun. Let’s work through the context issues so that it can occur as fast as possible.
3 continued
from page 14
the amount of resources their health system can provide. What we did in the document – something I’m proud of – was have a couple of paragraphs of introduction under each heading explaining why that section matters. Some of it is obvious and works the same for every ER in every country, but remember, there are going to be some pediatricians reading this who have no idea how to run an emergency department. Then the next title in every single chapter is, “Differences Between Children and Adults.” That’s the attention-grabbing bit. This is where I, as the general ER doc or the general manager, learn why I should care. Kids are actually different in some respects, and this second section of every chapter points out exactly why you need to keep reading. We hope that it will drive down healthcare costs around the world. We’ve gone to Cape Town and showcased the guidelines in their early stages to a bunch of doctors from all over Africa and beyond, and they were very well-received. Everyone was saying, “This is exactly what we
need in our country; we don’t have anything like this.” They can then take these standards to their hospitals and say, “Look, these are internationally agreed-upon standards. This is what we should be doing.” Beyond Africa, we’ve got representatives in the writing group from Israel, Argentina, Singapore and Australia – everyone is saying that this would be so useful to have in their own countries. The demand seems to be high and there are a lot of people out there trying very hard to fund the care of children who get neglected. We’re hoping to have a published version soon as well as the web-based version and I’m hoping they’re able to use this in their own organizations to bash their CEO over the head and say, “This is what we need to be doing.” But also we’re hoping that each country in IFEM will use its own conferences to propagate the work. We hope that each member country will be its own distribution point and use their own society, their own college to make people aware of it and publicize it and perhaps put links on their website. We’re hoping that everyone will pull their weight.
The International Emergency Medicine FACULTY DEVELOPMENT AND TEACHING COURSE November 11 -16, 2012 | Baltimore, Maryland, USA The International Emergency Medicine Faculty Development and Teaching Course is a weeklong educational experience, in Baltimore, Maryland USA, that combines didactic sessions, group discussions, and interactive workshops. The course is designed specifically to meet the career development needs of international emergency medicine faculty. It is intended for physicians who seek to enhance their own development as faculty members, to improve their skills as medical educators, and to participate in the development of emergency medicine in their home countries. Our goal is to provide course participants with:
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25
R report
// cancer emergencies
Korea’s ‘Cancer ER’ Improves Care While Lowering Costs
Table 1: Characteristics, main diagnoses, treatments and dispositions of the patients managed in the CER
Solid
4886
88.8
In 2009, Asan Medical Center in Seoul, Korea, set up a multi-disciplinary emergency department specifically for cancer patients. This retrospective study was conducted to compare the care provided before and after the Cancer ER (CER) was established.
-Gastrointestinal tract
1962
35.6
-Lung
1100
20.0
-Hepatobiliary
786
14.2
-Breast
576
10.5
-Others
462
8.4
Hematologic
616
11.2
Disease progression
3054
55.5
Infections
1257
22.8
Treatment related problems
806
14.7
Non-cancer related problem
385
7
Antibiotics
1590
28.9
Pain control (opioid titration, pain clinic consultation)
1260
22.9
Drainage
891
17.5
Supportive care (nutritional supply, hydration) only
589
10.7
Colony stimulating factor
456
8.3
Transfusion of blood components
429
7.8
Radiotherapy (WBRT, GKRS, palliative radiotherapy)
352
6.4
Others
172
3.1
Discharge for outpatient follow-up
2902
52.7
Admission to inpatient unit
2310
42.0
Transfer for hospice
248
4.5
Discharge with home service
32
0.6
Death
10
0.2
by shin ahn, md
W
ith increasing incidence of cancer in the general population, combined with improved survival and widespread use of cancer therapeutic agents relying on the outpatient treatments, emergency physicians are increasingly encountering patients who present with symptoms related to underlying cancer and diverse toxicities that are direct effects of its treatments [1]. However, there is minimal reference to the published literature regarding the percent of cancer patients who usually present with oncologic emergencies and their subsequent managements. In May 2009, Korea’s Asan Medical Center set up an ED cancer unit, named Cancer Emergency Room (CER), designed for focused and specialized management of oncologic emergencies. This paper will clarify the operating characteristics of the CER and provide support for its administrative benefits, as well as discuss relationships between the patients’ diagnosis and their subsequent managements, including dispositions in ED. Methods
The Asan medical center ED is a 97,000 visitsper-year ED in Seoul, Korea, and serves as a tertiary referral center. In May 2009, the CER was opened. In this year, it had monthly census of 360 patients with 18 beds allocated, and since January 2010, beds were increased to 22. This unit is staffed by one board certified emergency physician and one emergency medicine and one internal medicine resident work in turn. Patient managements are supervised by the board certified emergency physician, and oncology and hematology staffs are invited in making further decisions during their daily rounds. Adult patients 15 years and older with cancer and who were managed in Asan medical center oncology and
26
Age (years)
57.4±12.9
17–89
Male, N (%)
3070
55.8
Characteristics
Number
%
Underlying Malignancies
Main diagnoses
hematology department are eligible for the CER, so the new visitors or those who were managed in other departments are not allocated, and trauma related visits were also not indicated. Owing to its sixth floor location, the CER was not suitable for patients with profound shock, or requiring immediate resuscitation including airway management or cardiopulmonary resuscitation. When a patient enters the normal ED, he or she is triaged by triage nurse, and if the patient fulfills the criteria, he or she is assigned to the CER. Since this unit has fixed number of treatment beds (it was increased again to 30 beds in January, 2012), once the beds are full, all patients are sent to the normal ED. We performed a retrospective electronic medical record review of all patients admitted to the CER during the 12-month period between January 2010 to December 2010, and data of patients managed in the preexisting ED during January 2008 to December 2008 were collected to compare the care before and after the introduction of the CER. We recorded baseline characteristics, including age, gender, and underlying malignancies. Main diagnosis and treatments considered the most important were selected. Disposition of the patient, and their length of stay in the CER and inpatient unit for those admitted were calculated. Cost of ED and inpatient care were collected and calculated in United States dollars. Demographic data, chief complaints, cancer diagnosis, length of stay, and disposition were gathered electronically from the electronic medical record database. Diagnosis and main treatments were reviewed by two nurse practitioners who were blinded to the goals of this study, and data entry was reviewed on 30% of patients by one of the study’s lead investigators to ensure the consistency on the data acquisition. The study protocol was approved by the ethics committee of University of Ulsan.
