Dr. Saleh Fares on the rise of EM in the UAE Pan-Asian Council Promotes New Research Design: The Future of Psych EDs Cameron: Less Turf War, More Collaboration EMERGENCY PHYSICIANS INTERNATIONAL
Typhoon Haiyan Special Report Empowered community health workers form the backbone of disaster relief efforts. Two Filipino physicians share lessons learned following the typhoon disaster response.
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EDITOR’S DESK
It’s Time to Get Connected
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nternational emergency medicine continues to be a hotbed of activity. In June, IFEM will host the 15th International Conference on Emergency Medicine (ICEM 2014) which is IFEM’s official conference held every two years. ICEM 2014, organized and run by the Hong Kong College of Emergency Medicine, will be held in Hong Kong from June 11 to 14. Preceding the conference are a number of focused topic preconference workshops. ICEM 2014 will have multiple tracks covering all aspects of emergency medicine, and over 1000 scientific abstracts will be presented. At the IFEM Assembly meeting, the Assembly will vote on new officers as well as new member societies, including the national emergency medicine organizations of Vietnam, Tanzania, Libya, and the United Arab Emirates. EPI will be holding meetings at the ICEM to discuss the applications of new technologies to emergency medicine practice. EPI would very much like to meet with you and hear your ideas and opinions on the many new exciting electronic devices and web-based resources that can be applied in emergency medicine both for clinical practice and for education. EPI would also like to solicit articles and pictures from each of you for publication in EPI’s magazine and web posting about your international projects and activities. To connect, go to www.epijournal.com. IFEM has decided to start holding the ICEM every year instead of every two years. This will start in 2019 and bids are now being accepted for IFEM members to host the 2019 and 2020 conferences (the 2016 ICEM will be in Cape Town and the 2018 ICEM will be in Mexico City). The more frequent ICEMs will give more national emergency medicine organizations the opportunity to showcase their organizations and their national cultures, and of course gives all us ICEM participants the opportunity to experience more countries and cultures. So get your national emergency medicine organization to put in a bid to host an upcoming ICEM! (The application process is spelled out on IFEM’s web page www. ifem.cc). IFEM has just posted a standardized approved curriculum for ultrasound training in emergency medicine and has just finished a manuscript (soon to be web posted) on how to start and operate a national emergency medicine specialty society. A standardized paramedic training guidelines document is also in the works. These are just a few examples of the many practical resources that IFEM is developing and making freely available at no cost to support emergency medicine development. IFEM has a large number of active committees and task forces (including education and curriculum, specialty development and continuing professional development) which are working on multiple projects. Check out IFEM’s web site where many reference resources are posted. IFEM would also like to solicit your participation and input in its many projects. To join an IFEM committee or task force, just contact the IFEM secretariat by email (information at www.ifem.cc). Despite being the world’s largest emergency medicine organization, IFEM has never had very much in the way of financial resources. So it is embarking on developing a long term financial plan which will probably include having a financial Foundation to which people could make charitable donations to support IFEM’s work. IFEM is also developing a long term communications plan to better communicate with its members and with emergency medicine practitioners worldwide. If you have any good ideas on how IFEM should proceed with finances and communications, please contact the IFEM secretariat. Everyone in IFEM is looking forward to the Hong Kong ICEM and we hope to see you all there!
C. James Holliman, MD, FACEP, FIFEM editorial director
IFEM has just posted a standardized approved curriculum for ultrasound training in emergency medicine and has just finished a manuscript (soon to be web posted) on how to start and operate a national emergency medicine specialty society. A standardized paramedic training guidelines document is also in the works.
