EPI Issue 2 by Logan Plaster

When Will the EU Accept EM? Dr. Gunnar Ohlen

Observing UKâ&#x20AC;&#x2122;s 4-Hour Rule Dr. Peter Cameron

EM Developments in China

EMERGENCY PHYSICIANS INTERNATIONAL

Dr. Veronica Pei

Building a Legacy How South Africa used World Cup prep to stimulate EM development

Issue T wo // Fall 2010

epinternational.ning.com

Fall 2010 // Emergency Physicians International

Editor’s Desk

Heroic Measures

n the eve of Gulf War I in 1991 I was responsible for the health care for several hundred personnel on a compound just outside Riyadh, Saudi Arabia. We were expecting Iraqi missile attacks with chemical weapons, but the military had only issued enough chemical protective suits for me and my small medical staff. When I asked to see how much atropine our compound clinic had available to treat nerve gas victims, I was shown the 4 one-milligram vials on the cardiac arrest cart in the clinic. I immediately became agitated and, after a lot of phone calls and cajoling, managed to get us a number of cases of Mark-1 autoinjectors for atropine and praldoxime. A number of Iraqi Scud missiles hit in our area, but luckily, none contained nerve gas. We were fortunate that day, but every day, around the world, emergency care personnel are putting themselves in harms way – sometimes even giving their own lives – to provide care in areas of armed conflict. Much of the attention recently has been focused on Afghanistan and Iraq, but unfortunately, insurgency-related warfare is currently going on in a number of countries in Central and South America, Europe, Africa, and Asia. Sadly, a number of our colleagues have been killed or injured in these conflicts. In fact, in an unprecedented turn, emergency health care workers have recently been deliberately targeted by terrorist groups. In particular, the Taliban in Afghanistan and Pakistan have prominently made it a fundamental principle of their operations to murder or kidnap for ransom health care personnel, destroy health care facilities, and prevent health care delivery, including immunizations for children. We salute the International Medical Corps (IMC), an organization founded by emergency physician Dr. Bob Simon 30 years ago to train health care workers and medics for the war in Afghanistan. IMC has provided emergency health care delivery and personnel training in many conflict areas, including southern Europe, Africa, and Asia. IMC is working to bring modern emergency medicine to Iraq. We also thank Doctors Without Borders/Medicins Sans Frontieres (MSF) who, several years ago, won the Nobel Peace Prize for their highly successful work in providing disaster and refugee relief programs, particularly in Africa. Sadly, several MSF employees were murdered in Afghanistan a few years ago, causing the organization to pull its staff from that country. We salute our military emergency medicine and EMS colleagues who have provided a huge amount of emergency health care in the ongoing wars in Iraq and Afghanistan, obviously at great personal risk. These personnel are not just from the U.S. and the U.K., but include staff from the Netherlands, Canada, Jordan, Australia, the Czech Republic, Poland, Turkey, and others. These personnel have not just provided care for Coalition troops, but have also provided extensive care for the civilians caught up in the conflicts, and have conducted many training programs for host country medical staff. We also thank the large number of civilian health care personnel, many of whom work for the United Nations, international organizations such as the International Committee of the Red Cross, or for Non-government organizations, in conflict areas such as Iraq and Afghanistan. These personnel often do not have the security protection and logistics support provided to military personnel in the same conflict area, and despite the risks they continue to provide support and relief to the populations in these conflict areas. We at EPI want to thank all the emergency health care personnel who work, or have worked, in conflict areas. We thank them for their past and ongoing service, and we wish for their safe return home once their work is completed.

‘‘

...emergency health care workers have recently been deliberately targeted by terrorist groups. In particular, the Taliban in Afghanistan and Pakistan have prominently made it a fundamental principle of their operations to murder or kidnap for ransom health care personnel, destroy health care facilities, and prevent health care delivery, including immunizations for children.

C. James Holliman, MD, FACEP, FIFEM editorial director www.epinternational.ning.com

letter from the publisher

Enter the Marketplace

hese are pivotal times for international emergency medicine. After years of petitioning, Argentina’s Ministry of Health finally recognized emergency medicine as an official medical specialty last May. Meanwhile, in Europe, EM leaders like Gunnar Ohlen continue the Herculean struggle of getting emergency medicine fully accepted by the European Union (story on page 37). From Panama to Malaysia, foundational questions are on the table, questions that will define the future of this young medical specialty. Should emergency medicine be an independent specialty or a supra-specialty? Whose teaching methods should be followed? Whose voices should rise to the top? The decisions of who will lead specialty development, and in what direction, can be political, emotional, even personal. EPI was designed to be a marketplace of ideas, where literally a world of viewpoints on these and other issues can come together. On page 40 you’ll find the results from our first EPI survey, for which we received feedback from 35 different countries. In Source (page 15), you can read 11 different EM development reports, including an in-depth look at specialty development taking place in China. These struggles – for recognition, for independence – require time and a commitment to open dialogue. The magazine before you is an invitation to enter that discourse, to go beyond affiliations, and, hopefully, beyond the political entanglements which would beat back the progress of new ideas. Through EPI’s online network (www.epinternational. ning.com), you can even move these discussions forward in real time. I hope you will engage in this process, make it your own, and in so doing help EPI tell the whole story of emergency medicine development. Let the dialogue continue.

editorial director C. James Holliman, MD executive editors Peter Cameron, MD Terry Mulligan, do, mph Mark Plaster, MD editorial advisors ARIF Alper Cevik, MD Kate Douglass, MD Haywood hall, MD Chak-Wah Kam, MD Greg Larkin, MD Prof. Dongpill Lee Sam-Beom Lee, MD Gladys Lopez, MD Alberto Machado, MD Lee Wallis, MD creative director TRACEY JOLIFFE associate editor LONNIE STOLTZFOOS to order reprints, contact Greg rucker PARS Int’l 253 W. 35th Street, 7th Floor New York, NY 10001 p: 212.221.9595 ext. 105

Logan Plaster Publisher

on the web

connect with international colleagues on emergency medicine’s largest professional network www.epinternational.ning.com Join more than 600 current members from around the globe Create a professional profile for networking and communicating internationally Post international events and learn about new conferences being held Share photos, videos and educational materials with colleagues Join a discussion in progress or start a thread of your own

publisher Logan Plaster Logan@Plasterpub.com

Fall 2010 // Emergency Physicians International

advertising Michelle rucks mrucks@epmonthly.com 5 College Avenue Annapolis, MD 21401 Submissions & Letters c/o logan plaster Emergency Physicians International 210 Columbia Heights Brooklyn, NY 11201 logan@plasterpub.com

mark L. Plaster, md

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3 | Editor’s Desk 8 | Event Calendar 46 | IEM Fellowship Directory

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10 | Opinion p Dr. Björn Nicholas Aujalay, on why Sweden should abandon the supra-specialty model of emergency medicine. 11 | Clinical The gum elastic bougie is a simple, inexpensive, disposable and effective airway management device. Are you using it? 12 | Relief A day in the life of the Pakistan flood rescue effort, by MSF coordinator James Kambaki. 50 | Grand Rounds Dr. Peter Cameron, on sabbatical in the UK, observes the efficacy of Britain’s “4-hour rule.”

Source 16 | Dispatches Reader-generated updates on emergency medicine development around the globe. 18 | Sweden Though still a supra-specialty, EM training continues to build on the gains of the past decade 19 | China p An in-depth look at EM developments across China 24 | Malaysia EM struggles for recognition in the heart of Southeast Asia 25 | Germany In-hospital emergency medicine grows despite political opposition

Cover photo courtesy of Dr. Riaz Ismail

26 | India EM is beginning to benefit from governmental collaboration

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Fall 2010 // Emergency Physicians International

Features 28 | Building a Legacy p How South Africa turned World Cup preparations into an emergency medical stimulus plan. 34 | Graphing the Future Want to know where EM is heading? Start by watching these three key public health data trends. 37 | When Will the EU Accept EM? Will European Union rules restrict emergency medicine specialty development? 40 | The EM World Report EPI surveyed nearly 700 international EPs. 140 physicians from 35 different countries responded. 43 | Is Shift Work Killing You? Breaking sleep cycles can be as bad as smoking a pack a day

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EVENT CALENDAR 10/10–09/11

12 months of international EM c o n f e r e n c e s

OCT/2010

The IFEM Symposium on Resuscitation will be held in San Miguel de Allende, Mexico, June 22 – 24, 2011

International Emergency Department Leadership Institute (IEDLI) // Florence, Italy

ean Society of Emergency Medicine November 10 – 13, 2010 www.medicina-intensiva.cl/urgencias Official Language: Spanish

Teaching ED leaders the skills to successfully operate EDs in any part of the world. October 25 – 29, 2010 www.iedli.org

The biennial international congress of the Emergency Medicine Association of Turkey (EMAT) in collaboration with SUNY Downstate and the Singapore Society of Emergency Medicine (SSEM) October 28 – 31, 2010 www.eacem.org

Asociacion Colombiana de Medicina de Urgencias y Emergencias (ACEM) hosts “New Horizons in Emergency Medicine” November 11 – 13, 2010 www.acemcolombia.com Spanish and English language tracks

Focusing on EM education, research and collaborations in The Netherlands and EU June 9 – 10, 2011 www.nvsha.nl English and Dutch spoken

INTEM 2010 // Ahmedabad, India

1st IFEM Symposium on Resuscitation // San Miguel de Allende, Mexico

INTEM 2010 will be the 12th International Conference of the Society for Emergency Medicine, India (SEMI) November 12 – 14, 2010 www.intem2010.in

1st International Critical Care Symposium // Chennai, India

The Fifth International Congress of Emergency, Prehospital and Disaster // Panama City, Panama

This meeting aims to “bring together world renowned speakers” in a “friendly environment allowing informal discussion,” while providing CME credits. October 29 – 30, 2010 www.critcaresymposium.co.uk

2010 ITLS International Trauma Conference // Reno, USA

Asian Conference for Emergency Medicine (ACEM) 2011 // Bangkok, Thailand

DECEMBER

CSEM Scientific Assembly // Antofagasta, Chile Academic conference hosted by the Chil-

Fall 2010 // Emergency Physicians International

“Emergency Medicine in Global Crises: Lean, Safe & Seamless” July 4 – 6, 2011 www.acem2011.org

RESUSCITATION 2010 // Porto, Portugal What’s new in the 2010 Resuscitation Guidelines? What has changed and why? December 2 – 4, 2010 https://congress.erc.edu

Emergency Cardiovascular Care Update - ECCU 2010 // San Diego, USA The New AHA Guidelines - How will they impact you? December 7 – 11, 2010 www.citizencpr.org

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JULY

November 17 – 19, 2010 www.elpanama.com

Aims to meet the needs of all levels of EM personnel, from EMT-Bs to physicians, and offers educational sessions that focus on emergency and trauma care with an international perspective. November 3 – 6, 2010 www.itrauma.org

5th Dutch North Sea Conference in Emergency Medicine // Egmond aan Zee, The Netherlands

ACEM International Conference // Bogota, Colombia

2nd EurAsian Congress on Emergency Medicine (EACEM) // Antalya, Turkey

NOVEMBER

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–

SEPTEMBER

Sixth Mediterranean Emergency Medicine Congress // Kos, Greece Come to Greece for this biennial event hosted by EuSEM, AAEM and HeSEM. September 10 – 14, 2011 www.emcongress.org/2011

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björn nicholas aujalay, MD

OPINION

The Case Against the Supra-Specialty Model The current specialty model for emergency medicine in Sweden creates an overly costly and inefficient training pathway and dissuades new residents from joining.

ate last year I was recognized as a specialist in emergency medicine in Sweden. The interesting fact about this decision is that Socialstyrelsen (The National Board of Health and Welfare) until now only approved emergency medicine as a “supra-specialty,” meaning emergency medicine is only recognized in conjunction with another “base specialty,” such as internal medicine or family medicine. As I am trained in the United States where emergency medicine is a specialty of its own, I am not double boarded. I am also recognized as a specialist in Iceland and these credentials where sufficient for specialist approval in Sweden. I hereby urge Socialstyrelsen, in light of this decision, to recognize emergency medicine as a specialty of its own. Otherwise, Swedish emergency physicians will continue to be trained in a more costly and less efficient system compared to European colleges. Emergency medicine is today an established specialty in most English speaking countries, and indeed in many European countries. In the United States, emergency medicine was recognized as a specialty of its own in 1979 after a decade or more of emerging residency training and organization efforts. The same topics discussed then about emergency medicine as an independent specialty, from curriculum to organizational structure to double boarding, are being debated in Sweden today, 30 years later. Today, there is no real debate to abolish emergency medicine as a specialty, and this competency is taken for granted by the public and the medical community. Emergency medicine in the United States has proven itself with demonstrated competency, research and organization. Emergency medicine today in the United

States is one of the most popular specialties, reflected by the large number of highly qualified applications to resident training programs. In Sweden, a number of hospitals over the last decade have initiated a change towards emergency medicine practice with development of organization and residency programs. Since 2006, Socialstyrelsen has recognized emergency medicine as a “supra-specialty,” meaning physicians have to specialize in a traditional specialty before completing emergency medicine training to gain specialist recognition. This is against the recommendations of both SWESEM (Swedish Society of Emergency Medicine) and EuSEM (European Society of Emergency Medicine), and complicates matters for residency programs and organizational development. The supra-specialty model increases residency time by almost double, and increases costs both for the training hospital and the resident, whose time with resident salary is prolonged. This cumbersome system also sways away potential applicants from emergency medicine, making recruitment more difficult. Also, the supra-specialty model creates a conflict of interest during training. The training program for the base specialty has little or no interest in training a physician

Fall 2010 // Emergency Physicians International

I hereby request that Socialstyrelsen analyses the present overall situation and in fairness acknowledges Emergency Medicine as an independent specialty.

who is only partially going to practice in this field – or not practice at all. This adds to a negative training environment for junior physicians. I would argue this model produces inferior training of the residents as both specialties have to compromise in regards to supervision, training time and curriculum content. As mentioned there are substantial reasons for abolishing the supra-specialty model. In addition to the above mentioned reasons, we must now consider the fact that Socialstyrelsen recognizes me as a specialist. This because there is an agreement among the Nordic countries to acknowledge specialists from their respective countries. Since several countries within the EU recognize emergency medicine as a specialty, these physicians can go through the same credentialing process and ultimately become certified in Sweden like me. It is therefore unreasonable to continue to demand supraspecialty training for Swedish physicians given that European training is indirectly recognized. In addition, all medicine should be practiced based on the evidence, and according to accepted standards of care. Today there is sufficient international experience suggesting quality and efficiency is augmented with emergency medicine training and organization. To disregard this international experience is no longer valid or appropriate. I hereby request that Socialstyrelsen analyses the present overall situation and, in fairness, acknowledges emergency medicine as an independent specialty. This would indeed facilitate recruitment and training of emergency physicians. It would also speed up the process of a more appropriate organization, and move the development of Swedish emergency medicine towards an international standard of care. Björn Nicholas Aujalay, MD, was born and raised in Sweden. After completing medical school at Uppsala University and residency training at South Hospital Stockholm, he moved overseas for training at North Shore University Emergency Medicine Program in New York. Dr. Aujalay has been practicing EM in Fairbanks, Alaska for the last five years.