Fall 2012 // Emergency Physicians International
Main treatments*
Disposition
*Some patients receive more than one treatment
Results
During the year 2010, 7,288 adult patients with cancer visited our ED. Excluding 212 patients with newly diagnosed cancer who were transferred from other hospitals, 455 patients whose cancer not being managed in the oncology and hematology department, 108 trauma related visits, and 114 patients requiring immediate resuscitation, 6,399 were indicated for management in the CER. However, due to fixed number of treatment beds, a total 5,502 patients were managed in this area. The mean age was 57.4 years (range 17 â&#x20AC;&#x201C; 89), and 55.8% were men; 88.8% of underlying malignancies were solid tumors and 11.2% had hematologic malignancies. Lung (20%), stomach (17.5%), colorectal (12.9%) and breast cancers (10.5%) were the most
prevalent in terms of emergency visits among solid tumors, as lymphoma (5.7%) and multiple myeloma (3.2%) among hematologic malignancies (Table 1). Of the 5,022 patients, 90.8% were under active treatment with chemotherapeutic agents, and among them, 53.9% received anticancer treatment within one month (37.2% within 15 days, and 16.7% between 15 â&#x20AC;&#x201C; 30 days), and 12.0% had treatments between one and two months. In 24.8%, more than 2 months were passed since their last treatment. And 4.8 % were under radiation therapy and 6.2% were receiving supportive care without treatment. Emergency visit related diagnoses
Diagnoses varied but were grouped into four main categories: disease progression (55.5%), infection (22.8%), treatment related complications
(14.7%), and non-cancer related problems (7%). Bowel obstruction (10.9%) caused by peritoneal carcinomatosis, cancer invasion, or paralytic ileus was the most common diagnosis related to disease progression, and effusions (9.3%) including peritoneal, pleural and pericardial space, and cancer pain (7.7%) followed. Central nervous system metastases (7.0%) including brain parenchyme, spinal cord, and leptomeningeal seeding were also common diagnosis. Pulmonary system (10.7%) was the most common site for infections, and biliary tract (2.0%) followed. Although rare, catheter-related infection was important problem for those with port implanted in the subcutaneous space. Febrile neutropenia (8.0%) was the most frequent treatment related problems, and oral mucositis, chemotherapy induced colitis, and radiation pneumonitis, were all unique problems
Table 2: Difference in main treatments according to main diagnoses Main Treatments* Main diagnosis
Parenteral antibiotics
Pain control
Drainage
Supportive care only
Colony stimulating factor
Transfusion
Radiotherapy
27/3054 (0.9%)
1134/3054 (37.1%)
804/3054 (26.3%)
496/3054 (16.2%)
35/3054 (1.1%)
264/3054 (8.6%)
352/3054 (11.5%)
1166/1257 (92.8%)
76/1257 (6.0%)
65/1257 (5.2%)
19/1257 (1.5%)
15/1257 (1.2%)
15/1257 (1.2%)
0
Treatment related problems
375/806 (46.5%)
16/806 (2.0%)
18/806 (2.2%)
54/806 (6.7%)
406/806 (50.4%)
128/806 (15.9%)
0
Non-cancer related problems
22/385 (5.7%)
34/385 (8.8%)
4/385 (1.0%)
20/385 (5.2%)
0
22/385 (5.7%)
0
1590/5502 (28.9%)
1260/5502 (22.9%)
891/5502 (17.5%)
589/5502 (10.7%)
456/5502 (8.3%)
429/5502 (7.8%)
352/5502 (6.4%)
Disease progression Infections
Total
*Some patients receive more than one treatment www.epijournal.com
27
R report
// cancer emergencies
associated with cancer treatments. Main treatments
Parenteral antibiotics administration (28.9%) and pain control with opioid (22.9%) were the most common treatments. Tapping for effusions, stent insertion for obstructed bowel, drainage for biliary or urinary tract obstructions, repositioning of previously existing catheters, et al., were treatments classified as drainage procedures (17.5%). Supportive care with parenteral hydration and nutritional supply (10.7%), and colony stimulating factor administration for neutropenia (8.3%) were also common. Whole brain radiotherapy or gamma knife radiosurgery depending on the extent of metastases, palliative radiotherapy for metastatic bone pain or spinal cord compression, et al., were classified as radiotherapy (6.4%). Anticoagulation for newly diagnosed venous thromboembolism and vascular interventions including inferior vena caval filter or superior vena caval stent were rare but important treatments, and classified as “other treatments.” Difference in main treatments according to main diagnoses was analyzed. In patients with infection, parenteral antibiotics were given in 92.8%, and 46.5% of treatment related problems received parenteral antibiotics. Pain control was done in 37.1% of disease progression, compared with 8.8% of noncancer related problems. Supportive care only was provided most commonly to patients with disease progression (16.2%), however 1.5% of infection and 6.7% of treatment related problems received such treatment (Table 2).
catheter care, parenteral opioid administration et al., and 4.5% were transferred to other hospitals including hospice care center. Regarding disposition of patients, the largest proportion of patients with infections (64.3%) were admitted to inpatient unit, compared with relatively small portion of treatment related problems (26.4%), (P < 0.05). Although statistically not significant, half of patients with disease progression were discharged for outpatient follow up, while 7.7% were transferred to other hospitals including hospice care center. Death during stay in the CER took place in 10 patients, whose main diagnosis was all disease progression. Majority of patients with non-cancer related problems (89.9%) and treatment related problems (73.1) were discharged (P < 0.05) (Table 3).
cancer-related emergencies, which will present as a challenge for emergency physicians. In May 2009, for the purpose of prompt and pertinent management of increasing patients with oncologic emergencies, our institute established an ED unit for cancer, separated from the preexisting crowded ED treatment area. It is designed to segregate the cancer patients from the heterogeneous patient groups in ED, owing to their susceptibility to infections and their unique problems regarding malignancy and its treatment related complications. While ED oversees various units for the care of patients with different illnesses [3-5], to the best of our knowledge, ED units separated and specialized for oncologic emergency has not been reported elsewhere. An institute in Spain runs the oncology acute toxicity unit for improving the management of chemotherapy toxicity, but it is an outpatient facility, which is different from ours based on ED[6]. Definitive managements of various oncologic emergencies are usually performed in inpatient unit. However, our data shows that ED unit for cancer could deal with oncologic emergencies while patient staying in ED. This was possible because we have incorporated multidisciplinary team approach including emergency medicine, medical oncology, radiation oncology, interventional diagnostic radiology, and hospice and palliative care members. Using algorithm-driven cares allowing for standardized and rapid treatments, and policy of transfer to hospice center for the patients with low benefits of further palliative management also helped. Traditionally hospice care is defined as support and care for persons in the last phase of incurable disease, with a prognosis of 6 months or less[7]. Our department has a consultation program with a team consisting of hospice and palliative care nurse, home service nurse, and social workers, and incorporation of this team with medical practice for those who would unlikely benefit from further treatments, discharge with
Difference between 2008 and 2010
In 2008, 5,023 patients with cancer visited the ED, and when the criteria for the CER management were applied, 4,981 fulfilled these criteria. Of these 4981 patients, 4258 (85.5%) were admitted to the inpatient unit. Mean length of stay in ED was 31.6 ± 25.7 hours, and 13.8 ± 10.4 days in inpatient unit for those admitted. In 2010, 2310 (42.0%) patients were admitted to inpatient unit, which was significantly lower than that of 2008 (P < 0.001). However length of stay in ED (33.7 ± 23.7 hours), and inpatient unit (14.4 ± 10.7 days) were not significantly different. Median (range) cost of care in ED [2008: 725 (90 – 7,372) $ vs. 2010: 646 (40 – 5,005) $, P <0.001] and inpatient unit [2008: 3,530 (10 – 154,490) $ vs. 2010: 2,721 (11 – 104,998) $, P <0.001] were lower in 2010 than 2008 (Table 4).