Dr. Saleh Fares on the rise of EM in the UAE Pan-Asian Council Promotes New Research Design: The Future of Psych EDs Cameron: Less Turf War, More Collaboration EMERGENCY PHYSICIANS INTERNATIONAL
ISSUE 12
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SPRING 2014
. WWW.EPIJOURNAL.COM
Typhoon Haiyan Special Report Empowered community health workers form the backbone of disaster relief efforts. Two Filipino physicians share lessons learned following the typhoon disaster response
ABOUT EPI With a quarterly print and digital distribution and an online network of more than 2,000 members, EPI is the essential hub connecting global emergency care, sparking dialogue and creating a space for new collaborations. Find copies of the print magazine at international EM conferences around the world, or read it online at www.epijournal.com
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LETTER FROM THE PUBLISHER
Knowledge, Translated
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arlier this year, a group of investigators in the United States shared with the world the findings of the Protocolized Care for Early Septic Shock (ProCESS) Trial. This multi-center trial, funded by the NIH and coordinated by the University of Pittsburgh, confirmed two things. First, that more care isn’t always better care. According to ProCESS, saving lives in sepsis management is more about early detection, early fluids and early antimicrobials than it is about invasive, expensive monitoring (read our ProCESS cheat sheet on page 6). Second, ProCESS proved that the knowledge translation window in medical education is shrinking, and quickly. Within hours of the ProCESS Trial findings being released, Twitter was tweeting and the blogosphere was blowing up. From every corner of the world, emergency physicians joined the conversation, and waged intelligent debate about the role of early detection and complex algorithms in the care of sepsis patients. There were no barriers to entry, only an open invitation to read the literature and discuss. It wasn’t long ago that new research findings took years to make their way into medical practice. While there is still a lag, digital technology and social media are shrinking that “KT” timetable every day. Just a month after the publication of the findings, we asked our readers whether the ProCESS Trial would change sepsis management at their emergency departments. Twenty-seven percent said yes, and the rest responded that they already used the proper protocols. Every respondent save one – representing 19 countries – had heard of the ProCESS Trial and understood its impact on sepsis management (for a full run-down of how our readers handle sepsis, see Dispatches on page 7). In the end, however, the best knowledge translation still takes place face to face. If you are reading this edition of EPI in print, you are likely attending one of two emergency medicine conferences in the United Arab Emirates. Thanks to the recent formation of the Emirate Society of Emergency Medicine (ESEM), the UAE has become one of the newest voices in the global emergency medicine conversation (read EPI’s interview with ESEM president Saleh Fares on page 10). Now, in the UAE, there is a place where newly minted emergency physicians can discuss best practices face to face. In this ever-expanding, ever-quickening global dialogue, the voices from the UAE are joined by new emergency physicians in Sudan, Iraq and Papua New Guinea. As training programs and conferences are birthed in these locales, we’ll see the kind of knowledge translation that lasts, the kind built on high quality education and the trust of one’s medical community.
editorial director C. JAMES HOLLIMAN, MD
publisher LOGAN PLASTER logan@epijournal.com On Twitter @EPIJournal
executive editors PETER CAMERON, MD TERRY MULLIGAN, DO, MPH LEE WALLIS, MD PROF. V. ANANTHARAMAN
editors DR. RASHMI SHARMA LONNIE STOLTZFOOS GREGORY KING
regional corespondents CONRAD BUCKLE, MD MARCIO RODRIGUES, MD CARLOS RISSA, MD KATRIN HRUSKA, MD SUBROTO DAS, MD MOHAMED AL-ASFOOR, MD JIRAPORN SRI-ON, MD
editorial advisors ARIF ALPER CEVIK, MD KATE DOUGLASS, MD HAYWOOD HALL, MD CHAK-WAH KAM, MD GREG LARKIN, MD PROF. DONGPILL LEE SAM-BEOM LEE, MD ALBERTO MACHADO, MD JORGE OTERO, MD
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Spring 2014 // Emergency Physicians International
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EVENT CALENDAR
IN THIS ISSUE www.epijournal.com
03 | Editor’s Letter 04 | Publisher’s Letter
05/14–11/14
Field Report
SIX MONTHS OF INTERNATIONAL EM CONFERENCES
6 | Dispatches How is sepsis currently handled in your emergency department?