CLINICAL

Using the Gum Elastic Bougie This rescue airway device is simple, effective, inexpensive and disposable. Is your ED using this tool properly? by Kaushal Shah, MD

f you work in an emergency department (ED), you will inevitably encounter a difficult airway. In fact, they occur in approximately 4% of unpredicted cases and 25% of potentially difficult cases. What is your back-up plan?

Some of us are lucky to work in a large, academic institution with a “difficult airway cart” (containing various rescue airway tools), a video laryngoscope, and 24-hour availability of anesthesia consultants. This luxury is not available everywhere and certainly not throughout the world. The gum elastic bougie (GEB), also known as the Eschmann tracheal tube introducer or simply “bougie,” is a rescue airway device option that should be considered. It is simple, inexpensive, disposable and effective. The GEB is a long, semi-rigid device, much like a stylet, with a bent/angled tip that can be used to guide the placement of the endotracheal tube (ETT) when the view of the vocal cords is obscured. Successful endotracheal intubation entails cannulation of the trachea using the GEB followed by threading of the ETT over the bougie via the Seldinger technique. The brilliance of the bougie design is embodied in the angled tip that allows you to navigate the pencil-thin device anteriorly around the epiglottis when the vocal cords cannot be seen. The GEB is commonly used in the United Kingdom, Australia and it is increasingly being utilized in the United States. Anesthesiologists were the first to adopt and embrace the practice of using the GEB as a first-line rescue airway device (even before switching the laryngoscope blade) but emergency physicians have not been far behind (1, 2). The first published studies were conducted on “simulated difficult intubations” or Operating Room (OR) case in the anesthesia setting and often cite success rates of 95-100% (1-5). The only two prospective studies performed in the ED resulted in success rates of approximately 80% (6-7). It is not surprising that failure rates of the GEB in the ED setting are higher as the combination of situational stressors, patient acuity, cervical immobilization, lack of oxygen reserve, non-filtering of known difficult airways, ambient noise, and physiologic time pressures in ED patients with ongoing clinical deterioration all create substantially different intubating conditions. An 80% success rate is probably a reasonable estimation for use of the GEB by emer-

Diagram courtesy of Lippincott, Williams & Wilkens

Technique for GEB Insertion wPreparation: ETT should be at least a 6.0 size and the bougie may be lubricated with sterile water or KY jelly wThe bougie should be oriented such that the angled tip is directed anteriorly. wThe bougie should be carefully advanced through the partial view of the vocal cords or placed blindly as anteriorly as possible around the epiglottis. wCheck for “palpable clicks” and “hold-up”. If they are present, slide the ETT over the bougie. If “clicks” and “hold-up” are absent, bougie is likely in the esophagus and should be removed. wWhen passing the ETT over the bougie, rotate the ETT 90° counter-clockwise before passing thru cords wOnce the ETT is in place, pull out the bougie and the laryngoscope blade wConfirm tracheal ETT placement using conventional methods

gency physicians. This is further corroborated by the fact that a prospective study of anesthetized patients with truly unanticipated difficult airways in the OR also yielded a success of 80% (8). In addition to knowing the proper technique (sidebar above), to maximize the success of intubation with the GEB, emergency physicians should be familiar with four critical concepts: 1. “Palpable clicks” 2. “Hold-up” 3. Laryngoscope blade needed until the ETT is inserted 4. Rotation of the ETT 90 degrees counterclockwise “Palpable clicks” are the perceptible snaps of the GEB that occur as it passes along the rings of cartilage in the trachea (but are not present if the GEB is in the esophagus). “Hold-up” is the resistance encountered during insertion of a GEB; it occurs as a result of the tip abut- continued on page 44

www.epinternational.ning.com

DISASTER RELIEF

Pakistan

A Snapshot of Flood Recovery Efforts

u August 24, 2010: Receding waters bring rise in O.B. emergencies and water-born diseases by James Kambaki

e’ve been running a number of mobile clinics in Fadfedar canal, in the areas around Manjoshori, and in Khabula, where the people we struggled to reach not long ago are now relatively accessible. Here in Dera Murad Jamali (DMJ) we are treating a lot of watery diarrhea and we’ve begun to support obstetric emergency in the hospital. The number of women needing consultations has really increased and the doctors are working 24 hours. We’re seeing a lot of women with placenta praevia, eclampsia and all manner of obstructions, complications, and obstetric emergency cases. Our doctors are working around the clock to treat them. The sheer number of people in the city is complicating matters. DMJ usually has a population of approximately 50,000, but the flooding has meant that tens of thousands of people from the surrounding countryside and even from areas hundreds of kilometers away have poured into the city. The official figure for the influx is 60,000, but looking around, it’s easy to see that it could be much higher. Most of the towns and areas around DMJ are completely unAn MSF water distribution point in northern Pakistan. derwater, and their inhabitants have come here. In the first few photo by Jean Marc Jacobs/MSF days of the flooding, there was a mass movement of people, which was terrible to witness. On the surrounding roads outside the city, hospital compound, workers have found bodies of people who died just bethere were thousands of people all moving in the same direction. People were fore they made it to us. It’s terrible as we have no idea who these people are. on tractors, on ox carts, on donkey carts, on motorbikes, on tuk-tuks, and The water situation is really appalling. There are canals and small ponds on foot, picking up anything to cover themselves. Children were being carfilled with contaminated flood water that people are drinking from. We have ried, and people were carting everything they owned perched on top of their a number of water bladders and we are distributing [water] constantly. At the heads. Animals were dying on the way, people were struggling to walk, and moment, it is still not enough. But a major water purification system should the heat was extremely intense. We distributed plastic sheeting and thousands be up and running in a few days, which will really help alleviate the situation. of hygiene kits and cooking items. There are tents and temporary shelters everywhere, pitched in sports staWith so many people in the city, clean drinking water is still a major condiums, in school grounds, in colleges. There is one college with around 200 cern. We’ve seen an increasing number of watery diarrhea cases, which we are tents but not a single latrine. In the next couple of days, we are going to help managing, but in the past few days we have had a number of incidents when build 250 latrines there and others in a number of other locations. In situapeople have been so ill that they have died on the way to the hospital. In the tions like this, where water-borne diseases are a continuing threat, prevention is vitally important. With so much overcrowding, displacement and need, people are very By the end of August, MSF had... angry. I’ve seen quite a few protests and when we do distributions it’s very tough. People tell me they are upset because a lot of them have not received nDistributed 24,834 non-food item kits food and some have no shelter. I met one man who had travelled over 200 nDistributed 6,801 tents kilometers [120 miles] with his family. They had nothing and were desperate nPerformed 27,151 medical consultations for food and for somewhere to stay. He was extremely angry and I couldn’t nSet up 7 diarrhea treatment centers blame him. But we’re doing all we can to help people like him. nBuilt 258 latrines The team I have working with me is amazing. They are strong and they are nInstalled 11 Oral Rehydration Salt points working long hours. In the next few weeks our main focus is going to be treating the diarrhea cases and ensuring that more clean water is distributed. It’s a MSF’s existing and flood response programs in massive task, but we are making progress.

Pakistan are staffed by 1,279 Pakistani aid workers and 152 international aid workers.

Fall 2010 // Emergency Physicians International

James Kambaki is the MSF project coordinator in the Balochistan province of Pakistan.

1st international symposium on Resuscitation InternatIonal FederatIon oF emergency medIcIne

Resuscitation topics *Medical and Cardiac *Trauma *Pediatric and Neonatal *Obstetrical *Critical Care Ultrasound

JUNe 22 – 24, 2011

San Miguel de allende, gto.

Mexico

Keynote addRess JUdiTh TiNTiNalli

Guests PeTer CaMerON GaUTaM BOdiwala PaUl PePe BOB O’CONNer williaM BarsaN rOBerT sUTer darryl MaCias and more!

www.ifemsymposium2011.org

www.epinternational.ning.com

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source Firsthand reports of specialty development around the globe

dispatches 16 sweden 18 china 19 Malaysia 24 Germany 25

As a young specialty, emergency medicine struggles to survive in China, a nation steeped in the culture of traditional medicine. Story on page 19

india 26

www.epinternational.ning.com

SOURCE // DISPATCHES READER-SUBMITTED UPDATES FROM WEST TO EAST

canada

Developments: Unique to Canada is a dual EM certification system. Medical school graduates wishing to specialize in EM must choose between one of two types of residency training programs: a 5-year Royal College program, or a 1-year EM fellowship through the College of Family Physicians of Canada after 2 years of family medicine training (i.e. 5 years versus 3 years). Emergency physicians from both training streams work in a variety of settings, although the 5-year trainees are more likely to go to academic centers. Discussions over the pros and cons of having two training routes have gone on for more than a decade and now center around creating a single EM college. Will we soon see the Canadian College of Emergency Physicians? Who knows, but stay tuned. Challenges: ED overcrowding—like everywhere else, our emergency departments aren’t large enough or efficient enough to deal with the increasing number of aging and complicated patients who can’t otherwise get to a family physician in a timely manner. We recognize that this is not an EM problem—it’s a social problem that has seriously affected the healthcare system. As the 24-hour access point to that system, the emergency department experiences the greatest impact, and we who work in the system have been left to deal with it. -Andrew Worster, MD

Panama

“Will we soon see the Canadian College of Emergency Physicians?”

Developments: In Panama, emergency medicine is one of the more recent specialties, having begun in 2003. In June, 1995, the Academic Association of ER Docs of Panama was created. ASAMUP, as it is commonly known, has been charged with maintaining and furthering a high standard of professionalism in the field of medical education. Although no official political system exists for emergency physicians, the ASAMUP has already begun conversations with the political health authorities to develop these standards and maintain qualified physicians. In February, 2009, we began a United System of Managing Emergency Services (SUME 911). The first steps of the organization were focused on emergency services, specifically getting the government better focused on managing emergencies in our country. During the last few years, we have been working to further the development of various hospitals – from staff to equipment – but there is much work that still needs to be completed. -Elis González Portugal, MD

Brazil

Developments: Emergency medicine is not a recognized medical specialty here in Brazil. Several years ago we founded the Associação Brasileira de Medicina de Emergência (ABRAMEDE), a national society formed with the intention of developing the specialty in our country. Now, we are in the midst of a so-called political battle, because the internal medicine society still believes that EM is a branch of its area. We have only two EM residency programs in our country—one in Porto Alegre, in the state of Rio Grande do Sul; and another in Fortaleza, in the state of Ceará. challenges: First of all, to have the specialty recognized, so that we can create more residencies, it would be very important to have the support of emergency societies around the world. predictions: Over the past five years we have grown significantly. Most medical societies in Brazil support our idea for an independent medical specialty, as is now the case in many countries. Unfortunately, there is opposition to this formal recognition of EM, but I believe that if we keep growing, as it is happening now, we can succeed very soon. -Daniel Fontana Pedrollo, MD

Fall 2010 // Emergency Physicians International

“ASAMUP has begun conversations with the political health authorities to develop [EM] standards and maintain qualified physicians. “

Finland

Ireland

Developments: The first EM consultant in Ireland was appointed in 1974. We now have over 50 consultants in EM working in over 30 different EDs around the country. Many have trained abroad and brought to Ireland a wealth of experience from the US, Canada, Australia, Africa and Europe. There are now well established basic and higher training programmes nationally in EM. These programmes are conducted through the Royal College of Surgeons of Ireland. The Irish Association of Emergency Medicine (IAEM) represents all emergency physicians in Ireland. IAEM hosts a scientific meeting each year with a lively calendar of social events. The Irish Emergency Medicine Trainees Association organizes regular conferences and exam preparation workshops throughout the country for EM trainees. Challenges: Our main challenge is overcrowding caused by the practice of boarding admitted patients in the emergency departments for days. This problem is caused by both a lack of bed capacity in the Irish Health service, and lack of accountability of bed management within the system. Predictions: Ideally, each of the emergency departments in Ireland would aim to have at least 7 EM consultants. It’s unlikely, however, that each will expand by that degree. What is likely to happen over the next few years is a process of reconfiguration of Irish EDs, where smaller units close and large departments serve an expanding catchment area. -Jean O’Sullivan, MD

Developments: EM development is still a bit chaotic in Finland. An EM subspecialty has been approved, which only a few people have received so far. There is a certification curriculum and exam, but they are not required in order to receive accreditation. We do not think that EM will become a core speciality for a number of years yet. Many of our colleagues are working hard, however, to unify the specialties in which EM patients are seen throughout the country, and there are positive developments almost every month. Challenges: As in most developed countries, we struggle to meet the needs of an aging population. Alcohol and drug abuse are major problems. The challenge we face is that of separate units developing in different sections of EM that are often located in multiple clinical sites. For example, in Finland most EM patients are still treated by various specialities (surgical, medical, etc). There often seems to be an invisible border between medical and surgical departments of the ED, and therefore less cooperation than there ought to be; every specialty has understandably developed their own section of the emergency service. We also lack a forum through which to reach a unanimous consensus. Neither ATLS or AMLS have reached Finland, for example. We believe that a core specialty would be the key to solving a lot of our problems. Predictions: We trust that emergency medicine will develop in this country, but we are still in the early days. -Jani Mononen, MD & Victoria Webster, MD

“We do not think that EM will become a core speciality for a number of years yet.”

Bahrain

“What is likely to happen over the next few years is a process of reconfiguration of Irish EDs, where smaller units close and large departments serve an expanding catchment area.”

Developments: In 2000, EM was established as a specialty in Bahrain (population ~790,000). EM is under the umbrella of the Arab Board of Medical Specialties. We currently have two board certified emergency physicians, one of them a fellow of the American Academy of Emergency Medicine (AAEM). Two board certified physicians are soon to join after completing their fellowship training, and three board certified are waiting for their fellowship training program. Challenges: We need more board certified emergency physicians to train our new residents. New board certified physicians in EM are having difficulties in getting training in fellowship programs due to high demand for this specialty in the many countries where our physicians were getting fellowship training. Sponsorship fees have thus increased or tougher conditions for training implemented. Predictions: Following completion of fellowship training, a larger group of board certified physicians could lobby more persuasively for the rights of emergency physicians and improved patient care; to establish a better education program for EM residents; and to facilitate better communication with EM peers from other countries. -Munawar Al Hoda, MD

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Source

EM resident Tom Strandberg rides a “bike” used for rapid transport within the hospital. “The hospital is quite big. Some doctors bring their own mini scooters just for transport within the hospital.”

work week

36 to 40 hours per week (junior & senior staff alike)

vacation Five weeks per year

sweden

less than 1%

by Katrin Hruska, MD

is a cause of death four times more common than traffic accidents

Though still a supra-specialty, EM training continues to build on the gains of the past decade.

t is a constant struggle to develop and implement a new specialty like emergency medicine (EM). There are multiple stages to go through and several obstacles to overcome. Interestingly, these seem to have been more or less the same all over the world. Nations who started early with EM have reached further, but it has not been hassle free for anyone. To begin with, it takes a highly dedicated group. In 1999, in Sweden, such a group of people founded what would become, in 2002, the Swedish society for Emergency Medicine. Training programs in EM were started in a few enthusiastic hospitals in 2000-2001, but it was not until 2006 that EM was recognized as a specialty. To many aspiring emergency physicians’ disappointment, the National Board of Health and Welfare chose to recognize EM as a supraspecialty, making it necessary to train in a base specialty as well. All specialty training programs take at least 5 years. The EM specialty training does not have a set time frame, is goal-oriented, and it is estimated

that you need 2–3 years of training after completing your base specialty. Any clinical specialty is approved as base specialty, even psychiatry, but to fulfill the curriculum requirements would of course take longer with a less relevant base specialty. Internal medicine, family medicine, and anesthesiology are popular base specialties. Most residency programs now offer 7 years of integrated training in the base specialty—for convenience, mostly internal medicine and EM. This causes great frustration since a lot of time is spent in internal medicine wards learning things that are not really needed in the ED. Swedish emergency departments have traditionally been staffed by junior doctors and residents from the different departments of the hospitals. Most hospitals are still divided by specialty into at least a medical and a surgical unit, but several have separate units for cardiology, neurology, ENT, and infectious diseases. More hospitals have realized the advantage of having doctors working in the ED on a

Fall 2010 // Emergency Physicians International

of all invasive Staph Aureus infections are MRSA

suicide

regular basis and have started some sort of EM training program. Most have started out with a group of junior doctors and consultants from internal medicine, surgery, orthopedics, and anesthesiology to supervise them. There are also consultants, who have worked in their respective fields for many years, who have decided to become EM residents themselves. All these emergency physicians-to-be initially rotated their shifts between the different units, then gradually covered more and more shifts. In a few hospitals the emergency physician unit has gained overall responsibility for the ED, but there are still no hospitals that don’t have to rely on doctors from other specialties to cover part of their shifts. To date in Sweden there are around 30 certified EM specialists and close to 200 residents, training in 16 different hospitals. The biggest challenge is to secure the standard of this training, especially in hospitals where there are only a few residents and no specialists. Hopefully there will soon be enough specialists to convince The National Board of Health and Welfare to acknowledge EM as a base specialty. With the current practice it takes at least 7 years of training, after an 18-month internship, to quality as a specialist in EM. Patience and perseverance are crucial characteristics for emergency physicians, who, ironically, might have chosen this profession because they like the thought of finishing their work at the end of the shift and starting out with a clean slate the next day. But, again, this seems to be a common feature around the world.