Disposition of the patients
Of the 5,502 patients, 42% were admitted to the inpatient unit, 52.7% were discharged for outpatient follow-up, 0.2% died during the stay in the CER. Home service was supplied to 0.6% patients for palliative care including home nutritional support,
Discussion
With an aging population and improving outcomes of treatments, cancer has been an important public health concern globally[2], and increased incidence and prevalence will lead to more
Table 3: Difference in dispositions of patients according to main diagnoses Disposition Main diagnosis
Admission
Discharge
Transfer
Home service
Death
P
Disease progression (N=3054)
1250/3054 (41.0%)
1527/3054 (50.0%)
235/3054 (7.7%)
32/3054 (1.0%)
10/3054 (0.3%)
0.103
Infections (N=1257)
808/1257 (64.3%)
440/1257 (35.0%)
9/1257 (0.7%)
0
0
0.003
Treatment related problems (N=806)
213/806 (26.4%)
589/806 (73.1%)
4/806 (0.5%)
0
0
0.006
Non-cancer related problems (N=385)
39/385 (10.1%)
346/385 (89.9%)
0
0
0
0.008
2310/5502 (42.0%)
2902/5502 (52.7%)
248/5502 (4.5%)
32/5502 (0.6%)
10/5502 (0.2%)
Total (N=5502)
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Appendix 1: Exclusion Criteria for CER Management
Table 4. Comparison between 2008 and 2010 2008a (N = 4981)
2010 (N = 5502)
P
4258 (85.5%)
2310 (42.0%)
< 0.001
02 Patient transferred from other hospitals with a newly diagnosed cancer
ED (hours)
31.6 ± 25.7
33.7 ± 23.7
0.152
03 Patient not being managed in the oncology and hematology department
Inpatient unit (days)
13.8 ± 10.4
14.4 ± 10.7
0.605
725 (90 – 7,372)
646 (40 – 5,005)
< 0.001
3,530 (10 – 154,490)
2,721 (11 – 104,998)
< 0.001
Inpatient unit admission Length of Stay
Cost of care, median (range)b ED Inpatient a b
01 Pediatric patients
04 Patient requiring immediate resuscitation (systolic blood pressure < 90mmHg, immediate airway management, or cardiopulmonary resuscitation) 05 Injury related visit
Patients fulfilled inclusion criteria for the CER(Cancer emergency room) management Cost calculated in United States dollars
home service or transfer to hospice center is well established as a common practice. The fact that medical units dedicated to special subject can improve quality of care is well known [8], and in this respect, the ED unit for cancer is distinct from the general ED or inpatient beds, because we use algorithm-driven care allowing for standardized and rapid treatments and evaluation of the patients with oncologic emergencies, and further link to hospice and palliative cares for last phase of disease. Since pain is very common in advanced cancer patients [9], and patients with suppressed immunity are susceptible for infectious complications [10], disease progression requiring pain control, and infection requiring parenteral antibiotics were the most prevalent diagnosis in cancer patients’ emergency visits. Treatment related problems are common in patients receiving anti-cancer treatments, and are unique diagnosis comparing with other patients without malignancies [1]. However more than half of patients with disease progression and treatment related problems were discharged home after management in the CER, and these are conditions which specialized ED unit for cancer could have its
REFERENCES 1. Adelberg DE, Bishop MR (2009) Emergencies related to cancer chemotherapy and hematopoietic stem cell transplantation. Emerg Med Clin North Am 27 (2):311-331 2. Jung KW, Park S, Won YJ, Kong HJ, Lee JY, Park EC, Lee JS (2011) Prediction of cancer incidence and mortality in Korea, 2011. Cancer Res Treat 43 (1):12-18 3. Brillman J, Mathers-Dunbar L, Graff L, Joseph T, Leikin JB, Schultz C, Severance HW, Jr., Werne C (1995) Management of observation units. American College of Emergency Physicians. Ann Emerg Med 25 (6):823-830
benefits. After establishment of an ED unit for cancer patients, there was significant decrease in the numbers of patients admitted to inpatient unit, without significant increase in ED or inpatient unit length of stay, and the cost of ED care and inpatient care were reduced. However, the reasons for reduced cost of care are not well explained. Probably, protocolbased standardized care devoid of overutilization of unnecessary tests or delays in managements, and encouragement of early transfer to hospice care center for those who have no effective treatment could all played role. And making it a rule for the oncology and hematology staffs to participate in the decision making during their daily rounds could also have affected. Our study is limited as a single center, and to the best of our knowledge emergency department unit for cancer doesn’t exist elsewhere. So the administrative benefits of this unit that we intended to clarify may not be generalized. The data regarding diagnosis were obtained automatically base on electronic medical record, and only one main diagnosis was assigned, so there is a chance that the patient had
4. Daly S, Campbell DA, Cameron PA (2003) Shortstay units and observation medicine: a systematic review. Med J Aust 178 (11):559-563 5. Martinez E, Reilly BM, Evans AT, Roberts RR (2001) The observation unit: a new interface between inpatient and outpatient care. Am J Med 110 (4):274277 6. Majem M, Galan M, Perez FJ, Munoz M, Chicote S, Soler G, Navarro M, Martinez-Villacampa M, Garcia del Muro X, Dotor E, Laquente B, Germa JR (2007) The oncology acute toxicity unit (OATU): an outpatient facility for improving the management of chemotherapy toxicity. Clin Transl Oncol 9 (12):784788
more than one main diagnosis. And since medical insurance system varies among different countries, our results of costs of care require caution in its interpretation. Given the increasing incidence of cancer, and various toxicities related to its treatment regimens, there is substantial interest in specialized management unit for oncologic emergencies in ED. Establishing this unit cannot be generalized, depending on the institute’s size, manpower, financial status and treated patients’ pool. However, our ED unit for cancer have a valuable role in assessing and managing patients with cancers, not only progression of disease, but treatment with various toxicity and complications related to its treatment, and link to hospice and palliative care. Acknowledgment: The authors acknowledge the contributions of nurse practitioners HJ Chang and JH Ok, who participated in the data collection.
7. Hutcheson A (2011) Hospice care in the United States. Prim Care 38 (2):173-182 8. Beckett DJ, Raby E, Pal S, Jamdar R, Selby C (2009) Improvement in time to treatment following establishment of a dedicated medical admissions unit. Emerg Med J 26 (12):878-880 9. Portenoy RK, Lesage P (1999) Management of cancer pain. Lancet 353 (9165):1695-1700. 10. Hughes WT, Armstrong D, Bodey GP, Bow EJ, Brown AE, Calandra T, Feld R, Pizzo PA, Rolston KV, Shenep JL, Young LS (2002) 2002 guidelines for the use of antimicrobial agents in neutropenic patients with cancer. Clin Infect Dis 34 (6):730-751
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// icem dublin
P photo
ICEM 2012: Raising the Bar When Irish President Michael Higgins took the stage to open ICEM 2012 in Dublin, it marked a political high point in global emergency medicine awareness.