8 | Papua New Guinea
MAY SEPTEMEBER Inter-American Congress of Emergency Medicine // Buenos Aires, Argentina
10 | United Arab Emirates 11 | Ghana
3rd Annual Conference on Surfing Medicine 2014 // Sligo/Mullaghmore, Ireland
Departments
September 9-13, 2014 www.surfingdoctorseurope.com Contact: conference@surfingdoctorseurope.com
13 | In the Field
European Society for Emergency Medicine (EuSEM) Refresher Course 3 // Novara, Italy
8th Annual Symposium on Advanced Emergency EKG - Mediterranean Cruise // Barcelona, Spain
15 | Curious Cases
May 15-18, 2014 www.refreshercourse.org Contact: yemdsection@gmail.com
September 14-21, 2014 www.floridaep.com Contact: isales@floridaep.com
Joint Congress of European Neurology // Istanbul, Turkey
European Congress on Emergency Medicine (EuSEM 2014) // Amsterdam, The Netherlands
May 14-16, 2014 orlargentina.com/v-congreso-interamericano-demedicina-de-emergencias Contact: info@ampcongresos.com.ar
May 31 - June 3, 2014 www.jointcongressofeuropeanneurology.org Contact: registration.istanbul2014@congrexswitzerland.com
September 28 - October 1, 2014 www.eusem2014.org Contact: contact@eusem2014.org
JUNE
NOVEMBER
ICEM 2014 // Hong Kong
African Conference on Emergency Medicine (AfCEM) 2014 // Addis Ababa, Ethiopia
June 11-14, 2014 www.icem2014.org Contact: icem2014@swiretravel.com
AUGUST
November 4-6, 2014 www.afcem2014.com Contact: www.afcem2014.com/contact-us.html
Emergency Tasmania 2014 // Cradle Mountain, Tasmania, Australia
16th Conference for the Society of Emergency Medicine India (EMCON 2014) // Mumbai, India
August 8-10. 2014 www.conferencedesign.com.au/et2014 Contact: anna@conferencedesign.com.au
November 6-9, 2014 www.emcon2014mumbai.com Contact: vamahospitality@hotmail.com
LIST YOUR NEXT INTERNATIONAL EVENT FOR FREE ON THE EPI NETWORK – WWW.EPIJOURNAL.COM/EVENTS
In Rwanda, data collection project fuels innovation at the point of care A strange case of nausea, vomiting, and dizziness
Reports 16 | Journal // Africa A review of recent research from the African Journal of Emergency Medicine
18 | Journal // Global From China and Ghana, a new review by the Global Emergency Medicine Literature Review Group
19 | Pan-Asia PAROS network promotes cardiac arrest research in Asia.
20 | Special Report on Typhoon Haiyan Local physicians involved in relief efforts talk lessons learned.
27 | Global Consensus At SAEM, emergency medicine builds towards global goals.
29 | Design How ED design can decrease the stress and anxiety for behavioral health patients while increasing the efficiency of their care.
33 | Grand Rounds The importance of collaboration in progressing EM in Europe www.epijournal.com
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DISPATCHES READER-SUBMITTED UPDATES FROM THE FOUR CORNERS
Global Trends in Sepsis Management The ProCESS Trial in Brief This landmark trial suggests that complex, invasive sepsis care brings no statistical mortality benefit while consuming healthcare resources. Here is a quick run-down of the study that is shifting the sepsis conversation. by Steven Schauer, MD
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t’s been over 12 years since the landmark publication by Dr. Manny Rivers describing a protocol-based algorithm for treatment of patients with septic shock. Despite the age of this study it has remained a staple for emergency medicine residency journal club review. Among other things, the Rivers study highlighted the need to identify septic shock early, and this had significant downstream effects. It brought ICU-level care to the ED and forever changed the way we managed sick patients from the moment they hit the door. As with many things in medicine, these sepsis guidelines have been plagued with controversy. Multiple studies have called into question whether such aggressive transfusion rates were necessary given their inherent risks. While many large academic centers have all the fancy high-end gadgets to go with the protocol, does that mean that those of us practicing at smaller, community-based hospitals are providing substandard care? It is with this controversy front and center that emergency physicians anxiously awaited the results of the ProCESS trial, which was published in March. Would it fundamentally change the way we treat sepsis? Here is a cheat sheet of what they did, and what they found.