Bouncebacks: New Findings from Sweden In a 2010 analysis, 50% of non-urgent ED and unscheduled primary care visits resulted in a repeat health care contact within 30 days. Of those patients:

9% originating from unscheduled primary care visits led to a secondary ED visit 16% originating from non-urgent ED visits resulted in a repeat ED visit Backman AS, Blomqvist P, Svensson T, Adami J. Health care utilization following a non-urgent visit in emergency department and primary care. Intern Emerg Med. 2010 Aug 19. [Epub ahead of print]

source

“

The Chinese culture is traditionally very family-oriented. It is not uncommon for an entire family to accompany the sick or the injured to the emergency room and be intimately involved in their care.

EMS SYSTEM

300

The number of “emergency centers” in China.

china

The Current Status and Future Directions of Emergency Medicine Y. Veronica Pei, MD, MPH

ince 2001, I have traveled to China on multiple occasions and had the pleasure of visiting a number of emergency departments, as well as 1-2-0 emergency centers (“1-2-0” is one of China’s emergency medical numbers) in Shanghai, Beijing, Changsha, and Changde. During each of these visits, I interviewed emergency department directors, 1-2-0 emergency medical center directors, as well as emergency physicians at each of these locations on the current state of emergency medicine in China. BACKGROUND With rapid economical and technological advancement, the aging Chinese population faces an increased incidence of emergencies related to road-traffic accidents, as well as chronic conditions such as coronary artery disease, stroke, and diabetes. Rising tourism and more foreign nationals create additional demand for acute and emergency health care, leading to a growing need

for the development of a well designed and responsive emergency medical system. Although emergency medicine (EM) in China has undergone tremendous growth since the 1950s, it is still an area of medicine that requires further specialty definition and formalized training. Since the establishment of the Chinese Emergency Medicine Association, in 1986, the specialty of emergency medicine in China has grown to encompass three areas: prehospital medicine, emergency medicine, and critical care medicine. Models of EM practice in China primarily involved a multi-specialist approach using practitioners from medical sub-specialties to deliver emergency care in their area of expertise. However, as patients present to the emergency department with increasingly complex, undifferentiated chief complaints, it has become evident that specialized training is necessary in order to respond appropriately to the acute needs of emergency room patients.

At least 4 different types of EMS models have been adopted throughout China because of the range of economic and geographical needs.

1-2-0

The main EMS phone number in China. Others include: 1-1-9 1-1-0 1-1-2 9-5-1-2-0

Pre-hospital care system in China has been in development since 1980, when the Chinese Ministry of Health issued the “Directives to Further Strengthen the Emergency Care in Urban Areas.” China is currently in the midst of developing a nationwide pre-hospital network that incorporates modern technology. The Administrative Committee of Emergency Medical Center (First Aid Station) Branch of Chinese Hospital Association (EMCBCHA) was established, in 2002, under the direction of the Ministry of Health and the Chinese Hospital Association to assist in the planning and development of pre-hospital care system across China. While the quality of pre-hospital care has seen significant improvement over the past 50 years, much improvement is still needed, according to the EMCBCHA: 1. Pre-hospital aid development is unbalanced with great disparity in the nation. 2. There are no national standards for emergency care management, and certain current policies are counter-productive. 3. Multiple emergency response systems co-exist, and they are often in unhealthy and disordering competition. 4. There is a lack of systematic planning of emergency systems 5. There is a lack of information exchange and sharing Lack of health expenditure from the central government, and disparities in local resources, have contributed to the high variability in the quality and availability of pre-hospital medical services between regions. At present, over 300 “emergency centers” can be found throughout the country. At least four different types of emergency medical system (EMS) models have been adopted throughout China because of the wide range of economic capabilities and geographical needs between regions. Current EMS models range from privatized ambulance services, stand-alone emergency center, stand-alone 1-2-0 centers, hospital-based ambulance services, to a combination of these models. While the Chinese Ministry of Health has mandated “1-2-0” as the official medical emergency number since 1996, different EMS systems

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still coexist within the same city, creating added confusion. Multiple emergency medical numbers have been implemented within the same geographic region, as well: 1-2-0, 1-1-9, 1-1-0, 1-2-2, 95120, etc. Many medium-to-large cities, such as Shanghai and Beijing, have incorporated advanced technological equipment with global positioning tracking systems at local 1-2-0 control centers to monitor local pre-hospital ground units. However, communication and personnel training remain as major challenges for the current pre-hospital care system in China. It has been difficult to achieve effective communication between pre-hospital providers and receiving hospitals. In most cases, receiving hospitals get little or no notification before the arrival of critically ill patients. Medical direction and pre-notification are sometimes utilized in systems that have hospital-based ambulance stations. In these instances, the pre-hospital personnel are also hospital staff members, who will provide some pre-notification to the receiving emergency departments. Pre-hospital providers may include a driver, a transporter who functions as a basic provider, a nurse, as well as a physician. The specific combination of personnel varies between different EMS models. Training and certification of pre-hospital personnel varies between regions. In regions with a stand-alone 1-2-0 center, prehospital personnel may consist of dedicated physicians with very little post-graduate training, while hospital based models may use specialty-trained emergency physicians. In larger cities like Shanghai, a provider’s manual with treatment protocols has been created for the local providers. However, personnel training, practice standards, and certification have yet to be established across the entire nation. Patient transport protocols also vary depending on the EMS model adopted for the region. In general, pre-hospital providers may recommend the closest appropriate facility, but patients’ preference takes precedence in determining the receiving hospital. This is especially the case in EMS models that utilize local hospitals as satellite ambulance stations. Absence of transfer guidelines, and patients’ preference for larger and more reputable centers, often results in tertiary care centers being inundat-

ed with emergency and transfer patients. The Practice of Emergency Medicine In 1983, China established its first emergency department at the Peking Union Medical College Hospital in Beijing, under the leadership of Professor Xiaohong Shao. Over the last 20 years, emergency departments emerged quickly in many hospitals across the country. By the end of the 1990s, all hospitals at the levels of province, prefecture, and county were equipped with emergency departments. Several different models of EM practice can be found in China. In many cases, competition and limited resources have led hospitals within the same city to adopt different models of practice, and to establish various areas of emphasis and specialization. For example, the Beijing Tiantan Hospital specializes in neurosurgical emergencies, while the Chinese People’s Liberation Army (PLA) General Hospital First Affiliate Hospital (formerly PLA 304 Hospital) serves as the regional burn center. Until 2005, the Beijing Emergency Medical Center coordinated pre-hospital care through the “1-2-0” system and acted as a standalone trauma and emergency hospital. Most major urban centers have adopted a multi-specialist approach, where emergency room physicians are primarily internists. Patients presenting with all other complaints are typically evaluated by on-call specialists after triage. Upon arrival, patients are triaged into different areas based on chief complaint. For example, many emergency departments contain specific treatment rooms designated for OB/ GYN, ENT, Dermatology, Neurology and

Fall 2010 // Emergency Physicians International

other sub-specialty evaluations. A separate treatment area staffed by surgeons is typically used to evaluate surgical related complaints. While most emergency physicians in China root their practice in internal medicine, there are some centers, such as the Chinese PLA General Hospital First Affiliate Hospital, where emergency physicians evaluate all patients presenting to the emergency room. Hospital overcrowding, lengthy hospital stays, and lack of outpatient services have all contributed to extended stays in the emergency room. In addition, inpatient wards have become so highly specialized that patients with multiple conditions are often refused admission by individual specialties. The end result is that the emergency department is often left to manage patients that require admission or observation but have been deemed undesirable for sub-specialty inpatient services. Interviews with emergency physicians at hospitals in Shanghai and Beijing revealed that emergency room stays can range from weeks to months. In extreme cases, chronic stable ventilator-dependent patients have remained at the emergency department for years due to lack of outpatient facilities. As a result, emergency departments began to incorporate observation areas, inpatient wards, ICU, and even operating suites— in addition to triage and treatment areas—to meet this demand. Many urban hospitals have constructed a standalone “emergency building” rather than the typical “emergency room.” Therefore, the role of the Chinese emergency physician has evolved over the years to include the practice of acute, inpatient, as well as critical care, medicine.

new ed at xyh 3-level ED with 20-bed EICU and 40-bed observation unit

“

Absence of transfer guidelines and patients’ preferences for larger and more reputable centers, often results in tertiary care centers being inundated with emergency and transfer patients.

Working Conditions Emergency physicians and resident physicians typically work 40–50 hours per week. While some university hospital centers require attending physicians to be on-call in the evenings, the majority of attending physicians cover the emergency department during normal business hours. After-hour patient care is provided primarily by resident physicians and supervised by senior or chief residents. In smaller community centers, emergency physicians work 8–12 hours shifts around the clock. The working environment can be challenging. Emergency departments are regularly overcrowded and under-staffed. The patient volume of an urban emergency department typically ranges from 150,000 to 200,000 per year. Patients often overflow into the hallways and, in some instances, the hospital lobby area. The Chinese culture is traditionally very family-oriented. It is not uncommon for an entire family to accompany the sick or the injured to the emergency room and be intimately involved in their care. This frequently adds to the chaos and confusion in a busy emergency department. High out-of-pocket expense for medical care has resulted in demand for customer service-oriented practice environment and no tolerance for medical errors, through legal repercussions. As a new specialty in China, EM is significantly undervalued in most centers and suffers from lack of recognition and support among other departments and hospital administration. Emergency physicians are not viewed as “specialists” and do not have admitting privileges in most hospitals. In the presence of market economy, hospitals are struggling financially to survive within the complex system of private and public insurances. This has created competition for patient services between hospitals and departments. Many hospitals have implemented a financial quota that must be met by each department, which directly affects individual physician compensation. Unfortunately, this environment has placed the emergency departments at a disadvantage, given the high proportion of patients without ability to pay and the high costs of managing acutely ill patients. This has also contributed to emergency depart-

ment overcrowding when specialty wards are able to selectively admit patients based on ability to pay. Emergency Medicine Training The first EM residency program in China was established in Peking Union Medical College Hospital in 1986. Since then, many large urban centers have come to realize the importance of some form of post-graduate training in EM and have developed institution-specific training programs. The current post-graduate emergency medicine training process in China is highly complex. Because specialty certification in EM has not been established, formal training is not required to practice emergency medicine in China. Several options are available for those physicians who do choose to obtain training in EM. Medical school graduates can apply directly to hospitals for staff physician-in-training positions, which eventually lead to a staff position at that same hospital. The local health bureau may also assign physicians from smaller hospitals to be trained at larger academic centers. While these physicians may undergo the same training as the staff physicians, they will return to their own hospital once their training is completed. Finally, physicians who have completed previous post-graduate training may choose to apply for fellowship positions for further training in EM. Currently, there is no formal accreditation process for graduate medical education in China, therefore standardized post-graduate EM training curriculum has not been established. The absence of a national certifying body for the emergency medicine specialty has led to variable training standards across programs. The Department of Emergency Medicine at Peking Union Medical College Hospital was recently commissioned by the Ministry of Health to develop a national training curriculum for specialty training in EM. Since the practice of EM in China consists mainly of internal medicine, most of the training curriculum has also been focused accordingly. Off-service rotation in surgical specialties encompasses very little of the overall training curriculum. Unlike in the US, most resident physicians in EM remain at the same hospital as staff physicians

after completion of their training. Thus, the training curriculum at individual hospitals tends to reflect their own style of practice rather than global learning objectives. For example, an emergency physician training at a primarily adult care center will receive little or no training in pediatric emergency medicine. The perception is that training should be focused on clinical presentations applicable to individual hospital practice environment. Recruitment Recruitment of emergency physicians remains a challenge at most institutions. Heavy workload, difficult working conditions, limited reimbursements, and lack of recognition and respect among medical colleagues all contribute to the difficulty in recruiting emergency physicians. Most hospitals staff their emergency department with rotating residents from other specialties, with very limited numbers of EM attending physicians. As recognition for the specialty of EM continues to grow, the number of residents interested in EM has increased drastically. Academic Development Similar to other nations in early stages of EM development, a majority of the existing senior EM faculty members have been grandfathered in from other specialties. Given the complex scope of practice of EM that has evolved in China, Chinese emergency physicians are struggling with the development of basic and clinical research in their newly defined specialty. Funding for academic development in China has traditionally focused on basic laboratory research and well-established specialties. At present, a majority of the specialty development focuses on basic science research surrounding resuscitation, toxicology, as well as critical care medicine. Future Directions As a young specialty, EM in China is struggling to survive in a culture with over two thousand years of traditional medicine and that is dominated by subspecialty development. Rapid economic development and urbanization in China has already resulted in an epidemiological and demographic shift of its disease burden toward

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chronic illnesses and injuries. While it is recognized that the ability to provide care to acutely ill patients is essential to a healthcare system, China will need to strengthen its current emergency medical system in order to respond effectively to its changing healthcare priorities. A recent series of natural disasters, such as the earthquake in Sichuan, has reinforced the need for disaster preparedness and response. Scope of Practice The current practice of EM encompasses many roles, including EMS, acute patient care, ward medicine, and intensive care. However, no single model of EM practice has emerged. While there is a trend toward the specialty model of EM practice internationally, the likelihood of achieving such a practice model in China is questionable. Given Chinaâ&#x20AC;&#x2122;s vast population, complex health system, and variability in economic capabilities, a single model of practice may not even be feasible. China is in the midst of developing its own models, which are tailored to the needs of regional health systems. Emergency physicians in China will need to first develop a consensus as to their scope of practice. This first step is critical to future specialty development, as it is fundamental to the development of residency training requirements and specialty certification. The training development of emergency physicians with the ability to diagnosis and manage a full spectrum of acute illnesses across all ages may be a challenge in China, given the current configuration of health system and cultural perceptions of emergency physicians. When EM has delineated its scope of practice, further subspecialty development in critical care, pre-hospital care, and other areas can occur. It is encouraging that the Chinese Emergency Medicine Association has been a leader in this mission and will continue to offer direction for this development.