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text by andy neill, md photos by logan plaster
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mergency medicine is one of the younger medical specialties. While there have always been medical emergencies, it is only in the past 50 years that there have been both dedicated places (emergency departments) and dedicated doctors (emergency physicians) responsible for the care of every kind of medical emergency. We’re open 24 hours a day, 7 days a week. As some wise emergency physicians have emphasised – if emergency medicine didn’t exist we would 03
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01 Zoll demonstrates the LifeBand 02 The Convention Centre Dublin 03 ICEM Chair Fergal Hickey (L) with
Bob McQuillan 04 ICEM keynote Art Kellerman 05 IFEM founding president Gautam
Bodiwala with Patrick Plunkett 06 ICEM attendee heads to a lecture 07 IFEM president Peter Cameron (L)
with incoming president Jim Holliman 08 The ICEM 2014 cultural preview 09 An ICEM poster presentation
have to invent it. The evolving and growing significance of our specialty hasn’t always been acknowledged in the house of medicine but we reached a new landmark in June, 2012 when Uachtarán na hÉireann (The President of Ireland), Michael D Higgins gave the opening address at the 14th International Conference of Emergency Medicine in Dublin. As far as I am aware, this is the first time a conference of emergency physicians has been addressed by a head of state. It signalled that
emergency medicine is front and centre when it comes to healthcare policy - what we do matters, on the national and global political level. President Higgins is renowned as an intellectual, a human rights advocate and a patron of the arts but his words to the delegates showed that he also has a good grasp of what emergency medicine is all about. In the much-anticipated opening talk, there was no use of the outdated term “A&E” or “casualty” and there was a real appreciation of the diverse, specialist skill set that only we as emergency physicians possess. “An emergency physician must be competent in so many areas of expertise,” said President Higgins, “from cardiology to critical care medicine, and from anaesthesia to cardiothoracic surgery.” “There is no doubt that emergency medicine is not a choice for the faint hearted,” he continued, “or, indeed, if I might say so, for those who seek a life without significant challenges or those who wish to practice in the most remunerated branches of medicine.” Yet, he emphasized, emergency medicine is a central and invaluable part of any effective health system. President Higgins praised the significance of the International Federation of Emergency Medicine for bringing together over 40 different nations and highlighting the importance of emergency medicine for both developed and developing nations. He expressed a unity of mission in emergency medicine as a whole,
linking arms in a commitment to human rights and social equity. “Emergency medicine is an area that has continued to evolve, to progress and to push boundaries, constantly exploring how to do things better, more effectively and more efficiently,” said Higgins. Indeed it is our unique skill set that helps us to navigate these boundaries and to see how to expand them. To highlight this, President Higgins praised IFEM’s development of an international quality framework in emergency medicine and its significance in promoting progress and improvements in emergency medicine. Reflecting on his own experience following a fractured patella in Colombia, President Higgins told of his gratefulness as a patient that professionals were able to take fear out of the situation. It was a good reminder that just because emergency department attendances are routine for us, they’re frequently daunting and terrifying experiences for the patients. Medical emergencies are an important part of human experience and it is not only our technical skills that our patients need, but our care and compassion. As the conference was declared open and President Higgins gave delegates a warm Irish welcome, it became clear that emergency medicine had reached a new stage of global awareness. The question remains as to whether more heads of state will follow suit and make emergency care development an agenda priority. www.epijournal.com
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Entry Strategy In part II of EPI’s ED design series, Dr. Manuel Hernandez explains the importance of rethinking your emergency department’s front door experience. 01
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n the 1970’s there was an American shampoo commercial that coined the phrase, “you never get a second chance to make a first impression.” This Madison avenue catch-line applies as much to emergency departments as it does hair products. The experience patients have upon entering an ED can impact the overall length of stay, for better or worse. Many clinicians are unaware of the steps in the patient care process that occur at the “front end,” out of the sight line of the clinical areas. Yet often, it’s these very first elements of the patient encounter that contribute to overcrowding, declines in clinical quality, lower patient satisfaction, and spiraling costs. The impact of ED overcrowding cannot be overstated. Regardless of its cause, crowding has been demonstrated to have deleterious effects on morbidity and mortality, particularly for patients requiring inpatient hospitalization. Effects ranging from increased length of stay in the ICU and increased mortality have been tied directly to ED crowding (Richardson, Bernstein, Pines, Sprivulis). You might think that EDs just need to be bigger, but you’d be wrong. A 2007 study evaluating ED expansion showed that increasing treatment stations did not impact targeted performance metrics. ED treatment station expansion actually resulted in increases in total length of stay and length of stay tied to admission holds (Han). Studies such as this point to the need to fundamentally rethink how patients access and utilize the ED with a focus on accelerating the phases of care under the control of the ED while we continue to wage war on access block. There’s no better time to rethink the patient arrival process than during the design and construction of a new or renovated ED. Planned properly, a new patient arrival experience can accelerate care, reduce overall length of stay and mitigate crowding. The
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most optimized emerging ED designs are those that are informed by and responsive to processes, human capital models and technology acquisition strategies in such a manner that the ED is designed to support each effortlessly. The remainder of this article will review recent innovations in the patient arrival process from entry through the point of placement in a treatment station while discussing the best-in-practice design implications of these innovations. Clinical Greeters
The first step begins at the front door through the use of a clinical greeter. In the clinical greeter model, a healthcare professional is positioned at the walkin entrance of the ED to greet all arriving patients. Typically, the intention of this role is multifactorial. First, the clinical greeter is able to immediately identify obvious emergencies without delays associated with waiting for registration and triage. Combined with the direct bedding model (to be reviewed shortly), the clinical greeter can escort patients to treatment stations without delay. Finally, the clinical greeter, when positioned within proximity to the waiting area, serves the vital role of providing continuous surveillance of the waiting areas to rapidly identify any patients in the waiting rooms that might be experiencing clinical decompensation. Design considerations of the clinical greeter model are relatively simple. As illustrated in the figures above, it’s important that the greeter have a direct line of sight to the walk-in entrance. This creates an intuitive wayfinding process for newly arriving patients. Ideally, the ED would also be constructed such that the greeter can have a direct line of sight to the entire waiting room and, for security and communication purposes, direct access to the secured clinical areas of the ED.