Methods ProCESS was a multicenter, randomized trial, conducted at 31 academic centers all with an annual census of at least 40,000. All centers had to have the ability to perform screening lactates to identify patients with cryptogenic sepsis. To be eligible they had to be over 18 and meet their criteria
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for septic shock. 1351 patients underwent randomization into one of three groups: EGDT, their standard protocol, or the usual care. Randomization occurred with virtually identical baseline demographics across all three groups. The EGDT group protocol mimicked that of Dr. Rivers protocol. The standard protocol group required only 2 large-bore IVs (central line if unable to get reliable IV access), fluids, antimicrobials, and pressers if fluids failed to reach BP targets. The usual care arm essentially allowed the bedside provider free-reign to direct all resuscitation efforts without any protocol guidance.
Outcomes Their primary outcome was all-cause mortality at 60 days. There were no statistically significant differences in mortality rates across all three groups: EGDT (21.0%), protocol-based (18.2%) and usual care (18.9%). How about at 90 days? No difference. How about discharge location? No difference. It is worth noting, though, the EGDT group had higher rates of ICU admission and higher rates of blood transfusion. So while no mortality difference, the EGDT group did consume more resources.
ProCESS v. Rivers In the Rivers et al. study their 60-day mortality in the standard therapy was 57% in the usual care group and 44% in the EGDT group. So why the huge difference compared to the ProCESS groups? Most likely it’s because one thing we learned from the Rivers study: the need for rapid, early identification. Lactate studies are now almost ubiquitous. In the ProCESS group, 96% received fluids early, and an astonishing 97% received antibiotics in the first 6 hours.
In Practice So what does this mean going forward? It means that the things we postulated for many years have panned out – it’s really all about early identification, early fluids, and early antimicrobials when it comes to saving lives. While prior data suggested this, it’s time for everyone to get on board. You don’t need a complex algorithm, invasive and painful procedures, or expensive equipment to provide good care. And now you have the data to prove it.
Spring 2014 // Emergency Physicians International
We asked more than 7,000 emergency physicians from nearly 100 countries to tell us how sepsis is managed in their department. Here’s what you had to say.
Q. Will the recent ProCESS Trial findings change the way your emergency department handles sepsis? Yes 27% No 73%
Q. How is sepsis currently handled in your emergency department? ______________________
01 AUSTRALIA We use rapid assessment; bloods including 2 sets of cultures; early fluids, antibitotics, etc... then ionotrope therapy if needed after ~ 2 litres of IVF. Andrew Watson ______________________
02 BAHRAIN We follow early goal-directed therapy (EGDT). The ProCESS trial will NOT change this sepsis management. Ankur Verma ______________________
03 BELGIUM We use rapid infection source identification (cultures/lab/radiology); oxygen en rapid fluid administration; rapid antibiotics; rapid ICU transfer (if possible, often not); arterial line; ET/niBPAP if needed; SwGz never placed on ED; CV catheter quit often placed for inotropics (no CO measurement, no central venous oxygen follow up, bloodgases (with lactate) followed frequently. Turn over +/- 2 hours for above, transfer to ICU 2-6 hours. Ankur Verma ______________________
04 BRAZIL ProCESS will not change our sepsis management. We give antibiotics in the first hour; Volemic reposition with goal of MAP > 65 mmHg in the first hour; vasopressor if necessary. Rodrigo Antonio Brandão Neto ______________________
05 DOMINICAN REPUBLIC The ProCESS trial will change how we handle sepsis. Currently we use early identification via sirs/sepsis criteria, severity determination with vitals/end organ/lactic acid; Aggressive fluids resuscitation; Early antibiotics; EGDT; Effectiveness reassessment via lactate clearance, and end organ function. Amado Alejandro Baez, MD