Training and Certification When one or several practice models of Chinese EM have been defined, a national standardized residency training curriculum and certification process can then be developed. Standardized training and certification ensures that core competencies are met for each physician trained to be an emergency physician. Given the current state of EM in China, a number of models may be required based on regional health system needs. Therefore, the training curriculum and certification may need to follow a tiered process that matches individual practice models. In 2009, a new Chinese College of Emergency Medicine was formed under the direction of Dr. Xuezhong Yu. The mission of this new society is to provide a national platform for specialty specific training and education in EM. Collaboration International collaborations can be a critical component of specialty development and is widely in use in China. At a systems level, collaborations can serve to improve and enhance current emergency response systems. Integration of pre-hospital and hospital emergency care remains a major challenge. Inter-departmental collaborations should be enhanced to further the development of EM in China. Policies should be established in consultation and admission procedures so that patient flow through the emergency department can be optimized. Interdepartmental educational conferences can also serve to enhance knowledge and communication between the emergency department and other departments. The exchange of knowledge through faculty and resident physician exchange can be a valuable learning experience for all members involved. Advocacy and Research As a relatively new specialty, Chinese emergency physicians are struggling to define themselves as specialists. One of the most important roles

of Chinese emergency physicians is to advocate for policies, programs, and funding that support further development of their specialty. Advocacy can be performed through professional organizations such as the Chinese Emergency Medicine Association and may involve working with local government agencies, other medical professionals, hospital administration, general public, academic institutions, and other civic agencies. At the hospital level, the emergency department cannot be expected to sustain itself as an individual department, but must be viewed as a vital component of each hospital organization. While the emergency department is often faced with a large financial burden, it must be recognized that it provides a service to the community during times when no other services are available to or choose to. Moral and ethical concerns prevent the emergency department from turning away patients in need of emergency treatment. The emergency department should not be expected to bear this burden alone. Administrators should advocate receiving clinical, as well as financial, support from other departments, so that this service to the community may be continued. Funding should be provided by government agencies to establish baseline patient population data and additional research. More research is needed to ensure that clinical decisions are appropriate to the Chinese population. Additional research in EM training and education, clinical management of acutely ill patients, and administrative policies in the practice of EM, are also needed. As EM develops in China it will continue to face new challenges. With the development of a specialty model of practice, new educational and specialty requirements will follow. Continued advancement in education, research, and clinical practice will be vital to the EM specialty development. Finally, coordinated efforts from current EM leaders, academic institutions, and government agencies will be critical to the future of EM development in China.

References: 1. Burkle FM, Zhang X, Patrick W, Kalinowski E, Li Z. Emergency medical service systems in the United States and China: a developmental comparison. Prehospital Disaster Med. 1994;9:244-51.

4. Beijing Emergency Medical Center. Available at: http://beijing. emss.cn/. Accessed May 2, 2008.

2. Emergency Medical Center (First Aid Station) Branch of Chinese Hospital Association. China Emergency Medical Service System. Available at: http://www.emss.com.cn/eng/his.htm. Accessed May 1, 2008.

5. Mathers CD, Lopez AD, Murray CJL. The burden of disease and mortality by condition: data, methods and results for 2001. In: Lopez AD, Mathers CD, Ezzati M, Jamison DT, Murray CJL, eds. Global Burden of Disease and Risk Factors. New York: Oxford University Press; 2006:45-240.

3. Lui, CZ. Issues of Standardization of Pre-hospital Care in China (Chinese). In: Proceedings of the 10th National Congress on Emergency Medicine. 2004;Oct 29â&#x20AC;&#x201C;Nov 2. Shanghai, China:17-19.

6. Smith J, Haile-Mariam T. Priorities in global emergency medicine development. In: Arnold LK, Smith J, eds. Emerg Med Clin N Am. 2005;23:11-29.

Fall 2010 // Emergency Physicians International

LIFELINE FOUNDATION

a ab ed

m Ah

N ov .

Presents

INTEM 20

12th International Conference of Society for Emergency Medicine, India

Theme: Emergency Medicine in South Asia Participating Countries:

Venue: Ahmedabad Management Association, Ahmedabad Pre-conference Workshops: November 10-11, 2010 Conference: November 12-14, 2010 For Registration Visit: www.intem2010.in WORKSHOP Topics Basics of Trauma & Medical Resuscitation

Dates 10-11 Nov, 2010

CONFERENCE Conducted by GVK EMRI, Hyderabad

Paediatric Emergencies

11 Nov, 2010

SUNY Upstate Medical University, New York, USA

Critical Care and Toxicology

10-11 Nov, 2010

Vinayaka Mission University, Salem

USG in EM

10-11 Nov, 2010

Ronald Reagan Institute of EM, George Washington University, USA

Trauma Care in ED

10-11 Nov, 2010

Vinayaka Mission University, Salem

Neurological

Asian Scenarios

growth in medical tourism 2003 102,946 medical tourists

2007

Malaysia

341,288 medical tourists

Emergency Medicine Struggles for Recognition in the Heart of Southeast Asia by Keng-Sheng Chew, MD

he first specialty training program for EM in Malaysia started in 1998, and the first batch of its candidates, composed of 6 people, graduated in 2002. Currently, EM in Malaysia is in its “consolidation” phase, in the sense that after 8 years of being established as a specialty by itself, every state in Malaysia now has at least 2 or 3 emergency physicians. Unlike 10 years ago, when emergency departments were often perceived as the “dumping grounds” of the hospital for medical officers who had no where else to go, the situation has now improved. Major emergency departments throughout the states in Malaysia are now speaking the same “language,” due to the standardization of specialist care by the respective emergency physicians. Secondly, EM is slowly expanding beyond its traditional frontiers. The most obvious example is the ubiquitous utilization of ultrasonography, More and more emer-

gency physicians are learning to advance their skills to master this handy tool. As in many countries, ultrasound utility in EM is no longer confined to its use as the adjunctive Focused Abdominal Sonography in Trauma (FAST) scan; it has gone beyond that to include its use in guiding various invasive procedures such as central lines insertion, nerve localization for regional nerve block, bedside echocardiographic screen, as well as an assessment of inferior vena cava caliber and diameter as a measure of preload status. In other words, the boundary between EM and various other disciplines is becoming blurred. Challenges Like many other disciplines of clinical sciences in Malaysia, there is a dichotomy of service track (predominantly managed by the Ministry of Health Malaysia) and the academic track (predominantly managed by the various universities under the purview of Ministry of Higher Educa-

Fall 2010 // Emergency Physicians International

tion Malaysia). To a certain degree this is a handicap, as it creates a gap between the day-to-day clinical work and research work. Nonetheless, the situation is improving as we are beginning to see more joint effort between service hospitals and universities for nationwide epidemiological research works in Malaysia. Secondly, in an effort to master clinical skills beyond the traditional frontiers of EM, an emergency physician in Malaysia is likely to encounter resistance from colleagues from other disciplines where those skills are traditionally and jealously guarded. As expected, many of these skills are the very branding assets that give these disciplines a sense of identity and pride, eg, echocardiography belongs in the domain of the cardiologists, and ultrasonography belongs in the domain of the radiologists. In other words, much of such resistance is politically motivated. And, unless each of us is willing to lay down our fears for the sake of our patients and go beyond guarding our own self-interest, EM will not be able to go very far. Predictions

there are

states in Malaysia

with a total population of

28 Million

Ideally, because of various advances in the specialty, and because moments of need inevitably arise, we could be seeing more “mergers and acquisitions” between EM and its neighboring specialties. For instance, although Malaysia is considered a very blessed nation as her geographical location is relatively protected and free from major natural disasters (so far), outbreaks of infective diseases respect no boundaries, as the recent H1N1 infection has reminded us. Thus, one of the major areas in upcoming EM would be the management of infectious outbreaks, encompassing public education and disease prevention. Public education and disease prevention traditionally belongs to primary care and public health, but due to current circumstances, an emergency physician must rise up to take the challenge of championing public education. Will EM one day “merge” with family medicine? Unfortunately, in light of the various challenges discussed, how far we can go is yet to be seen.

Source

Germany

In-hospital emergency care grows even as the specialty faces staunch political opposition. by Barbara Hogan, MD & Dr. Matthias Brachmann

major effort is underway in Germany to gain recognition of emergency medicine as a specialty. Established medical societies oppose this, but there are no arguments being given to oppose the specialty except that other medical societies do not want change. The German Society of Emergency Department Physicians (DGINA) presented a formal request for the emergency specialty to the German federal medical council, in 2008. Other German medical societies are now in the passive-resistance phase, using delaying tactics. A debate by the federal medical council was postponed from 2009 to 2010, and in 2010 postponed again without a decision. We are still waiting for an official answer about our application. The central German medical societies

published a joint article in February 2010 dismissing the introduction of a specialty physician as unnecessary. The reaction of the executive bodies of EuSEM and DGINA was clear and strong. Individual reactions were published in many letters to the main German medical journal from emergency physicians all over the world. The letters were dominated by a demand without compromise for the emergency physician in Germany. This was coupled with repeated comments about the lack of arguments presented by the opponents. The real reason for the opposition was seen in the protection of vested interestsâ&#x20AC;&#x201D;the desire of the established medical societies not to share decision making with any new specialty. DGINA undertook intensive discussions with BAND, the association of Ger-

Emergency physicians at Asklepios Klinik Altona, in Hamburg, Germany, rush a patient through the emergency department and to an open exam room.

man pre-hospital emergency medicine, in order to seek common ground. DGINA is seeking to persuade BAND to end its opposition to the introduction of the specialty physician. BAND currently sees no requirement for a theoretical training program beyond an 80-hour course, and rejects a further professionalization of clinical EM, the specialty physician, and the EuSEM training program. DGINA executive board members have made speeches about the new emergency speciality at congresses organized by the other societies, and is taking part in podium discussions. They have called on Germany to implement the European guidelines on EM training. We argued our case in other areas to strong resistance from established medical societies. We started talks with the Federal German Health Ministry in Berlin and found support there. We held talks with the association of health insurance providers, and with the association of hospital operators, and found support. We have also held talks with the German army, which needs specialty emergency physicians for its growing operations overseas. To sum up, who supports introduction of the emergency medicine specialty in Germany? Doctors actually working in emergency departments and hospital operators, because of economic pressure. Who is against the specialty? Other medical societies not working in emergency departments. Quality Certification We have made considerable progress in quality certification for emergency departments in Germany. DGINAâ&#x20AC;&#x2122;s new quality certification system, called DGINA ZertÂŽ was launched in 2009. We believe this certification system has huge potential, and there is already major interest from hospitals. The first emergency department has already been certified to these standards. More Emergency Department Patients In-hospital emergency care in Germany is growing strongly. Surveys of DGINA members showed a rise in patient contacts

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“

In India, 5,000 people die each day of heart attacks, 2,500 are paralyzed due to stroke, and 1,280 lives are lost in accidents or suicides.

Growth Rate of ED Patients 2006

2007

in German emergency departments of 4% in 2006 and 8% in 2007. With around 12 million emergency patients in 2007, this meant around 960,000 more patients were treated in German hospital emergency departments than in 2006. More hospitals are ending the old system of having 10 or more emergency departments for each medical area, and are now introducing central emergency departments. These central facilities have sought to achieve greater professionalism and to optimize working processes, which in turn has enabled them to attract large numbers of patients. German emergency care is also provided by emergency cooperative practices of physicians in private practice rather than hospitals. But physicians in private practice are increasingly withdrawing from emergency care, partly because of inadequate payment, and also general unwillingness to work unsocial hours. As German patients have freedom of choice about where to seek emergency care, many patients have reacted to this trend by seeking emergency care in hospitals. New efforts are being made in Germany to cut emergency department waiting times. A new German scientific initiative was from Dr. Hogan, Prof. Dr. Rasche and Dr. Singh, who presented the “First View” concept, a medical management paradigm for emergency department working processes to reduce patient waiting times. This publication showed that a reduction in patient waiting times before first physician contact from over 120 minutes to only 15 minutes could be achieved.

Informal Providers 44% of accident victims in Mumbai are rescued by good Samaritan passers-by; 39% are transported to the hospital via taxi cab. (Nobhojit Roy et al., 2005)

Fall 2010 // Emergency Physicians International

India

One of India’s newest specialties, emergency medicine is beginning to benefit from governmental collaboration and regulation. Parivalavan Rajavelu, MD Tausif. A. Thangalvadi, MD & Tamorish Kole, MD

mergency medicine continues to meet demand and supply gaps in India’s healthcare needs. According to India’s national crime record bureau, around 5,000 people die each day of heart attacks, 2,500 are paralyzed due to stroke, and 1,280 lives are lost in accidents or suicides in India. Emergency medicine was recognized as the 33rd post-graduate medical specialty last year and is therefore one of India’s youngest medical specialties. Traditionally viewed as the casualty department, emergency medicine in India began through the efforts of groups of individuals and isolated institutions. A dedicated core group of emergency physicians from developed countries, particularly the USA, Singapore, UK, and Australia, has aided with the development of this specialty. The Society of Emergency Medicine was formed in 2000, and its members are primary physicians and specialists from various fields who practice in, or head, emergency departments. At present, frontline emergency patient

care is provided by medical graduates and nurses with no formal training in emergency medicine. Pre-hospital care is in its infancy, and there is no national number for emergency medicine service. This is changing in many states across India, with emergency medicine service being provided free or at cost by public-corporate partnership both in rural and urban areas. The Indian Cabinet cleared the Clinical Establishment Bill in 2010, making way for emergency care to be mandatory in all hospitals. The global standard for trauma care during the Golden Hour (The ATLS protocol) is being rolled out by the Government of India and All India Institute of Medical Sciences (AIIMS) to train manpower. With the recent recognition by the Medical Council of India, emergency medicine is now being officially offered as a post graduate training program by many universities in India. Faculty development, and accreditation of various emergency departments are now underway.