Fall 2012 // Emergency Physicians International
Kiosks
Planning for technology solutions that provide both accelerated time to evaluation and diagnosis and clinical decision support is critical when planning tomorrow’s ED. This is particularly important in moderate- to high-volume EDs where such technology solutions can facilitate parallel streaming of multiple patients simultaneously. Electronic kiosks similar to those found in many airports have begun to be used in multiple roles in many EDs. The most common use of electronic kiosks is selfdirected patient registration. Allowing patients to self-register has been shown to reduce overall registration time with user satisfaction rates in excess of 90% (Welch). Electronic kiosk systems can also be tied to the larger electronic health record and tracking boards to allow for rapid recognition of patients requiring immediate assessment with subsequent notification of nursing staff. Such systems have been tried at Parkland Hospital in Dallas, Texas and at Newark’s Beth Israel Hospital. Electronic kiosks are also beginning to be utilized for direct clinical decision support. In a study supporting this approach, randomized females with symptoms suggesting a UTI were guided to a kiosk where a series of questions identified the likely presence or absence of an uncomplicated UTI. The responses were then reviewed during a brief clinical encounter and appropriate treatment initiated. Using this model, length of stay was reduced by 57 minutes with similar time to illness resolution, number of return visits and satisfaction with care as patients not using the kiosks (Stein). From a design perspective, electronic kiosks require minimal space. Regardless of the number of kiosks employed, they should be positioned in a manner ensuring proper patient privacy and access by patients with mobility issues. All Images © 2012 Cannon Design
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01 The clinical greeter (middle right) should be positioned
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03 04
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Direct Bedding
Direct bedding has become recognized as an effective strategy for patient streaming. In this model, patients arriving at times when the ED is not at full capacity are immediately placed into a treatment station where triage and registration functions can occur without delaying physician evaluation and initiation of diagnostics. A 2002 study demonstrated that initiation of a direct bedding model resulted in reduced patient waiting times of approximately 27 minutes and an overall reduction in ED length of stay of nearly 90 minutes (Spaite). While there is no real direct design implication of direct bedding models, it is recommended that EDs using this model ensure proper adjacencies between the triage / care initiation area and treatment stations most commonly used by walk-in patients. Rethinking the Triage Process
The efficacy of triage in the ED remains controversial. Triage proponents point to more accurate identification of potential emergent conditions while critics point to a lack of reliability and throughput delays resulting from a redundant system. A 2011
to ensure direct line-of-sight to the walk-in patient entrance and the waiting areas. Locating imaging closer to low acuity areas such as the care initiation area reduces travel distances for staff, speeds imaging turnaround times and can significantly lower overall length of stay. Blueprint of waiting room with centrally-located clinical greeter The care initiation area is designed with lounge chairs or trolleys. Lined with medical gasses and monitoring equipment, it can be used for lower acuity patients and moderate acuity patients who are ambulatory and awaiting diagnostics. Care initiation area
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Scandinavian review of research into triage systems from 1966 through 2009 called into question the reliability of all triage scales studied (Farrohknia). This would seem to suggest that the investment in existing triage models may not be yielding the desired outcomes. These findings are supported elsewhere in the literature. Earlier this year a study demonstrating poor inter-rater agreement between users of the Canadian Triage and Acuity Scale also called the effectiveness of triage into question (Dallaire). Rethinking the traditional triage model to shift away from a simple assignment of acuity and/or potential resource utilization toward a model that focuses on early provider evaluation, rapid initiation of appropriate diagnostics and acceleration of clinical interventions can have a positive impact on performance metrics, regardless of ED size and volume. Examples of such models have shown success in Europe, North America, Asia and Australia, to name a few regions. The design implications of these more innovative triage models are significant, often requiring more space and resources than customary in a traditional triage model. In one advanced triage model, the
triage area – aptly renamed the care initiation area – contains not only tradition triage rooms, but also additional workspace for supplemental staff. The design also includes a dedicated “quick turn” room for simple diagnostics such as phlebotomy and EKGs as well as discharge counseling and minor procedures for patients requiring no further intervention. These rooms are frequently designed to mirror a typical treatment station in the main ED. A more advanced care initiation area may also include an area known as a diagnostic staging area. As illustrated in Figure 4, a diagnostic staging area is a cluster of exam lounge chairs. These spaces can be used for low-acuity patient holding and management of ambulatory patients that do not require a stretcher. These stations, commonly lined with medical gasses and monitoring equipment, can be used by patients waiting for diagnostics and, in some EDs, is shared space between the triage, or care initiation care, and the main ED. In the most innovative designs, newer EDs are being designed with a fixed plain imaging unit immediately adjacent to the triage or care initiation area. In instances where imaging adjacent to patient www.epijournal.com
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arrival processes is combined with nurse- or physician-directed diagnostics in triage, improvements in patient throughput have been experienced. One anecdotal report in a U.S. ED cited length of stay reductions in excess of one hour (Horton). Figure 2 illustrates a design solution that provides adjacencies between plain imaging and the care initiation areas. By maintaining adjacency to treatment stations as well, the plain imaging unit is better positioned for all patients who might require its services, regardless of when imaging is ordered. Physician / Advanced Provider Triage and Care Forward Models
Physician triage is an emerging model of care that moderate-to high-volume EDs that struggle with high walk-out rates and long waiting rooms times have begun to implement in earnest. Multiple studies across the globe have demonstrated the efficacy of stationing a physician or advanced practice nurse in the traditional triage area (Imperato, Holroyd). In this model, an advanced provider works with the triage nurse with the goal of ordering appropriate diagnostics and, in certain circumstances, treating and releasing low-acuity patients entirely within the triage area. A UK study showed that treating low-acuity patients in a cubicle area with two chairs, staffed by a physician, as opposed to a full exam room, reduced the total number of ED patients waiting for treatment more than 60 minutes by 11% (Cooke). Similarly, an Australian model known as the Senior
REFERENCES Bernstein SL, Aronsky D, Duseja R, et al. The effect of emergency department crowding on clinically oriented outcomes. Acad Emerg Med. 2008;16:1-10. Cooke MW, Wilson S, Pearson S. The effect of a separate stream for minor injuries on accident and emergency department waiting times. Emerg Med J. 2002;19:28-30. Dallaire C, Poitras J, Aubin K, Lavoie A, Moore L. Emergency department triage: do experienced nurses agree on triage scores? J of EM. 2012;42(6): 736-740. Farrohknia N, Castrén M, Ehrenberg A, Lind, L, Oredsson S, Jonssom H, Asplund K, Göransson KE. Emergency department triage scales and their components: a systemic review of the scientific evidence. Scandinavian J of Trauma, Resuscitation and Emergency Medicine. 2011;19(42): 1-13.
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Streaming Assessment Further Evaluation after Triage, or SAFE-T, showed improved performance for three metrics: time to physician, did-not wait rates and off-stretcher times for ambulances (Shetty). The SAFE-T model includes an area known as a dynamic transition waiting room, known in other parts of the world as an internal waiting room or diagnostic staging area which is used to initiate diagnostics, treatment and disposition without the use of a dedicated treatment station. Similarly, a US-based model known as Supplemented Triage and Rapid Treatment, or START, supplemented the traditional triage model with a clinical team tasked with initiating diagnostics and providing disposition of discharge of loweracuity patients requiring no further evaluation and management (White). The START model resulted in an overall reduction in ED length of stay of 29 minutes and a reduction of walk-outs from 4.1% to 2.4%. In communities where resource allocation does not favor the placement of a physician or advanced provider at the point of patient intake, or in instances where ED volume does not support such an investment, opportunities exist to re-envision the traditional role of the triage nurse away from simple collection of metrics and to a model focused on accelerated diagnostics. A 2010 Dutch study assessed the impact of nurse-directed diagnostics on length of stay and quality (Rosmulder). The study demonstrated that nurse-directed diagnostics initiated in triage resulted in an overall reduction in ED length
Han JH, Zhou C, France DJ, Zhong S, Jones I, Storrow AB, Arnosky D. The effect of emerge cy department expansion on emergency department overcrowding. Academic Emergency Medicine. 2007;14: 338-343. Holroyd BR, et al. Impact of a triage liaison physician on emergency department overcrowding and throughput: a randomized controlled trial. Acad Emerg Med. 2007 Aug;14(8):702-8. Horton E. Personal interview. Apr. 2012. Imperato J, Morris DS, Binder D, Fischer C, Patrick J, Sanchez LD, Setnik G. Physician in triage improves emergency department patient throughput. Intern Emerg Med. 2012. On-line pub. 1-6. Pedersen GB, Storm JO. [Emergency department x-rays requested by physicians or nurses]. Ugeskr Laeger. 2009;171(21): 1747-1751. Pines JM, Hollander JE. Emergency department crowding is associated
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of stay of 14 minutes and 27 minutes for patients receiving diagnostics ordered in triage. While there was an 8% increase in diagnostics ordered, retrospective review demonstrated that the nurses initiated diagnostics correctly and fully in 93% of cases. A similar study conducted at a Danish emergency department also demonstrated that nurse-initiated diagnostics reduced patient waiting times (Pedersen). In each of the advanced triage models discussed in this section, successful design solutions warrant creating a robust care initiation area with adequate space for triage, initiation of diagnostics, patient staging in chairs and, if possible, basic imaging. This design solution creates a low-acuity, rapid throughput ED-within-an-ED for selected patients. Conclusion
The prospect of designing a new ED or renovating an existing one presents a golden opportunity to rethink traditional patient arrival and triage models. In any design project, a combination of new processes, staffing models and technology strategies must all come together to inform the facility design process. Doing so will enable future EDs to be designed to support patient streaming and parallel processes while accelerating diagnostics and care and, ultimately, reducing overall length of stay and walk outs.