______________________
06 FRANCE We obey the sepsis guidelines from 2013. The ProCESS trial will not change this. AK ______________________
07 GERMANY We have a sepsis guideline – early recognition and resuscitation are key (“early goal directed therapy”). As soon as sepsis is considered, antibiotic therapy is started. Andreas Huefner ______________________
08 INDIA The ProCESS trial will change our sepsis management. We followed early goaldirected therapy (EGDT). Dr. Asit Misra ______________________
09 NEW ZEALAND Screening tool for sirs in use with uptriage for those with 2 criterea, cultures, lactate, abx, and 1rst liter of fluid. Patients are to be seen in 10 minutes. Renee Garcia ______________________
10 QATAR We more or less follow practice consistent with the third arm (i.e.the non-protocol) arm of PROCESS trial, so it will NOT change how we handle sepsis. Dharmesh Shukla --------------Our sepsis management variees. It does not involve scvo2 catheter or dobutamine. Early antis plus fluid plus source control emphasised. Inotropes and antibiotics very variable. Fluid management variable.... Process trial will make people focus on the basics of good supportive care. Peter Cameron, MD
______________________
11 SAUDI ARABIA ProCESS will change our management. We give Abc, fluid, Abx, ICU. Some attendings still give EGDT ______________________
12 SOUTH AFRICA We use early antibiotic treatment (preferably within one hour); Judicious fluid management; Test to evaluate source started in the ED; Admission as soon as possible for further treatment in the hospital. ProCESS will NOT change how we operate. Anita Groenewald ______________________
13 SOUTH KOREA Our department cares for sepsis patients in collaboration with several other departments in the hospital. ED triage, check all labs, blood cultures and all films including CT or MRI without delay. Give broad spectrum antibiotics, shock management, etc... If surgery required, directly call the surgery department and admit to ICU. Sam Beom Lee, MD ______________________
14 SUDAN We manage sepsis according to the surviving sepsis campaign guidelines of 2012. ProCESS will not change what we do. Abderrhman Alnour Alimam ______________________
15 SWEDEN We use standardized protocols (in conduct with EGDT) for sepsis and septic shock. The protocols are very sensitive for sepsis and are also helpful to detect those patients that are at risk for deterioration, and maybe we overtreat some patients. The protocols stress immediate fluid resuscitation. Since we are obliged to see all patients within an hour of arrival to the ED, the chance of early detection of sepsis is quite high.
Unfortunately we have not studied if the protocols we use (since 2012, developed locally by an emergency physician) have changed the outcome for septic patients at our hospital. Sepsis is of course common, but the patients presenting with septic shock are quite rare in our ED. Frida Meyer ______________________
16 TURKEY The ProCESS trial will NOT change our sepsis management. We currently handle sepsis like the second group in the ProCESS trial. Intensive therapy, but only rarely using a central line. John Fowler, MD ______________________
17 UNITED ARAB EMIRATES The ProCESS trial WILL change our sepsis management. Currently we use EGDT Protocol following the Surviving Sepsis Guidelines – strictly adhered to with compliance measured as a Key Performance Indicator (KPI). Bob Corder, MD ______________________
18 UNITED KINGDOM The ProCESS trial will NOT change our sepsis management. We currently handle sepsis with early goal-directed therapy (EGDT). Luca Pensabene ______________________
19 USA Fluid resuscitation--strict I&O; Moisturized O2; Vasopressors if needed; Antimicrobials quickly-following; cultures--also done quickly; Steroids if indicated; Non-invasive respiratory support unless too ill--then RSI and vent.Unless DNR or DNI. Warming patient (BAIR hugger) if needed (or if not available-warm blankets loosely over patient with another over blanket to form “pocket of air”). Anxiolytics if needed; Pain control if needed. Heidi Steventon Rothenberg MD
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FIELD REPORT SPRING 2014
According to The Economist, Port Moresby is one of the world’s least livable cities (ranked 139 of 140), due in part to high levels of violence and unemployment.