7th European Congress on Emergency Medicine

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Building a Legacy How South Africa turned preparation for the World Cup into an emergency medical stimulus plan. by Dr. Wayne Smith, Dr. Sophie mackenzie main & Prof. lee Wallis photos by Dr. riaz ismail

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in 2004, SOU TH AFR I CA BECAM E TH E FIR ST COU N T RY in the African continent to win the bid to host the FIFA Soccer World Cup. 64 games would be played between 32 teams over 4 weeks, in 8 of the country’s 9 provinces and in 10 stadia – many of which were newly built for the occasion. Six years and much hard work later, was FIFA’s faith in us justified, and was it worth the expense for the country? Medical planning for this event commenced in January 2007 and entailed the development of a dedicated Health Unit to oversee all the preparation within the Western Cape. This included input into the design of the medical facilities within the new stadium as well as undertaking a comprehensive gap analysis as regards staff, equipment as well as the systems that we wanted in place for the event. The level of hospital preparedness as regards their ability to deal with a major incident was also assessed. Certainly, South Africa’s ability to successfully host such a mega sporting event was of worldwide concern, due in part to the reputation for violent crime (another story in itself, but one in which statistics hide many facts), lack of infrastructure and labour unrest. However, much of this seems to have been media generated and, come the opening match, disappeared with the referee’s whistle blast. Few would argue that the tournament was anything but a huge success for South Africa, placing us firmly on the world stage as a can do country, and uniting the people of the country in a way not seen since the early 90’s. Foremost in many people’s concerns before the tournament – at home and abroad – was the ability of the health service to deliver on the FIFA mandate. Despite being relatively well funded, health in South Africa comes from a strange place (the legacy of apartheid) and is effectively a developing world service, at least in the public sector. Already over-stretched parts of the system were to be asked to prepare for and deliver upon the world’s biggest sporting spectacle. While we would not claim that the whole country’s health services pulled this off without any problems, we will report on our experience in Cape Town – one of 9 host cities – and try to spell out some key lessons which we have learned which may help others in the future when preparing for such events. BACKGROUND Cape Town sits at the South-Western tip of the African continent, on a small peninsula surrounded by stormy oceans. It is a place of extraordinary beauty, and is often ranked in the top 3 places to visit on earth. It is cosmopolitan and friendly; there is extreme wealth in the city, and extreme poverty. It has some of the best

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building a legacy// Lessons Learned at the 2010 World Cup medical facilities in the world, and some of the worst, and it has what is undoubtedly one of Africa’s best EMS and emergency medicine services looking after its population. It is home to Africa’s largest EM training programme, at the University of Cape Town and Stellenbosch University. However, it is a city with four clear seasons and the FIFA World Cup was planted right in the middle of our winter. Cape Town was chosen to host eight matches, with a brand new stadium built for that purpose. CHALLENGES The FIFA soccer world cup is not undertaken lightly! High expectations combine with the world’s biggest television audience to mean that screw-ups are not well received. Planning for delivery of such a spectacle has many inherent challenges: 1. Lack of information: FIFA does not provide a “health recipe” for how to plan or respond. However, they do have final “sign off ” on any plans put in place, which makes for years of speculation and fumbling around in the dark, not knowing whether they would be happy with the direction we were heading. 2. Too many cooks: the medical chain of command which was established had several levels, with too many bosses and often diverse opinions. The medical chain might look like this: FIFA Medical c LOC Medical c National DOH Medical cProvincial DOH Medical cImplementation Agency 3. Too many opinions: The chain of command issues were compounded by the presence of several medical role players with varying agendas and interpretations of what was required. For instance: FIFA c LOC c NDOH c PDOH c Local Authority Health c Host City SAMHS 4. Lack of roles and responsibilities: With so many role players and lack of clear delineation of roles and responsibilities, confusion was created. As is often the case, when everyone is in charge, no-one is in charge! Decisions in the early stages of planning had a habit of drifting along looking for an owner. This remains true of financial responsibilities, many of which

Emergency medical planners worked with stadium designers to allocate special red seats throughout the stadium for EMS personnel. This allowed easy access to EMS and more effective control of resource distribution

(as they relate to medical services rendered) have still not been finalised. 5. Lack of funding: South Africa is a developing nation with social challenges and great demand already placed on existing health services. Taking money from the fiscus to develop some of the best stadia in the world has an inevitable effect on other areas of government spending. (We will leave the reader to decide whether they think these were reasonable choices.) LESSONS LEARNED Overall, few could doubt that the tournament was anything but a great success for the country, with doomsayers eating a healthy dose of humble pie. But how did health fare? Luckily, we weren’t tested. Initial analysis suggests that hospitals were quieter than usual, and that the majority of injuries were minor in nature. From a reflection and learning perspective, which will continue for a long time yet, there are many lessons:

1. Keep it simple: don’t over engineer the plan. Hospitals were quieter than their normal winter workload; the overwhelming majority of patients seen were for primary health care problems only (in keeping with international literature), and the ever-present threat of annihilation by the latest flu virus failed to materialise (again). 2. Learn from previous hosts: many South African officials visited the previous hosts of the FIFA World Cup (Germany, Korea and Japan), as it is important to learn from their experiences. However, one size does not fit all, and it is advisable to select only what can be adapted to fit into your local environment; don’t simply import their plan in situ. Your medical plan needs to be home grown, with only some ingredients included from other hosts. 3. Start early: ensure that the gap analysis and planning commence early, so as to accommodate the (very) drawn-out procurement processes. Furthermore, staff may need to be selected for particular positions, and then be adequately

Short Hand // FIFA: Federation Internationale de Football Association | LOC: Local Organising Committee | NDOH: National Department o

Fall 2010 // Emergency Physicians International

160 140 120 100 80 60 40 20

1-June

5-June

9-June

13-June

17-June

21-June

25-June

29-June

3-July

7-July

11-July

Figure 1 – Event-related patients as seen throughout the Western Cape. Shows peaks on match days.

t Novel EMS transportation like this retrofitted golf cart allowed for easy movement through large crowds, which improved access to care.

was mostly unhelpful, as their models required more staff than we employ throughout our entire EMS service! A locally-produced and validated mass gathering resource model was adopted as the national standard for FIFA World Cup (and will soon be given the required legislative backing in South Africa to ensure a thorough risk analysis is done for all mass gatherings, with the provision of adequate medical coverage). The model has fewer resource requirements than overseas versions, but we still provided more than enough staff on site (the model was validated again with world cup data, and this is being published this year). trained. An early start gave us a very distinct advantage: by being part of the city’s planning team from day one, we had exactly what we wanted for medical facilities at all venues, including a wonderful facility within the stadium itself. 4. It’s all about relationships: The challenges created by preparing to host such a mega event meant that all role players had to work together closely towards a common goal. Planning for such an event virtually forced all tiers of government, from safety and security through treasury to health, at national, provincial and local levels, to interact closely and communicate in such a way so as to ensure the efficient delivery of all requirements. In health, this also

meant a close working relationship between the public and private sectors, and with the military health services. In this way, we made best use of the knowledge and experience of people from a particular discipline or sector – and cross referenced their skills into other sections of the planning, with great effect. 5. Resource appropriately: South Africa has never had a standard or legislation which determined the medical deployment to mass gathering events. Frequently, medical was the last component to be considered (usually when the event budget was exhausted, which in many cases resulted in insufficient medical coverage at mass gatherings). Looking at overseas experience

6. Build a legacy: the eyes of the world were turned south for four weeks in 2010. No one in this country wanted to mess this up, and such conditions provide an ideal opportunity to leverage what you need. The bulk of the health service planning focus was on Emergency Medicine / EMS, and so there was a great chance to derive a real legacy from this event (beyond the new transportation systems, roads, etc… which were also developed). Every new staff member, every new vehicle, and every new piece of kit we purchased for the World Cup had a legacy plan attached to it. Building a Legacy staff: A dedicated World Cup team was t

of Health | PDOH: Provincial Department of Health | EMS: Emergency Medical Services | SAMHS: South African Military Health Services www.epinternational.ning.com

building a legacy// Lessons Learned at the 2010 World Cup 171

pulled out of their normal rotation to perform designated FIFA specific duties. They received dedicated training in the years leading up to the event, and their pride in, and ownership of, their role was very apparent. These staff started believing in themselves again, and were more than willing to work long hard hours without complaint. These staff have been re-integrated into the EMS service with a very positive effect on their colleagues too. That being said, it would be wise to not underestimate the effects of fatigue. The World Cup is a challenging tournament with great demands on staff, both emotional and physical. This applies not only to those working the event, but also those who were left in normal service to meet the daily “business as usual.” stuff: FIFA greatly assisted our medical planning by not being prescriptive, which although initially seemed a challenge, in-fact allowed us to do what we wanted. Everything we bought was with legacy in mind, so all that remained was to persuade budget holders. For instance, a portable ultrasound was purchased “in case a soccer star requires rapid evaluation of a suspected rotator cuff injury.” This equipment has since been deployed into a local emergency department where emergency physicians put it to good use providing point of care ultrasound. Two HEMS helicopters were upgraded to “improve mountain and sea rescue capability for the tourists who come for the world cup,” which, of course, has left us with a much improved HEMS service in Cape Town post event. Thirty new Ambulances entered service so we could “meet FIFA requirements on response times,” and a brand new Medical Procedures Container (which can be used for rescue operations as well as mass casualty situations) was required “in case of disaster.” This container can be quickly hoisted onto the back of a rescue truck, and deposited wherever required and used as an emergency treatment facility (or even a surgical

vout of africa In January, 2011, the newly-formed African Federation of Emergency Medicine (AFEM) will launch the African Journal of Emergency Medicine (AfJEM)

Leg

Foot

27 13 Head

Face

Spine

6 Trunk

Arm

Hand

Figure 2 – Anatomical distribution of injuries seen during FIFA 2010 events hosted in the Western Cape procedures location for rural outreach services).

CONCLUSION

systems: Huge improvements in our local systems occurred in the run up to the World Cup, which will leave a lasting legacy. EMS and other pre-hospital staff were widely trained on the MIMMS course, meaning that, for the first time in South Africa, all emergency response agencies are now planning and responding using one multidisciplinary and widely adopted system. A digitalised Electronic Bed Bureau system was developed, which creates data flow between pre-hospital and hospital services (public and private), maps real time bed availability and status, and facilitates ambulance routing in a proactive manner. This new system allows patients to be transferred to a hospital with beds available for the correct level of care. All world cup designated hospitals were identified early according to the event footprint, and all (public and private) underwent training in the Hospital MIMMS course, in addition to being placed onto the EMS radio network and linked to Integrated EMS medical systems and services.

Mega events, such as the FIFA Soccer World Cup, present the host country with an opportunity to spend lots and lots of money and mobilise many resources for the duration of the event: in this case, four weeks of football. It would be a crying shame if it ended at that. South Africa showed that such events can create real opportunity for building a legacy, improving a country’s health care delivery long after the crowds have dispersed. Hosting such events is hard work, requiring medical plans in place to address any eventuality, but it is also important to have fun while doing so. We have been left in Cape Town with multiple legacy improvements, and a team with improved morale and a strong sense of a job well done. Furthermore, South Africa has proven able to successfully host a world class event and is now seen as a serious tourism and business destination, which in turn creates significant economic benefit to the country. In closing, we leave a parting piece of advice to future planners of such an event: milk the event, don’t let the event milk you.

n November 2009, in Cape Town, the African Federation for Emergency Medicine (AfEM) was formed to actively promote and support the development of emergency care across Africa. The African Journal of Emergency Medicine (AfJEM) will be the federation’s official journal, and will promote AFEM’s vision

Fall 2010 // Emergency Physicians International

and aims across the continent. It will also actively work to develop research and academic expertise in emergency care in Africa. AfJEM will launch its first issue in January, 2011. The journal will be primarily published online, but will be supplemented by print, 4 issues per year. The primary language will be English, but all

articles will have a French summary. Anyone interested in being part of the journal, or in submitting articles, can contact the editor at journal@afem.info

-Lee Wallis, MD, AFEM President

EuSEM 2010 6th European Congress on Emergency Medicine 12th Annual Meeting of SweSEM 11-14 October 2010 | Stockholm, Sweden

Welcome to Stockholm www.eusem2010.org

Photo: Yanan Li - Stockholm Visitors Board

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graphing the future

Want to know what the future of international emergency medicine will look like? Start by looking at global public health trends. by terry mulligan, do, mph

global mortality projections for selected causes, 2004 to 2030 The Trend: WHO Data on the Global Burden of Disease shows for the first time in history, the leading causes of morbidity and mortality worldwide are non-communicable, chronic diseases instead of communicable, infectious diseases. This phenomenon is called “epidemiologic shift” and happened in well developed countries starting in the 1920’s, in developing countries in the 1960’s, and just occurred in underdeveloped countries in the 1990’s. Why It Matters: Epidemiologic and demographic public health data reveal an already overwhelming need for

emergency medicine (EM), trauma and acute care development. According to 2006 WHO studies on the Global Burden of Disease [WHO 2006], the worldwide forces of demographic and epidemiologic shift have elevated non-communicable diseases to the single largest cause of morbidity and mortality worldwide. The non-communicable diseases of trauma, cardiovascular disease, stroke and cancer have surpassed traditional communicable diseases as the major global causes of death for the first time in history. The so-called “diseases of Western Society” have become global, are increasing at a much faster pace than earlier anticipated, and in precisely those areas with the least-developed health care systems [WHO 2006], regardless of socio-economic status, GDP and/or states of development.

CANCERS

Deaths in Millions

ISCHAEMIC HD

STROKE

4 ACUTE RESPIRATORY INFECTIONS ROAD TRAFFIC ACCIDENTS PERINATAL

HIV/AIDS TUBERCULOSIS MALARIA

0 2005

2010

2015

2020

2025

2030

Updated from Mathers and Loncar, PLoS Medicine, 2006

Fall 2010 // Emergency Physicians International

# Percent of population age 65 or older 5 World

1980

2010

2040

The Trend: Within 50 years, for the first time in history, there will be more older people than younger in the world. • Today there are about 630 million people older than 60 • By 2050 that number will rise to over 2 billion • By 2050 the average age in Western Europe will be 47 (today the average age world-wide is 26 years) • By 2030, experts estimate that 3/4 of all old people in the world will be living in developing countries, precisely those areas with the least-developed health care and emergency care delivery systems.

3 3

Africa

6 4 Asia

7 15 4

Latin America/ Caribbean

Why It Matters: As populations age, the diseases that affect them also change, away from maternal and child health issues, immunizations and traditional public health issues such as trauma and injury prevention, nutrition, food and sanitation. In their place rise health issues like non-communicable, acute exacerbations of chronic diseases such as complications of hypertension, heart disease, cerebrovascular disorders and cancer.

7 16 8

More Developed Regions

the Rapid aging of the global population

16 25

Source: United Nations, World Population Prospects: The 2008 Revision (Medium Scenario), 2009

The Number of Countries with Emergency Medicine

Why It Matters: More and more, national and regional health care systems are realizing the need for trained emergency physicians, and for organized, structured emergency medicine and acute care delivery systems. This means a greater and greater ability to collaborate internationally and find solutions to common problems. Source: The International Federation

number of countries

The Trend: Over the last 45 years, there has been a dramatic and explosive rise in the number of countries that have emergency medicine as an official medical specialty.

of Emergency Medicine (IFEM)

1965

1970

1975

1980

1985

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1995

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2010

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IEDLI

The annual 5-day course for emergency department leadership

The International Emergency Department Leadership Institute As the number of interdisciplinary emergency departments grows internationally, where can ED leaders acquire the administrative skills they need to build and sustain successful emergency departments? The International Emergency Department Leadership Institute (IEDLI) was created by Harvard Medical School faculty and other international experts in order to provide ED leaders with the skills and knowledge they need to operate successful emergency departments in any part of the world. In this one-week course consisting of over 35 hours of interactive lectures and workshops. Leaders will explore strategies to: • Establish the ED’s role in the hospital • Improve efficiency and control costs • Decrease overcrowding • Develop quality improvement programs • Educate and motivate ED doctors and nurses • Develop an emergency medicine training program • Form a strong administrative structure According to the World Health Organization, the global economic crisis presents a unique opportunity to make needed health reforms and to find more efficient ways to use limited health resources. Now is the perfect time for leaders to address inefficiencies and organizational problems in their emergency departments. The IEDLI program will challenge the way you think about the problems facing your emergency department. Together with ED leaders from around the world, you will explore leadership topics that offer solutions to the challenges of emergency care today. This program is designed for doctors, nurses and administrators.