with poor care for patients with severe pain. Ann Emerg Med. 2008;51:1-5. Richardson DB. Increase in patient mortality at 10 days associated with emergency department overcrowding. Medical Journal of Australia. 2006;184: 213-216. Rosmulder RW, Krabbendam JJ, Kerkhoff AH, Schinkel ER, Beened LF, Luitse JS. [Advanced triage improves patient flow in the emergency department without affecting the quality of care]. Ned Tijdschr Geneeskd. 2010;154 A1109. Shetty A, Gunja N, Byth K, Vukasovic M. Senior streaming assessment further evaluation after triage zone: a novel model of care encompassing various emergency department throughput measures. Emerg Med Australasia. 2012;24: 374-382. Spaite DW, Batholomeaux F, Guisto J, et al. Rapid process redesign in a university-based emergency department: decreasing waiting time intervals and improving patient satisfaction. Ann
Emerg Med. 2002;39:168-177. Sprivulis PC, Da Silva J, Jacobs IG, Frazer ARL, Jelinek GA. The association between hospital overcording and mortality among patients admitted via western Australian emergency departments. Medical Journal of Australia. 2006; 184: 208-212. Stein JC, Navab B, Frazee B, Tebb K, Hendey G, Maselli J, Gonzalez R. A randomized trial of computer kioskexpedited management of cystitis in the emergency department. Academic Emergency Medicine. 2011;8: 1053–1059. Welch SJ. Making information technology a team player. Emerg Med News. 2010;32(2): 20-1. White BA, Brown DF. Sinclair J. Chang Y. Carignan S, McIntyre J, Biddinger PD. Supplemented triage and rapid treatment (START) improves performance measures in the emergency department. J of Emerg Med. 2012;42(3): 322-328.
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Lost in Translation: HTN in Belize A US-Belizean cooperative studies patient perceptions of hypertension in the developing South American nation
by justin bammer, alexander marinica, christian vannier, phd, john flack, md, mph, phillip levy, md, mph
M
ission and overseas outreach trips to lesser developed nations are a familiar part of modern medical education in the US. Medical students and residents in training are encouraged to participate in international programs and universities commit considerable resources to enhance their international education opportunities.1 While some programs are part of an enduring health service exchange, many others involve a brief interaction where participants work with local ambassador organizations to create day clinics in areas of presumed neglect. With progressive adoption of the “Western” diet, developing nations around the world have seen a dramatic rise in the prevalence of chronic diseases such as hypertension. Accordingly, blood pressure measurement has become a ubiquitous component of these “hands on” international healthcare experiences. Anticipating that they will encounter patients with newly diagnosed or poorly controlled hypertension, these “pop-up” clinics frequently stock small quantities of antihypertensive agents. Unfortunately, such endeavors are often conducted without a complete understanding of the intended beneficiaries’ healthcare needs resulting in the superimposition of perceived goodwill rather than integration of a program that is complementary to existing infrastructure. To address this, we sought to define illness perceptions as they relate to hypertension for a group of patients taking part in a visiting medical clinic in a representative, developing nation. Our objective was to provide a more comprehensive understanding of the belief system surrounding an important chronic disease and, in turn, facilitate development of a more
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meaningful and effective plan of action for future international outreach efforts. Methods
As part of an international medical experience for undergraduate students from Wayne State University (WSU) in Detroit, MI, half-day medical clinics were established in eight rural villages in the Cayo district of western Belize. These clinics were arranged in cooperation with Pro World Belize, an outreach organization with extensive experience developing similar activities in this region. Clinic participants were assessed for basic demographic information, including age, sex, height, weight, and prior medical and social history, including history of hypertension. Blood pressure screening was conducted using averaged bilateral automated brachial cuff measurement. Individuals with elevated blood pressure (defined as ≥ 140 mm Hg systolic and/or ≥ 90 mm Hg diastolic) or a self reported history of hypertension were asked to complete two objective and validated cross sectional survey instruments: the Short Form-12 (SF-12) and the Illness Perceptions Questionnaire-Revised (IPQ-R). The SF-12 is a generic approach to patients’ self assessment of overall health designed to give mean mental and physical health scores of 50 with a standard deviation of 10 in a US population2. Though it is not disease specific, the SF-12 does provide a valid metric of overall wellness. The IPQ-R provides quantitative support for studying patients’ illness perceptions as they relate to symptoms and self-assessment of health risk, coping, and functional adaptation to disease3. In contrast to the SF-12, many disease-related IPQ-R instruments have been developed, including the hypertension specific form used in this study. Categorical responses to the IPQ-R were compared between patients
with a history of hypertension and those with de novo elevated blood pressure and among those with known hypertension based of whether or not their blood pressure was controlled using the chi-squared test. Mean summary scores for the SF-12 were compared for these same groups using the Student’s ttest. Data analyses were performed using SPSS version 19 (SPSS Inc; Chicago, IL) and a p-value of < 0.05 considered statistically significant. All screened patients received health education about hypertension, with enrolled patients doing so only after completing the survey instruments. The project was approved by the Institutional Review Board of WSU and the regional medical authority in Cayo, Belize prior to initiation. Results
Of the 326 patients screened, 22% (n = 71; mean [SD] age = 49 [15] years; 32% male) had a documented history of hypertension (n = 49) or were found de novo to have elevated blood pressure (n = 22); mean [SD] BP=142[14]/91[10] mm Hg). Among the 49 patients (mean [SD] age = 51 [15] years; 20% male) with a previous history of hypertension, 30 (61%) had elevated blood pressure at screening (mean [SD] blood pressure = 150[23]/91[11] mm Hg) with adequate blood pressure control in the remaining (mean [SD] blood pressure = 119[10]/76[9] mm Hg). Only 7 (37%) of those with a history of hypertension and controlled blood pressure however, reported that they were taking anti-hypertensive medications. In the 22 patients (mean [SD] age= 44 [16] years; 59% male) who met criteria for de novo hypertension, mean (SD) blood pressure was 142(14)/91(10) mm Hg). High blood pressure was most commonly www.epijournal.com