PAPUA NEW GUINEA Given its high levels of violent crime, trauma and snakebites, this resourcerich nation has benefitted greatly from emergency medicine development. apua New Guinea (PNG) has been described as “an island of gold floating in a sea of oil” for its rich mineral reserves1. It has lush tropical rainforests, powerful large rivers divided by a central rugged mountain range. These physical features make travel within the country very difficult and have helped create great challenges for the distribution of health care. There are over 800 different tribes and distinct languages spoken in PNG with currently 87% of PNG’s people living in rural areas in widely scattered communities that are often not accessible by road2. There are several challenges of practicing medicine in PNG, namely the remoteness, limited medical education and lack of both human and medical resources.
commonplace in PNG. Most people in PNG primarily seek advice from the village medicine man (“puri-puri” man) for healing. Often the nearest medical clinic is several days walk and even once you get there the clinic may be unmanned. There are no roads joining the capital city to any of the other major centres, making travel via airplane often the only viable mode of transport between centres. Community nurses and Health Extension Officers (HEOs) play a key role in delivering health care in rural areas. They are considered the backbone of healthcare delivery in rural PNG and function as rural clinicians, public health officers and health centre managers. Health Extension Officers undertake a 4 year bachelor’s degree at the Divine Word University in the provincial capital of Madang. In 2010 an exciting program was devised and implemented for the support of the HEO training process. The “Visiting Clinical Lecturer Program”3 allowed overseas emergency physicians and emergency registrars to help support in the clinical teaching of HEO students in Madang. Emergency doctors can visit for 2 weeks to 3 months and emergency registrars have the possibility of accredited training time through the Australasian College for Emergency Medicine.
Rural Medicine
EM Training in PNG
by zafar smith, md
P
Physical isolation from any medical care is
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In 2006 the first Papua New Guinean
Spring 2014 // Emergency Physicians International
The lack of speed limit enforcement, limited seatbelt use and poor quality roads in Port Moresby makes motor vehicle related trauma high on the list of ED presentations.
emergency physician graduated with a Masters of Medicine in Emergency Medicine (MMedEM) from the University of Papua New Guinea. This was a landmark event following the commencement of the Masters program in 19964. The program is four to six years long with an entry exam, exit exam, research requirement and minimum term requirements5. The main centre for emergency medicine training is in the Port Moresby General Hospital (PMGH) Emergency Department (pictured left). There are currently five emergency physicians based in Port Moresby offering a robust teaching program for junior doctors. Port Moresby has consistently been ranked as one of the most violent and unlivable cities on the earth6. With massive unemployment, dense urban settlements and a general lack of law and order, there are frequent presentations to the emergency department of crime and domestic violence-related injuries such as stabbings and lacerations from machete use. The lack of speed limit enforcement, limited seatbelt use and poor quality roads in Port Moresby makes motor vehicle related trauma also high on the list of presentations. Infectious and tropical diseases make up another large proportion of case presentations. Tuberculosis, malaria and HIV-related illness are 3 common infectious diseases seen. In an anonymous survey of a random sample of 300 patients requiring blood tests in the ED, 18% were found to be HIV positive7. Other cases recently have included filariasis, cryptococcal meningitis, botulism, actinomycosis, and rheumatic fever8. Many people present late after seeking advice from local witch-doctors or village healers and only come to the emergency department once at death’s door. The educational benefit of such florid pathology is balanced by several key challenges in the Port Moresby emergency department. Personal safety in Port Moresby is an issue, not just outside the hospital but also within the ED from needle-stick injuries, infectious disease exposure and burnout from being overworked.
Disposable medical items frequently run out, particularly personal protective gear such as sharps bins, gloves and masks. Donated equipment such as intravenous pumps become unusable due to appropriate tubing sets running out. There is currently one ventilator in the emergency department, so any additional intubated patients get manually ventilated by family members while sometimes waiting days for an intensive care bed. Future developments in emergency medicine training in PNG include further support for the Health Extension Officers training in Madang, increasing the time spent in ED for local emergency registrars, the introduction of an emergency medicine first part exam (since current trainees do the surgical first part exam) and the possibility of an emergency medicine diploma for doctors9.