IEDLI Faculty Include:

Florence • Italy October 25-29 • 2010

Boston • USA October 24-28 • 2011

First edition IEDLI textbook to be released in 2011: Emergency Department Leadership and Management: Best Principles and Practice

Ron Walls, MD, FRCPC Professor, Harvard Medical School Chairman, Dept. EM, Brigham and Women’s Hospital

Andrew Schenkel, PhD Assistant Professor, Stockholm School of Economics

Richard Wolfe, MD Associate Professor, Harvard Medical School Chief of Emergency Medicine, BIDMC

Inger Søndergaard, MD Director, Emergency Department Herlev Hospital, Denmark

The annual for For program details 5-day andcourse registration visit www.IEDLI.org emergency department The International Emergency Department Leadership Institute is a collaboration between leadership Fall 2010 // Emergency Physicians International Harvard Medical Faculty Physicians at BIDMC and Brigham and Women’s Hospital.

When Will the EU Accept EM? Could the Official Journal of the EU limit specialty growth in Europe? by Drs. Gunnar Ohlen & David Williams

EU Directives The European Union Directives 2005/36/EC and 2006/100/EC regulate the mobility of healthcare professionals by recognising professional qualifications of comparable value. The Directives include lists of hospital medical specialties and the EU countries in which they have official recognition. One of the lists is headed “Accident and Emergency Medicine,” the name by which the specialty was initially known in the UK and Ireland. Unfortunately, this heading still remains, even though the UK and Ireland have officially changed their title to Emergency Medicine and have now been joined on the list by seven of the countries which have entered the EU since 2004 (Bulgaria, Czech Republic, Hungary, Malta, Poland, Romania and Slovakia). The Directive requires that the minimum period of training for the specialty should be five years.

Growth of Emergency Medicine in Europe (by year of recognition as a primary medical specialty)

# of Countries

he European Society for Emergency Medicine (EuSEM) seeks to represent the whole of the continent of Europe and thus potentially relates to more than 50 countries with almost as many different languages, cultures and systems of health care. Within the continent of Europe is found the European Union, which currently includes only 27 of those countries but which is perhaps the most complex geopolitical union in the world. One of the many complexities of the EU involves the recognition of medical specialties, a struggle in which emergency medicine has been embroiled for a number of years. However, significant progress is now being made, due in great part to the contribution made by the EuSEM Federation of national societies of Emergency Medicine, a federation of 25 societies with a combined membership of more than 16,000 medical members.

1970

1980

1990

years ago. As recently as March of 2010, the Grand Duchy of Luxembourg passed a law to recognise several additional medical specialties, including ‘Traumatologie et Médecine d’Urgence’. This is their first revision of medical specialties since 1997, but past experience shows that these changes are very unlikely to achieve publication in the Official Journal of the EU. Countries with Emergency Medicine Currently, there should be at least eleven countries in the Directive under the heading of “Emergency Medicine” and there are two or more other EU countries which could also qualify for inclusion. Countries which currently have Emergency Medicine as a supra-specialty, such as Sweden, are not eligible for inclusion. Neither are countries which have a training programme of less than five years’ duration. However, there remain only about five EU countries which have yet to recognise emergency medicine as a hospital-based specialty and two of these have very active national societies which are an important part of the EuSEM Federation.

The Unchangeable Journal of the EU

European Growth of EM

The lists of recognised medical specialties are published in the Official Journal of the European Union. Theoretically, there are provisions for changing these lists, however they have yet to be successful. Several unsuccessful attempts have thus been made to include Belgium – a country where legislation for the establishment of the specialty of ‘Medecine d’Urgence’ was enacted almost five

The graph above illustrates the remarkable growth in the national recognition of emergency medicine in Europe since EuSEM was founded in 1994. However, there is currently a potential threat to the recognition of emergency medicine in the EU because the Directive is scheduled for revision in 2012. One of many proposals is that the number of recognised specialties should be greatly reduced

2000

2010

or even restricted to only those specialties which have recognition in all countries of the EU. Partial Acceptance by the UEMS The Union Europeenne des Medecins Specialistes (UEMS) represents hospital medical specialists within the member states of the EU and also beyond because other European countries can be included as associate members or participating observers. The statutory purpose of UEMS is the harmonisation and improvement of medical practice in the European Union and it has created specialist Sections for each major discipline which is recognised in more than one third of the EU countries as published in the Official Journal of the EU. Emergency Medicine thus just fails to qualify, but has been accepted in UEMS as a Multidisciplinary Joint Committee (MJC) which includes representatives from other established Sections with an interest in our specialty. MJC on Emergency Medicine The Multidisciplinary Joint Committee now includes the Secretary-General of UEMS and a representative from each of the UEMS Sections of Anaesthesiology, Cardiology, Geriatric Medicine, Internal Medicine, Neurology, Orthopaedics and Traumatology, Paediatric Medicine, Plastic and Reconstructive Surgery and General Surgery, as well as from the Committee on Intensive Care Medicine, the Permanent Working Group of European Junior Doctors and, of course, EuSEM. Meetings are held in Brussels every six months. Dominating agenda items have been the Policy t

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When Will the EU Accept Emergency Medicine?

Current Emergency Medicine Specialty Status in Europe n Basic Specialty n Supra-specialty n No Formal Specialty

“

There is currently a potential threat to the recognition of emergency medicine in the EU because the Directive is scheduled for revision in 2012. One of many proposals is that the number of recognised specialties should be greatly reduced or even restricted to only those specialties which have recognition in all countries of the EU.

Statement on Emergency Medicine in Europe, the European Curriculum for Emergency Medicine and, most recently, the development of a European Diploma. Policy Statement On EM The Policy Statement on Emergency Medicine in Europe was initially developed by the European Society but later adopted and adapted as a joint statement by EuSEM and the MJC on Emergency Medicine. The concluding summary states that ‘The main objective of EuSEM and the MJCEM is that the specialty of Emergency Medicine should develop to the standards endorsed by the Council of UEMS to seek to ensure the highest quality of emergency care for patients. This care should be delivered by physicians trained in Emergency Medicine.’ This Policy Statement on Emergency Medicine in Europe was endorsed by the full Council of UEMS at their meeting in Istanbul on 17 October, 2009. The representatives of only two EU Member states declined their support. A European Curriculum The summary of the policy statement includes reference to ‘the standards endorsed by the Council of UEMS’ and these are the standards enshrined in the comprehensive European Curriculum for Emergency Medicine, which was approved by the Council of UEMS at their previous meeting in April last year. The curriculum

not only includes the body of knowledge relevant to emergency medicine and the associated core competencies but also establishes the essential principles for a rigorous training programme. It was developed by a multi-national task force under the chairmanship of Dr. Roberta Petrino and reflects the harmony that now links emergency physicians across Europe. Board of Emergency Medicine The rules of procedure of UEMS allow each specialist section to create its own European Board as a working group. This board has the specific aim of guaranteeing the highest standards of care in the specialist field by ensuring that training is raised to the highest possible level. The MJC on Emergency Medicine already has this purpose and thus functions as a Board, but without the associated status within UEMS. However, it is hoped that this situation may be resolved by the time this article is published because the UEMS Council will have met in Prague in early October of this year. One of the agenda items is a proposal that Council approves the establishment of a European Board of Emergency Medicine. European Assessment/Examination/ Diploma

ful completion of specialty training. Many of the UEMS Sections and Boards (and the MJC on Emergency Medicine) recently established a separate Council for European Specialist Medical Assessment (CESMA) to seek to harmonise postgraduate qualifications. Specialties which already offer a European diploma conduct their assessments in very different ways and one of the main purposes of CESMA is to seek to identify the most appropriate format to assure European accreditation of medical specialty qualifications. Looking to the Future At the last EuSEM Executive Committee meeting in London in July, 2010, it was agreed upon to approve a recommendation from the MJC to establish a joint Task Force to develop proposals for a European assessment in Emergency Medicine. This will again be chaired by Dr. Petrino and will include representatives of countries which already hold examinations, as well as members of the MJC. This will again be a challenging task but it will hopefully be another important step on the road towards a Europe of and beyond the European Union, in which emergency medicine is rightfully and universally recognised as one of the major primary medical specialties.

The curriculum document concludes with a short reference to possible future developments in Emergency Medicine in Europe, including an examination or assessment to confirm success-

Dr. Gunnar Ohlen is the president of EuSEM. Dr. David Williams is the Chairman, UEMS Multidisciplinary Joint Committee on E.M.

Fall 2010 // Emergency Physicians International

A DV E RTI S E M E N T

in June 2010 i ATTended my firST SAem conference in phoenix, ArizonA, uSA. I recently started my Emergency Medicine (EM) residency training in the United States; this was my first opportunity to indulge in a four-day event focused on the presentation of research and the exchange of ideas. My prior training was in the UK. It was an enlightening experience to learn about academic emergency medicine and the development of this field in America!

Visit SAEM at EuSEM at Booth B-22

To my surprise, SAEM is not restricted only to Americans! It is open to any emergency physician in the international community. SAEM could be an academic voice for Emergency Physicians all over the world, especially for countries where EM is still fighting for recognition. Below is a brief summary of what SAEM has to offer.

Bhakti Hansoti, MD, Graduate, University of Edinburgh The SocieTy for AcAdemic emergency medicine (SAem): SAEM is dedicated to improving care of the acutely ill and injured patient by improving research and education. SAEM is headquartered in the Chicago area, and provides administrative support to the Association of Academic Chairs of Emergency Medicine (AACEM) and the Council of Emergency Medicine Residency Directors (CORD), as well as to the SAEM journal, Academic Emergency Medicine (AEM). SAEM is a 501c3 (non-profit organization), incorporated in the USA.

Administrators in Emergency Medicine; AGEM - Academy Of Geriatric Emergency Medicine; AWAEM â&#x20AC;&#x201C; Academy of Women in Academic Emergency Medicine; CDEM â&#x20AC;&#x201C; Clerkship Directors in Emergency Medicine; and the Simulation Academy.

conferenceS: SAEM hosts an Annual Meeting in May or June, with over 1700 attendees who come from around the world and several Regional Meetings. Attendees include specialists in Emergency Medicine (EM), EM trainees, medical students, and a wide assortment of persons with academic and teaching interests in Emergency Medicine. The SAEM Annual Meeting is considered one of the largest meetings dedicated to new Emergency Medicine research on topics of interest to researchers and educators of EM. Increased International representation in academic medicine could only encourage a wider range of debates and an improved body of knowledge.

inTereST groupS: The primary goal of Interest Groups is the sharing of information and expertise in areas of mutual interest relating to academic Emergency Medicine. There are currently over 25 interest groups, ranging from Toxicology, to Disaster Medicine, to Emergency Department overcrowding. WebSiTe: WWW.SAem.org The SAEM website contains a wealth of information related to academic EM. Perhaps the most useful resource for the international member interested in academics and residency development, the website is free and regularly updated

JournAl: SAEM sponsors the peer-reviewed, academic journal, Academic Emergency Medicine (AEM). AEM has an impact factor of 2.478 and publishes research which furthers emergency medicine; AEM is interested in submissions from around the globe. It offers editorial assistance to authors who have good work to publish, but trouble writing professionally in English.

concluSion The Society for Academic Emergency Medicine has one clear mission: to lead the advancement of emergency care through education and research, advocacy, and professional development in academic emergency medicine. This organization is open for membership to anyone, from any geographical location that has an interest in Academic Emergency Medicine. SAEM provides a podium for research and education, as well as a community for persons of similar interests within the diverse specialty that is Emergency Medicine. With increased international participation, academics in Emergency Medicine can develop in leaps opposed to merely strides.

AcAdemieS: An Academy is a group of 100 or more members. The academies provide a forum for members to network, collaborate on educational initiatives, develop policy, collaborate in research, and provide faculty development pertaining to their area of special interest or expertise. There are currently five academies: AAAEM - Academy of

editors: Vicken Totten, Scott Weiner, ian martin and christine houser facebook.com/saemonline twitter.com/saemonline

-memberShip opTionSfull memberShip Academic physicians. Benefits: Paper & OnLine AEM and Newsletter. First Interest Group membership free. Can Vote, hold office. Reduced fees for attendance at SAEM Annual and Regional Meetings.

AffiliATe memberShip Online-only access to AEM and SAEM Newsletter One free Interest Group membership Reduced fees for attendance at SAEM Annual/Regional Meetings Complimentary membership in the International Interest Group

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The EM World Report What is the greatest clinical challenge that you face? Do you feel physically safe when you practice? We asked these and a few other questions to a group of 650 international emergency physicians. 140 physicians replied, representing 35 nations from every corner of the globe. Here’s what you had to say.

COUNTRY RESPONDENTS ARGENTINA AUSTRALIA BOTSWANA BRAZIL CHILE COLOMBIA COSTA RICA CUBA ECUADOR FINLAND HONG KONG INDIA IRAN IRELAND ISRAEL ITALY JAMAICA KOREA LEBANON MALAYSIA MEXICO NETHERLANDS PALESTINE PANAMA PARAGUAY PERU SAUDI ARABIA SOUTH AFRICA SWEDEN TURKEY UAE UK USA VENEZUELA YEMAN

Sweden

“New speciality in sw new field for all colleg

United States of America United States of America

“Financial constraints on health sytem / hospital”

“Irate drug seekers who do not get their fix”

Puerto Rico “No adequate security services”

Panama “Lack of trained paramedic personnel”

Columbia “Lack of institutional support”

Chile “No data on exposure of personel of prehospital care. We wear common suits, latex gloves”

South Africa

“TB, poor infection psychotic patients i room for long perio

Argentina “The ED is too crowded” said challenges they faced in emergency medicine are more OPERATIONAL

Fall 2010 // Emergency Physicians International

said challenges they faced in emergency medicine are more CLINICAL

WHAT IS YOUR EMERGENCY DEPARTMENT’S ANNUAL VOLUME?

REGIONAL RESPONDENTS

<10,000

PURPLE TAGS

10,000 – 30,000

What is your primary safety concern in the ED?

30,000 – 50,000

GREEN TAGS

50,000 – 75,000

“My clinical challenges in the ED are primarily due to . . .”

>75,000

Finland

weden, gues”

“No “No specialty” Specialty”

ARE THE CLINICAL CHALLENGES THAT YOU FACE MORE DUE TO THE LACK OF...