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attributed to diet or eating habits (79%), stress or worry (74%), and patient behavior (61%), while only 44% believed it was influenced by heredity (Figure 1). Notably, 61% also thought that treatment would cure hypertension while 35% felt they did not understand the illness. When compared with de novo elevated blood pressure patients, those with a history of hypertension were less likely to attribute their disease to diet or eating habits (35% vs. 71%, p=0.03). Among those with a history of hypertension, IPQ-R data were generally similar whether or not their blood pressure was controlled (data not shown). Overall, mean [SD] physical (42 [11]) and mental (46 [10]) health SF-12 summary scores were low compared with Hispanic population norms4, with no statistically significant difference between groups. Discussion
Belize is a popular destination for foreign medical outreach groups to visit, many of whom participate in population screening and health education for chronic conditions such as hypertension5. Planning for these efforts typically relies on extrapolated assumptions rather than in-depth knowledge of community needs. In this brief report, we present field data which show elevated blood pressure to be present in 16% of rural Belizeans; a finding that was often, but not exclusively associated with a prior diagnosis of hypertension. Several points related to this warrant further discussion and may be impactful for future outreach projects in this region. First and foremost, poor blood pressure control among those with a history of hypertension is likely to be encountered and the need for some form of meaningful intervention beyond simple provision of unsustainable quantities of antihypertensive therapy should be anticipated. Given the results of our IPQ-R surveys, basic education focusing on hypertension itself (risk
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factors, consequences, etc...) with specific emphasis on the lasting (rather than transient) nature of the disease process seems especially important. Second, detection of elevated blood pressure in patients without a history of hypertension can be anticipated, necessitating some response mechanism. As we have shown, however, the degree of blood pressure elevation in such patients is unlikely to be significant and initiation of antihypertensive therapy or establishment of a new diagnosis of hypertension is probably the wrong approach. Guideline-based management within the context of available healthcare resources (especially referral to a primary care provider) will undoubtedly yield more lasting benefit. Moreover, as many of these individuals appear to appreciate the relevance of diet, reinforcement of lifestyle modifications as a means to control blood pressure
Fall 2012 // Emergency Physicians International
is important. Lastly, patients with an established “history” of hypertension but normal blood pressure are likely to be seen. For some of these individuals, this represents enactment of an effective treatment plan and little needs to be done. There will be others in this group, however, who are not on antihypertensive medication, calling into question the veracity of the diagnosis. Though we did not collect data on how the diagnosis was established, a number of such individuals reported that previous visiting physicians from the US had told them that they were hypertensive. While these data represent but one region in a small country, they do serve to highlight a widely generalizable tenet of the Hippocratic oath: primum non nocere. Not knowing an area prior to arrival risks inducement of great harm and it is incumbent that
Figure 1: Illness perception questionnaire responses in previously diagnosed hypertensive patients vs those with de novo BP elevation My illness will last for a long time
25 43 59 61
My treatment will be effective in curing my illness I don’t understand my illness
03
01 The busy clinic saw between 80 and
100 patients per day 02 Sign-in station at the clinic 03 Dr. Phillip Levy gives advice to a
When I think about my illness I get upset
36 35 36 45 46 43
Causes: Hereditary-it runs in my family
76
Causes: My own behavior
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young patient
77 73
Causes: Stress or worry visitors do their homework6. In Belize, for instance, many are surprised to learn that the healthcare system provides better access to government-subsidized primary care clinics and free chronic-disease medication than in the United States7. Understanding the healthcare landscape will facilitate integration with an established system and avoid potential disruption of on-going therapeutic relationships8,9. Further, it will help align logistics, particularly as they pertain to anticipated medical supply needs. Emergency physicians possess an extremely portable skill set and are able to function without dedicated operating rooms or advanced imaging equipment. As such, many EM trained physicians are drawn to the international experience, as evidenced by the growing number of international emergency medicine fellowships. We encourage our EM colleagues to use the information provided and, perhaps more importantly, the approach we have employed, as a REFERENCES 1. Panosian C, Coates TJ. The New Medical “Missionaries” — Grooming the Next Generation of Global Health Workers. N Engl J Med 2006; 354:1771-1773 2. Ware JE, Kosinski M, Keller SD. How to Score the SF-12 Physical and Mental Health Summary Scales. 3rd ed. Lincoln, RI: QualityMetric, Inc.; 1998. 3. Moss-Morris R, et al. The Revised Illness Perception Questionnaire (IPQ-R). Psychology and Health, 2002;17:1-16.
Causes: Diet or eating habits
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New finding of HTN (N=22) Previously diagnosed HTN (N=49)
guide to similar planned projects. In this way, interventions aimed at directing treatment toward gaps in disease-specific knowledge can be better developed and improvements in health status as well as selfmanagement of chronic diseases such as hypertension can be better achieved. In conclusion, it appears that gaps in knowledge and awareness exist for patients suffering from hypertension in Belize. Such gaps may contribute to poor blood pressure control making hypertension 4. Jerant A, Arellanes R, Franks P. Health Status Among US Hispanics: Ethnic Variation, Nativity, and Language Moderation. Med Care 2008;46:709-17. 5. World Health Organization. Country Cooperation Strategy Brief: Belize. WHO 2008. Available at: http://www.who.int/countryfocus/cooperation_strategy/ccsbrief_blz_en.pdf Accessed May 20, 2012. 6. Iserson, KV, Biros, MH, James Holliman, C. Challenges in International Medicine: Ethical Dilemmas, Unanticipated Consequences, and Accepting Limitations. Acad Emerg Med. 2012 Apr 30. doi: 10.1111/j.1553-2712.2012.01376.x. [Epub ahead of print]
education (not provision of short-term medications) the priority of visiting international healthcare groups to this region. Future efforts replicating our experience in this or other locations should seek to understand their target population ahead of time and work within the existing healthcare infrastructure to achieve a more meaningful intervention. Like ice machines in the jungle10, the delivery of regionally inappropriate care by medical outreach groups has the potential to do more harm than good. 7. World Health Organization. NCD Country Profiles: Belize. WHO 2011. Available at: http:// www.who.int/nmh/countries/blz_en.pdf. Accessed May 20, 2012 8. Suchdev P, Ahrens K, Click E, Macklin L, Evangelista D, Graham E. A Model for Sustainable Short-Term International Medical Trips. Ambul Pediatr 2007;7:317-20. 9. Roberts M. A Piece of my Mind: Duffle Bag Medicine. JAMA 2006;295:1491-2. 10. Theraux P. The Mosquito Coast. Houghton Mifflin (Boston, MA). 1982.