Turkey “Lack of acceptance of EM as a unique specialty by doctors of other specialties”

TRAINING Saudi Arabla “Language barriers”

control, in the front ods of time”

EXPERIENCE Yemen

EQUIPMENT

“blood borne pathogens”

Malaysia “Infectious diseases, particularly airborne”

IMPORTANCE OF CLINICAL TOPICS In your practice, are the following clinical topics . . . Very Important / Somewhat Important / Neutral / Not Important

South Africa

AIRWAY MANAGEMENT

“Poor system infrastructure”

STROKE MANAGEMENT DIAGNOSTIC IMAGING SPLINTING WOUND REPAIR SUBSPECIALTY ACCESS PROCEDURAL SEDATION CARDIOVERSION JOINT REDUCTION TECHNIQUES

OPHTHALMOLOGICAL EVALUATIONS ACS (ACUTE CORONARY SYNDROME) LUMBAR PUNCTURES NASAL PACKING

RESPONDENTS

Is Shift Work Killing You? Circadian interruption can be as bad as smoking a pack a day by Louise B. Andrew, MD , JD

f you’ve ever worked a night shift (or come in early for a day shift), you drug abuse can certainly also be contributing factors. know that there is an increased incidence of cardiovascular catastrophes So, what’s an EP to do? Shift work is rarely avoidable in our profession. Some such as stroke and MI in the morning hours (approximately 6 AM to very excellent information is available on rational management of shift work noon). This phenomenon is attributed to normal diurnal changes in in the Policy Research and Education Paper that accompanies the American human vascular endothelium and possibly platelet function, coupled with a College of Emergency Physicians’ recently revised Shift Work and Circadian surge in blood pressure that is a response of mammalian cardiovascular sys- Rhythms Policy (www.acep.org). Recommendations include rational schedultems to typical circadian influences. Some of these changes apparently relate ing using either dedicated night shift workers (who are appropriately compento baroreflex activity and our adrenergic vascular responses, and possibly to sated for the additional toll that may be taken on their bodies), or rotating but periods of inactivity followed by infrequent night shifts on a clockwise rotation (which minimizes typical awakening activities such as risk of circadian disruption), and scheduling eight-hour shifts. mobilization. Practical sleep hygiene measures should be applied by shift EPI asked emergency physicians from What physicians are less likely workers, such as establishing a quiet, dark, cool place around the world how long typical to appreciate, however, is that this to sleep without the encroachment of beepers, emergency department shifts last 140 same increased risk of cardiovasphones, doorbells, etc. These should be couphysicians from 35 different countries cular disease is conferred upon pled with continuing education of famresponded. EPs who have forced variations in ily, friends and neighbors about the their normal mammalian circadian necessity of quality day sleep for patterns, such as the imposition those who work even occasional of rotating shift work. In fact, the nights. Anchor sleep periods shift work schedule confers an apshould be developed by dedicated proximate 40% increased risk of night shift workers and rigorously developing cardiovascular disease. observed, even on days off, in orThat is a risk nearly the equivalent der to be maximally effective. of smoking one pack of cigarettes a Departmental and hospital adday. Since cardiovascular disease is a ministrators should understand leading cause of death for adults in and excuse those who work night all age groups worldwide, this stashifts from daytime meetings even tistic should strike fear in the minds if alternative arrangements must – indeed, the hearts – of emergency be made for CME and adminispersonnel everywhere. trative updates. Adaptive dietary Other research has indicated that habits such as avoidance of alfluctuations in blood pressure throughcohol and caffeine, and the conout the day can increase the potential for sumption of a carbohydrate rich cardiovascular disease, as well as sustained meal before sleeping, and intake hypertension, not to mention unremitting of high protein on arising should stress. All of these can occur during shifts in a high be developed. Other manipulavolume ED. More recently, evidence has begun to accumutions such as exposure to bright late that rotating shift work with its associated sleep disorders can alter our lights on awakening, exercise, hydration, and possibly the use of melatonin endocrine systems in such a way that lipid profiles, insulin resistance, estrogen when necessary to promote sleep may be applied, but routine pharmacologic and testosterone levels are shifted so as to increase the risk for development of manipulation should be avoided because of the increased addictive potential diabetes, hypertension, hyperlipidemias, and incidentally, certain hormonally- of some of these interventions when chronic use is prompted by work requiredependent tumors. Truncal obesity is a risk factor for development of Meta- ments. bolic Syndrome and Type II diabetes, both of which increase cardiovascular Obviously, smoking cessation should be the cornerstone of any cardiovasrisk. Anxiety, stress and depression are aggravated by circadian disruption, and cular risk reduction strategy. There is evidence that this can be effective at any unfortunately depression is another independent risk factor for the develop- time in a smoker’s life. In some EDs it seems that a smoke break may be the ment of cardiovascular disease. only “legitimate” excuse for taking time out of a stressful shift, and this tempAnd it bears mentioning, though is hardly news, that smoking, poor dietary tation may be more of a hazard even for ED nurses than EPs. Establishing a and exercise habits will contribute to the development or the exacerbation of quiet “break room” where napping or meditation is actually possible should cardiovascular disease to which we may already be predisposed. Alcohol and be considered as a health preserving alternative to smoke breaks, and although

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Proper Use of the Gum Elastic Bougie ting a small bronchus preventing further advancement, and therefore occurs at a significantly more distal point of insertion than palpable clicks. In the single prospective ED study, the sensitivity of “palpable clicks” and “hold up” (55.0% and 33.3%, respectively) was lower than those documented in the anesthesia setting (65-89.7% and 13-100%, respectively) (2). Again, the difference can be accounted for by the fact that the OR and ED constitute very different practice environments. Failure rates have been reported as high as 2550% when there is a breech in proper technique (9,10). There is a tendency for physicians to remove the laryngoscope blade after placement of the GEB. The thought may be, “Phew, I’m in!” but this is a mistake. You’re “in” when the ETT is successfully in place. The ETT is wider and more rigid. Although you can often force the ETT over the GEB, the space created by keeping the laryngoscope blade in the mouth will facilitate smooth and successful passage of the ETT over the bougie. Another helpful maneuver is to rotate the ETT 90 degrees counterclockwise before passing it through the vocal cords. This prevents the beveled tip of the ETT from catching on the arytenoids or the vocal cords. Although it may seem insignificant, in simulated difficult airways, rotating the ETT has been demonstrated to be significantly more successful (9). Finally, the emergency physician should be aware of the potential difficulties encountered

Is Shift Work Killing You? it is not an option for nurses in most institutions to “nap” on the job, there is no reason that such an accommodation should not be available to nurses as an alternative to a “timeout on the ambulance ramp.” We must develop healthy alternatives (such as protein bars, yogurt, fruit and nuts) to the typical night shift snack of cold pizza and deep fried doughnuts. Our police partners (who in North America at least get free handouts from late night fast food places and often share them with us at night) are at least slightly to blame for the centripetal weight gain frequently experienced by night shift workers. Although caffeine is almost a necessity on night shift, all forms of caffeine should be avoided for at least four hours prior to anticipated sleep. A high protein snack or drink

from page 11 with the GEB (7). What causes the 20% failure rate? Surprisingly, 50% of cases involve an inability to pass the GEB past the hypopharynx. It is not entirely clear why this is the case; it is possible the laryngoscope blade is being relaxed (creating a tighter space) or forcing the bougie too anteriorly is causing it to bend in the hyopharynx. 25% of failures are reported as inability to pass the ETT over the bougie – this can likely be avoided by following

the proper technique already mentioned: leave the laryngoscope blade in place and rotate the ETT 90 degrees counterclockwise before passing it through the vocal cords. Esophageal intubations occur in approximately 15% of cases and these can certainly be avoided by becoming more familiar (and preferably expert) in appreciating the “palpable clicks” and “hold-up”.

References: 1. Nolan JP. Orotracheal intubation in patients with potential cervical spine injuries. Anaesthesia, 1998; 48:630-3. 2. Kidd JF, Dyson A, Latto IP. Successful difficult intubation. Anaesthesia 1988; 43:437-8. 3. Sackles JC, Laurin EG, Rantapaa AA, et. Al. Airway management in the emergency department: a one-year study of 610 tracheal intubations Ann Emerg Med 1998;31 (Mar):325-332. 4. Cook TM. A new practical classification of laryngeal view. Anaesthesia 2000;55:274-9. 5. Latto IP, Stacey M, Mecklenburgh J, Vaughan RS. Survey of the use of the gum elastic bougie in clinical practice. Anaesthesia 2002;57:379-84. 6. Shah KH, Kwong BM, Hazan A, Newman DH, Wiener D. Success of the Gum Elastic Bougie as a Rescue Airway in the Emergency Department. J Emerg Med. 2008 Nov 8. [Epub ahead of print] 7. Shah KH, Kwong B, Hazan A, Batista R, Newman DH, Wiener D. Difficulties with Gum Elastic Bougie Intubation in an Academic Emergency Department. J Emerg Med. 2010 Jun 25. [Epub ahead of print] 8. Combes X, Suen P, Dumerat M, Duvaldestin P, Dhonneur G. Validation of an intubation algorithm for unanticipated difficult tracheal intubation occurring in operating room. Anesthesiology 2004;100:1146- 50. 9. Dogra S, Falconer R, Latto IP. Successful difficult intubation. Tracheal tube placement over a gum-elastic bougie. Anaesthesia 1990;45:774-6. 10. Marks RJ. Successful difficult intubation. Anaesthesia 1991;46:72-3.

from page 43 might be substituted late in the shift, the arousing effects of which may be dissipated more rapidly than caffeine when bedtime arrives. I am a big believer in dietary supplements and recommend both a quality multivitamin, extra Vitamin D, Calcium, Magnesium, Coenzyme Q-10, Resveratrol, EPA and DHA (fish oil) supplementation for all adults, but especially for those of us who pursue shift work. We don’t yet have precise data about the overall risk or potential for increased mortality among emergency personnel due to cardiovascular or other effects of shift work or work in a highly stressful specialty. We are still a young specialty and only a few studies have even broached the subject or reached maturity. More research undoubtedly should be pursued. But the best

Fall 2010 // Emergency Physicians International

prevention of any catastrophe is always avoidance of the cause. All emergency practice groups should attempt to secure dedicated night shift staff. Research has shown that older physicians are far more susceptible to circadian rhythm disruption and associated dysfunction. So we can offer this option to younger physicians, who often carry substantial student debt loads, providing a substantial shift differential. We should be teaching all emergency personnel starting at the very beginning of training, that our potential increased risk of developing several lethal diseases, notably cardiovascular, mandates redoubling our efforts to live as healthy a lifestyle otherwise, as we possibly can.

Career and lifestyle

an opportunity too good to miss.

Calling all Emergency Physicians to idyllic South Australia Combine a challenging and rewarding career in Emergency Medicine with wonderful lifestyle opportunities. Qualified specialist emergency physicians will work in one of Adelaide’s major hospitals providing critical emergency care to the local community. The South Australian health care system offers varied and interesting clinical work, excellent collegial support, superior working conditions and dedicated clinical support time. Opportunities exist to combine clinical work with teaching, research and special project work. South Australia’s emergency departments provide you with an opportunity to engage in retrieval, trauma care, paediatrics and community-based emergency medicine. Consultants Senior Medical Practitioners

It’s a demanding, high-energy career, but one that will be complimented by the idylic lifestyle of South Australia. Enjoy the best of all worlds in this vibrant region that boasts famous wineries, beautiful beaches, stunning outback panoramas and a Mediterranean climate. SA Health offers competitive remuneration packages including an attraction and retention allowance and access to outstanding professional development allowances.

AUD $ $332,500 - $431,525 $138,040 - $168,896

EUR € €232,388 - €301,610 €96,491 - €118,060

For more information on what SA Health has to offer visit www.health.sa.gov.au/careers and view the Emergency Physicians details or email recruitment@health.sa.gov.au EUR € valid as at 13 August 2010.

The IEM Fellowship Directory California

Harbor-UCLA/IMC Global Health Fellowship Regional Focus: Iraq, Haiti and possibly others Contact: Ross I. Donaldson, MD, MPH, Harbor-UCLA Medical Center Department of EM 1000 West Carson Street, Box 21 Torrance, CA 90509 Length: 1-2 years Salary: Very Competitive Shifts: 5 per month Degree: MPH, DTMH available Positions: 1-2 Deadline: November 1 ( (310) 222-3500 8ross@rossdonaldson.com :www.emedharbor.edu/ Global.html :www.internationalmedicalcorps .org Keck School of Medicine at USC Regional Focus: Chile, Ghana, Mumbai, Thai-Myanmar border, British Guyana Contact: Billy Mallon, MD Department of EM 1200 North State Street Room 1011 Los Angeles, CA 90033 Fax: (323) 226-6454 Length: 1-2 years Salary: Competitive Shifts per week: 2 Degree: MPH, DTMH Positions: 1 Deadline: December 1 ( (323) 226-6667 8 wkmallon@yahoo.com : www.cbooth.info Loma Linda University Regional Focus: Vietnam, China, and Kenya Contact: Debbie Washke, MD Department of EM 11234 Anderson St,. RM A108 Loma Linda, CA 92354 Fax: (909) 558-0121 Length: 1-2 years Salary: About $80,000 Degree: MPH with 2-year program Positions: 1 Deadline: March 1 ( (909) 824-4344 8 dwashke@llu.edu Stanford International Emergency Medicine Fellowship Contact: S.V. Mahadevan and Matthew Strehlow Stanford University

701 Welch Rd. Bldg C Palo Alto, CA 94304 Fax: 650 723-0121 Length: 1-2 years Positions: 1-2 Salary: Please contact Hours per week: approx. 15 Degree: MPH possible for 2 yr candidate Deadline: ACEP Scientific Assembly ( (650) 723-0063 8 jgalfin1@stanford.edu : emed.stanford.edu/fellowships/ international.html UCLA-CIM International Medicine Fellowship Contact: Nicole Durden, UCLA Medical Center Dept. of EM 924 Westwood Blvd., Ste 300 Los Angeles, CA 90024 Length: 1-2 years Salary: Competitive Shifts: 5 per month Degree: MPH, PhD Positions: 1 Deadline: October 15 ( (310) 794-3086 8ndurden@mednet.ucla.edu :http://cim.ucla.edu

Connecticut

Yale University School of Medicine Regional Focus: Africa Contact: Simon Kotlyar, MD Department of EM 464 Congress Ave, Suite 260 New Haven, CT 06519-1315 Fax: 203-785-4580 Length: 2 years Positions: 1 Salary: PGY level, MSc tuition, travel stipend, excellent benefits Shifts/hours per week: 0.5 FTE Degree: MS, London School of Hygiene and Tropical Medicine Deadline: December 1 ( (203) 785-4058 8simon.kotlyar@yale.edu :medicine.yale.edu/ emergencymed/fellowships/ global/index.aspx

Delaware

Christiana Care Health System Regional Focus: Africa Contact: Susan E. Thompson, DO Christiana Care Health Systems Dept. of EM Administration 4755 Ogletown-Stanton Road Newark, DE 19718 Length: 1 – 2 years

Fall 2010 // Emergency Physicians International

Shifts: Between two and three 8or 9-hour shifts/week Degree: MPH with 2-year program Deadline: November 15 ( (302) 733-3904 8susthompson@christianacare.org

District of Columbia

George Washington University Regional Focus: India, Malawi, Egypt, El Salvador, Ethiopia, Peru Contact: Kate Douglass, MD, MPH 2150 Pennsylvania Avenue, NW, 2B-417, Washington, DC 20037 Fax: (202) 741-2921 Length: 2 years (1 year possible under special circumstances) Salary: Highly competitive, MPH tuition and generous CME Degree: MPH Positions: 1-2 Deadline: November 15 ((202) 741-2954 8kdouglass@mfa.gwu.edu :www.gwemediem.com