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Grand Rounds
PETER CAMERON, MD // PRESIDENT OF IFEM
Qatar: EM Under Construction A new post in resource-rich Qatar means unprecedented opportunities to develop the specialty
A
Being an emergency physician, I have a fairly short attention span. I like things to happen with speed and hopefully some excitement! After nine years in Melbourne, Australia, developing an academic
Predicting the model of care five years from now in a constantly changing environment is not possible; flexibility is the key. The ED is huge, seeing about 1500 patients per day. Fortunately, most injuries are minor and are seen in the Fast Track areas. In fact, it is not uncommon for a bus load of workers to arrive with minor ailments and injuries. The short stay model of care has taken off with more admissions going through short stay than inpatient beds. The “Short Stay” model has now expanded to a projected 72 hours length of stay, to account for deficiencies in inpatient processes. Although very efficient, this goes beyond the program and working with the clinical and research teams at The Alfred normal short-stay model. Hospital and Monash University, I needed some time out. The program is going The physical layout of the Qatari ED is much different than I would have well – lots of grants, good people and plenty of publications – but I just needed expected, coming from a Western-style department. There are separate entrances a new challenge. and waiting areas for men and women – and one dedicated to the local Qatari So when the opportunity arose to spend some time in a very different envipopulation. There is a strong Muslim influence and this extends to many pracronment, in a region where I had little experience and didn’t know what to exticalities such as a lack of eateries during the fasting times in Ramadan, prayer pect, it was a no-brainer. I was asked to become the Chair times and strict customs regarding male/female interacin Emergency Medicine in Qatar, a place with financing, tions. Doctors and nurses working in the ED come from but lacking the guidance in how to develop emergency all over the world – many from countries dominated by Emergency Medicine medicine. other religions and cultures. This leads to many potential isn’t the only thing Leaving a lot of half-finished projects in Melbourne clashes in culture and unmet expectations. Whilst waiting developing in Qatar.. has not been easy, but fortunately there are many talented for my medical examination I casually sat down in a vacant Experts expect the people who will continue that work. Hopefully they will seat next to a woman who was also waiting. I couldn’t quite Qatari construction forgive me for my dalliance in the Middle East. understand why everyone was staring at me, then I realmarket to grow by an I had every reason to anticipate a rough entry into ized that the “male waiting area” was around the corner. average of 12.5% each Doha. I arrived in the middle of summer’s sweltering heat, Soon after, in my usual Australian manner, I went to shake year over the next with Ramadan underway (people were fasting and grumpy hands with the nurses only to be quickly reprimanded for decade, compared and many services were shut down). On top of that I had with an average of 1.7% attempting to touch a woman. I am hoping that we can growth in Europe over all the normal administrative matters that I’d need to sort plan to develop the best-designed ED in the region while the same period. quickly if I was to get up and running. However, the entaking into account these and other cultural sensitivities. try into this new environment went more smoothly than Overcrowding has been a big issue in the ED, with expected. The organization has bent over backwards to asup to 60 patients waiting each morning for admission. sist and everyone has been very helpful. A month in, I have Fortunately, this has been a focus of improvement across the hospital over most of the important paperwork completed and can focus on the tasks at hand. the last six months. The success of this program has been evident by the rouQatar is literally ranked as the world’s richest country, as measured by adjusttine occurrence of no patients pending admission over the last month or two. ed per capita purchasing power. The Persian Gulf emirate’s wealth is relatively Sustainability will be an issue, but the process improvements underway will go new, however, and recent growth has been rapid, both in infrastructure and a long way to maintain the momentum. The main changes have been routine population. The wealth is based mainly on gas, rather than oil, and the facilities tracking and reporting of patients waiting for admission and ward discharge data for exporting large quantities of gas have only recently been developed. The curto ensure that there is a hospital wide focus on the issue. Emphasising inpatient rent population is estimated at 1.8 million, however only about 300,000 of these unit accountability for admission and discharge decisions in the ward has also citizens are actually Qatari. The rest are expatriate workers, employed to build a been important. nation. This means that 75% of the population is male and most are under 40 There are a huge number of doctors working in the ED. Approximately 200 years. Unfortunately, because of wealth and poor public health programs, the emergency doctors with varying levels of emergency training and experience biggest killers for the local population are obesity-related diabetes, heart disease from all over the world are working at Hamad General Hospital and associated and trauma. “walk-in clinics.” At present we have one Qatari consultant in adult emergency My first impression of the Hamad General Hospital ED (the only tertiary ED medicine, although this is likely to change over the next few years. One of our for the country) was that it was a chaotic construction site! The ED is underimmediate challenges will be to develop a coherent workforce strategy that will going a renovation to temporarily improve patient flow before a major rebuild ensure a sustainable model for training new graduates and maintaining and uptakes place in 2-3 years time, followed by an even more impressive rebuild in grading skills of the present workforce. There is no mandated CME program 8 years. Hopefully by the third rebuild, we will get it right. We are desperately specifically for emergency medicine and no Qatar board exam. There is a fourseeking input from global authorities on ED design, such as Manny Hernandez. year Arab Board training program, which is beginning to deliver good graduates.
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July2012 Fall 2012 // // Emergency EmergencyPhysicians PhysiciansInternational International
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At present we have one Qatari consultant in adult emergency medicine, although this is likely to change over the next few years. One of our immediate challenges will be to develop a coherent, sustainable workforce strategy.
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The intention is to develop a three-year fellowship program in addition to the Arab Board over the next couple years, resulting in a high level fellowship qualification. The fellowship program would cover the topics that are typically not well covered by basic board qualifications, including management, disaster medicine, research and teaching skills and elective subjects such as ultrasound and critical care. The case mix in the ED is different than any other ED I have worked in. The trauma cases are similar, although there is virtually no penetrating injury. Heat exhaustion and heat stroke are common, as the temperature during summer hovers around 45-50 C with high humidity. Amazingly, manual workers continue to work outside in these temperatures. Even more bizarre is the fact that many of the workers come from Nepal (a trifle colder than here). Meanwhile, I get heat exhaustion walking to the car. With the hot weather, renal colic is common, along with dehydration and electrolyte disturbances. There are many minor injuries associated with manual labor. The older patient group has a high rate of diabetes, heart disease and renal failure associated with high obesity and smoking rates. There are also some very unusual diseases associated with the countries that guest workers come from. For example, Neurocysticercosis is common in the Nepalese workers, presenting as seizures. These are usually managed in the short stay area. I saw only a couple of these in 20 years of ED practice in Melbourne. Prehospital care has been neglected in this country until recently. Over the last five years there has been a massive investment in paramedic training and development. In addition, the coordination, quality control programs and clinical practice guidelines have been massively upgraded. Despite this, most patients prefer to come by private vehicle, even when seriously ill. The politics are very different here compared with most Western countries, in that there is a hereditary ruler with no elected government. One would expect that this would make government less responsive to the population than with a democracy, but that has not been the case in my experience. There is a perceived need by the Qatari government to keep the population satisfied with their health services â&#x20AC;&#x201C; a desire to please that seems even stronger than in many democracies. Political involvement in clinical planning seems as strong here as in Western democracies. The ruling family and Ministries are frequently seen in the hospitals and demand a lot from health administrators. Importantly, emergency medicine is seen as a high priority area and there is strong backing to take it to the highest level internationally. Given the potential resources available and the political will, it seems inevitable that emergency medicine will improve in Qatar. Hopefully, eventually, Qatar will showcase the value of investing in this cornerstone of modern medicine. I am hoping that we can demonstrate just what a difference good emergency care can make to the way the healthcare system functions and ultimately to patient outcomes.
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