Georgia

Emory University Contact: Scott Sasser, MD Department of EM 531 Asbury Circle - Annex Suite N - 340 Atlanta, GA 30322 Fax: 404-778-2630 Length: 2 years Positions: 1 Salary: Instructor Deadline: Check with department ((404) 778-5975 8ssasser@emory.edu Medical College of Georgia Regional Focus: Peru, Bangkok Contact: Hartmut Gross, MD 1120 15th Street Augusta, Georgia 30912 Fax: (706) 721-7718 Length: 1 year Salary: Competitive salary, benefits, CME, int’l travel funds Shifts per month: half-time EM clinical faculty position Degree: None Positions: 1 ( (706) 721-4412 8hgross@mail.mcg.edu :www.mcg.edu/ ems/residency/ internationalMedFellow.htm

Illinois

Cook County Hospital Contact: Jamil Bayram, MD & Robert Simon, MD Cook County Hospital, Rush University Medical Center Dept. of EM 1653 W. Congress Parkway, 177 Murdock Chicago, IL 60612 Fax: (312) 942-4021 Length: 2 years (with MPH) Salary: Very competitive, benefits, tuition fees for the MPH, travel expenses and stipends Positions: 1- 2 Deadline: Open ( (312) 942-4978 8 jamil_bayram@rush.edu University of Illinois at Chicago Contact: Janet Lin, MD, MPH Department of EM, College of Medicine East Suite 469A 808 South Wood Street Chicago, IL 60612 Length: 2 years Salary: N/A Positions: 1-2 Deadline: Open ((312) 413-7393 8jlin7@uic.edu

Maryland

The Johns Hopkins University Contact: Alexander Vu, DO, MPH International Emergency Medicine Center for Public Health and Human Rights 5801 Smith Avenue, Suite 3220 Baltimore, MD 21212 Fax: (410) 502-8881 Length: 2 years Salary: Competitive Positions: 1-2 Degree: MPH Deadline: September 15 ((410) 735-6436 8avu3@jhmi.edu University of Maryland Regional Focus: China, Egypt, South Africa, Botswana, The Netherlands Contact: Veronica Pei, MD, MPH University of Maryland Department of Emergency Medicine 110 S. Paca Street, 6th Floor, Suite 200 Baltimore, MD 21201 Length: 2 years Salary: Competitive Positions: 1 Degree: MPH Deadline: Open

The IEM Fellowship Directory ( Phone: (410)328-8025 8veronica.pei@gmail.com massachusetts Harvard University / Beth Israel Deaconess Medical Center Contact: Philip D. Anderson, MD Department of EM One Deaconess Road W/CC -2 Boston, MA 02215 Length: 2 years Salary: Competitive, benefits, CME benefits and MPH tuition Positions: One Degree: MPH Deadline: December 1 ( (617) 754-2324 8 pdanders@bidmc.harvard.edu Harvard University / Brigham and Women’s Hospital Regional Focus: Various Contact: Stephanie Rosborough, MD, Department of EM 75 Francis Street Boston, MA 02115 Length: 2 years Positions: One

Salary: Competitive with excellent benefits Shifts/Week: 1-2 Degree: MPH Deadline: November 20 ( (617) 732-5813 8 iem@partners.org : www.brighamandwomens.org/ dihhp/iem

New York

Bellevue Hospital Center/ New York University School of Medicine Contact: Peter Gordon, MD Emergency Care Institute Room 345A, Bellevue Hospital Center 27th Street and First Avenue New York, NY 10016 Length: 1 - 2 years Salary: Competitive Positions: 1 ( (212) 562-8147 8peg.aao@att.net New York - Presbyterian: The University Hospitals of Columbia and Cornell Regional Focus: Africa (Uganda,

Tanzania, Kenya, Sudan, Ghana, Malawi, Sierra Leone); India, Sri Lanka, Montenegro, Dominican Republic, Burma; WHO in Geneva Contact: Rachel T. Moresky, MD, MPH Columbia University Medical Center - Center for EM 622 West 168th Street PH 1-137 New York, NY 10032 Length: 2 years Salary: Competitive Positions: 2 Degree: MPH Deadline: November 1 ( (212) 304 5745 8rtm2102@columbia.edu : www.nypemergency.org/ fellowships North Shore - Long Island Jewish Health System Contact: Sassan Naderi, MD Dept. of EM 270-05 76th Ave New Hyde Park, NY 11040 Length: 1 year Positions: 1 - 2 Salary: $90,000

Hours per week: 18 Deadline: Rolling ( (718) 470-7501 8 snaderi@nshs.edu St. Luke’s Roosevelt Hospital Center - Global Health Fellowship Focus: HIV/TB/Tropical Contact: John D. Cahill, MD Dept. of EM 1111 Amsterdam Avenue New York, NY 10025 Length: 2 years Positions: 2 Salary: $87,000 Hours per week: 20 Degree: MPH optional Deadline: Rolling ( (212) 523-3330 8applications@slredglobalhealth. com : www.slredglobalhealth.com University of Rochester Medical Center Contact: David H. Adler, MD Dept. of EM 601 Elmwood Avenue, Box 655 Rochester, NY 14642

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The IEM Fellowship Directory Length: 2 years Salary: $80,000 - $100,000/year depending on clinical time; CME, benefits, 5k/year travel Positions: 1 Degree: MPH, clinical investigation, or medical management Deadline: April 15 ( (585) 463-2945 8david_adler@ :www.urmc.rochester.edu/ emergency-medicine/education/ international.cfm North carolina Duke International EM Fellowship/Global Health Residency Program Focuses: East Africa, Casualty department epidemiology, trauma epidemiology research, validation of trauma scoring in resource limited settings Contact: Charles J. Gerardo, MD Duke University, DUMC 3096 Durham, NC, 27710 Length: 2 years Positions: 1

Salary: Competitive, including tuition for advanced degree Degree: MS in Global Health (MSc-GH) Deadline: September 24 ( 919-681-4458 8 gerar001@mc.duke.edu : www.dukeglobalhealth.org :globalhealth.duke.edu Oregon Oregon Health & Science University - Global Health Fellowship Contact: Amy Marr, MD OHSU Dept. of EM 3181 SW Sam Jackson Park Road, CDW-EM Portland, OR, 97068 Length: 2 years Positions: 1-2 Salary: PGY level, CME allowance, benefits Shifts per week: 1 Degree: Master’s or certificate options (tuition support provided) Deadline: Rolling ( (503) 494-8220

Providence, RI 02903 Length: 2 years Salary: $87,500 Positions: 1-2 Hours per Week: 16 Degree: MPH from Brown University ( (401) 444-5826 8lproano@lifespan.org

8 marra@ohsu.edu : www.emergencyresidency. com Pennsylvania University of Pittsburgh Contact: Allan B. Wolfson, MD Dept. of EM 230 McKee Place, Ste. 500 Pittsburgh, PA 15213 Length: 2 years Salary: Negotiable Shifts per week: Negotiable Degree: MPH offered from the University of Pittsburgh Graduate School of Public Health ( (412) 647-8265 8wolfsonab@upmc.edu : affiliatedresidency. health.pitt.edu

tennessee

Vanderbilt University International EM Fellowship Regional Focus: South America Contact: Seth Wright, MD Vanderbilt University 703 Oxford House Nashville, TN, 37232 Length: 1-2 years Positions: 2 Salary: $92,000 + excellent benefits, tuition, travel expenses Hours per week: 14.75 Degree: MPH, DTMH Deadline: Rolling ( (615) 936-0075 8seth.wright@vanderbilt.edu : emergencymedicine. mc.vanderbilt.edu

Rhode Island Rhode Island Hospital Regional Focus: Liberia, Rwanda, Uganda, Kenya, and Haiti Contact: Lawrence Proano, MD University EM Foundation 593 Eddy Street,

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For additional information call 858-345-1103 or email mrszuch@checourse.com

Fall 2010 // Emergency Physicians International

The IEM Fellowship Directory texas Baylor College of Medicine / Texas Children’s Hospital Regional Focus: Various Contact: Charles G. Macias, MD, MPH Texas Children’s Hospital 6621 Fannin, MC 1-1481 Houston, TX, 77030 Length: 4 years (pediatrics trained); 3 years (EM trained) with Board eligibility in PEM at completion Salary: PGY level Positions: 1 Hours per week: 32-40 Conferences/week: 4 hours, except PICU rotation Degrees: MPH, MEd, MS, MBA Deadline: August 31 through ERAS (apply for PEM Fellowship) ( (832) 824-5468 8pwomack@ :texaschildrenshospital.org University of Texas Southwestern (Dallas-Parkland) Regional Focus: Mexico/Latin America. Others negotiable.

Contact: Robert E. Suter, DO, MHA Div. Emergency Medicine UT Southwestern Medical Center at Dallas 5323 Harry Hines Boulevard CS2.122 Dallas, TX, 75390-8579 Length: 2 years Salary: Competitive Positions: 4 Hours: 56 clinical hours/month Degrees: MPH Deadline: December 1 ( (214) 648-3916 8robert.suter @utsouthwestern.edu

utah University of Utah Regional Focus: Ghana, Thailand, India, Peru Contact: Erik Barton, MD, MS, MBA University of Utah Health Care 30 North 1900 East, Rm 1C26 Salt Lake City, UT 84132 Length: 1 to 2 years Salary: competitive Positions: 1 or 2

Forthcoming Programs

Shifts: 7 per month/54 hours Degrees: MPH Deadline: Rolling ( (801) 581-2417 8erik.barton@hsc.utah.edu

South Africa: Univ. Cape Town / Stellenbosch Univ. Regional Focus: South Africa Contact: Lee Wallis, MD 8leewallis@bvr.co.za

-----------------------------------

the netherlands The NVSHA Contact: Terry Mulligan, DO, MPH 8terrymulligan@yahoo.com Contact Dr. Pieter van Driel 8vandrielpieter@hotmail.com Length: 1 to 2 years Number of positions: 1 or 2 Degrees: Subspecialty/ Fellowship Status in Dutch EM System Deadline: Rolling. Currently open only to Dutch EPs ( +31 624 11 3566 : nvsha.nl

Australia / New Zealand Regional Focus: Australia, NZ & South Pacific Contact: Peter Cameron, MD 8peter.cameron@med.monash. edu.au and Gerard Oreilly 8oreillygerard@hotmail.com IFEM Fellowship Regional Focus: Global Contact: Peter Cameron, MD 8peter.cameron@med.monash. edu.au Canadian Association of Emergency Physicians Regional Focus: Global Contact: Valerie Krym 8v.krym@utoronto.ca

Global Collaboration

TeamHealth partners with institutions throughout the U.S. and the world to foster academic emergency medicine. In 2009 and 2010 TeamHealth awarded grants to 23 emergency medicine residents, affording them the opportunity to travel to and participate in the Annual INDO-US Emergency and Trauma Program in India. The main mission of this partnership is to foster the growth of academic medicine in the fields of Emergency Care and Traumatology. This collaboration promotes the exchange of knowledge and mutual development between academic institutions in India and the United States. TeamHealth is proud to support educational opportunities for emergency medicine residents and to play a role in advancing emergency and trauma care around the world. For more information on this particular initiative, visit www.indusem.com.

80 0 .8 1 8 .1 498 www.teamhealth.com www.epinternational.ning.com 1939 Emergency Physicians International.indd 1

9/3/2010 10:45:14 AM

Grand Rounds

with peter cameron, MD

Reflections on the UK’s “4-Hour Rule”

Sure, the hallways are clear, but are time-based performance indicators improving care in British emergency departments? Only time will tell.

Following a couple of months in the UK as an observer, where emergency physicians have been “suffering under the yoke” of The 4-Hour Rule, it is interesting to reflect on the effect of this controversial solution to the ubiquitous international problem of overcrowding in emergency departments (EDs).

It is important to emphasise, for those people outside the UK, that the introduction of a 4-hour standard across England has basically eliminated corridor patients in the ED. I have visited many EDs across England and looked at local and national data and there is no doubt that the EDs in England are the emptiest of any that I have seen in the developed world. More than 98% of patients are out of the ED within four hours of arrival. There are obviously examples of fudging of figures and data manipulation, but overall the figures are fairly accurate. It is also important to note that prior to the introduction of the new standard, overcrowding and access block for emergency patients was as bad in the UK as it was elsewhere – so the dramatic improvement was from a poor base. To achieve this, a large amount of money was invested in the NHS and a lot of initiatives were undertaken over a short period of time. Innovations such as fast track, clinical decision units, walk-in clinics, acute medical/surgical admissions units, nurse practitioners and complete re-engineering of hospital processes were commenced to facilitate compliance with the new rule. There was also an investment in community and social services to enable more rapid discharge of patients. Importantly, all hospital and Trust executives were held accountable for performance against the standard. The average appointment duration of Trust CEOs was quite short during the introduction. So was the introduction of the four-hour rule good for patients? Did it result in better care? Were all emergency physicians happy? The answers to these questions are necessarily complex. The first point to make is that we have no idea whether patient outcomes are better or worse following the introduction of the new processes. There is no systematic measurement of properly risk-adjusted outcomes in key risk areas. There is little data regarding the outcomes of those patients diverted from EDs or admitted precipitously to the ward to meet the target. There are many anecdotes and a few isolated pieces of data that are enough to raise concerns regarding patient safety and quality of care. A much quoted example is the MidStaffordshire Trust, where an inquiry found that a focus by management on time-based KPIs, to the exclusion of quality of patient care, had resulted in poor patient outcomes. In general, patients themselves are happy that they have some guarantee about process time – they are blissfully unaware of our concerns regarding

Fall 2010 // Emergency Physicians International

quality of care. The doctors in the ED are happy to have empty corridors – especially the senior doctors, who had to shuffle patients in corridors previously. However, many junior doctors feel that their role has been reduced to a triage officer and they have little time to undertake procedures or focus on clinical medicine. As a purely subjective impression, the general mood of ED doctors (especially junior doctors) in the UK appeared less upbeat than the mood in Australian EDs. Of course, this might just be lack of sunshine! Will the improvement in overcrowding be sustainable? Unfortunately, the UK is in the throes of an economic disaster, which is likely to result in public spending cuts of up to 25%. It is highly unlikely that the NHS will be spared – despite government assurances. This, combined with the continuing 5% growth in ED attendances, is inevitably going to result in a major test of the present system. At the same time the new coalition government has promised to move away from a “target culture” to improvement in patient care quality and outcomes. Although the four-hour target will not be scrapped, it will not be the main focus of concern for the new government. Balancing the reduced focus on time with achievement of new quality benchmarks, will result in a major challenge for the NHS in general and EDs specifically. What is the message for other regions? Should they adopt this standard? The main message is that it is possible to empty the EDs of corridor patients if the whole health system focuses on a major expansion in services. Second, patients generally like the idea of a guaranteed service within a short time period. But it is not known whether the huge investment and process improvements actually resulted in better patient outcomes. The effect on work practice for emergency physicians is considerable and may not be desirable for many clinicians. It is not known what time frame is most appropriate for safe and efficient care in the ED (e.g. 4 hours, 6 hours or 8 hours). It clearly depends on the model of care and patient mix. It also depends on the level of care within the rest of the hospital and support services available. However, a simple one-size-fits-all approach is most likely to work politically. Personally, I found the ability of a health system to actually deliver an outcome that it promised very inspiring. However, I was concerned that it may have done this, in some instances, at the cost of ensuring good patient care. Some would argue that anything is better than treating patients in corridors, but I am not sure! The challenges in front of the NHS are considerable as it looks to maintain the time-centred standard, whilst changing focus to ensure that quality of care is improved. Dr. Peter Cameron is the president of the International Federation of Emergency Medicine (IFEM).

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Fall 2010 // Emergency Physicians International