Snakebite Research Snakebite remains a common cause of injury and death, especially for young, ruraldwelling people in southern Papua New Guinea10. In PNG there are an estimated 3500 snakebites per year with at least 200 deaths per year11. A small team of dedicated people from the University of PNG and the University of Melbourne Australian Venom Research Unit (AVRU) have collaborated to form the “Snakebite Research Project” in PNG. Exciting progress is being made with a new double blinded randomised controlled trial being currently conducted by the Snakebite Research Project team which includes Australian herpetologist David Williams and emergency physician Simon Jensen (from AVRU and director of the Charles Campbell Toxicology Centre in Port Moresby). This
REFERENCES
Manineng
1. PNG gas project faces risks – Jo Chandler, Sydney Morning Herald, Business Day, May 29, 2012. Extracted from http://www. smh.com.au/business/png-gasproject-faces-risks-20120528-1zfb6. html#ixzz2uWwrhzZo on 5th March 2014
4. The Emergency Medicine program in PNG – capacity building for general acute care. Chris Curry. Newsletter of the International Emergency Medicine Special Interest Group of ACEM. Volume 3, Issue 1, November 2006
2. Country profile for Papua New Guinea, World Health Organisation, Western Pacific Region. Extracted from http://www.wpro.who.int/countries/png/en/ on 5th March 2014 3. Emergency Medicine Australasia (2012) 24, 547–552, “Capacity building in emergency care: An example from Madang, Papua New Guinea” by Georgina A Phillips, Jamie Hendrie, Vincent Atua and Clement
5. Update on Emergency Medicine in Papua New Guinea. Colin Banks. Newsletter of the International Emergency Medicine Special Interest Group of ACEM. Volume 9, Issue 2, December 2013 6. A Summary of the Liveability Ranking and Overview - August 2012. The Economist Intelligence Unit Limited 2012. www.eiu.com 7. Emergency Medicine Australasia (2004) 16, 343–347. Education and
Right:: A 17-year-old boy suffers as a result of delayed presentation following a snakebite. His right arm shows severe swelling and multiple postules after 2 months.
trial is comparing a new PNG-taipan specific antivenom against the current CSL-brand of taipan antivenom. This will be the first ever randomised controlled trial of any CSL antivenom against an alternative product and the first new snake antivenom intended for human use in Australasia for more than 50 years. It is hoped that the trial will not only yield a positive result for the new antivenom, but that it will significantly benefit the development of medical science in PNG by training staff involved in the trial in various capacities11.
Conclusion Remoteness, medical education and lack of resources are some of the challenges for emergency physicians in Papua New Guinea. Exciting new developments in the last few years include the support for Health Extension Officers training in Madang, a growing body of locally trained emergency physicians, and the ground-breaking Snakebite Research Project with its new antivenom trial.
Training Emergency medicine in PNG - The first year of a formal emergency medicine training programme in Papua New Guinea. Chris Curry, Carolyn Annerud, Simon Jensen, David Symmons, Marian Lee and Mathias Sapuri
Guinea: A Treatment Guide for Health Workers and Doctors. Australian Venom Research Unit, Melbourne, September 2005, pg 416. ISBN 0-975937-0-5. Extracted from http:// www.avru.org/research/research_ pngsbp.html on 5th Mar 2014
8. www.emergencymedicinepng. com – a website to help promote emergency medicine in Papua New Guinea. Zafar Smith 2013
11. Snakebite Research in PNG - Simon Jensen, Medical director of the Charles Campbell Toxicology Centre, School of Medicine and Health Sciences (SMHS) at the University of PNG (UPNG) and of the Australian Venom Research Unit (AVRU) - UPNG Snakebite Research Project. Newsletter of the International Emergency Medicine Special Interest Group of ACEM. Volume 8, Issue 1, August 2012
9. Update on Emergency Medicine in Papua New Guinea. Colin Banks. Newsletter of the International Emergency Medicine Special Interest Group of ACEM. Volume 9, Issue 2, December 2013 10. Williams DJ, Jensen SD, Nimorakiotakis B, Winkel KD (Eds). Venomous Bites and Stings in Papua New
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FIELD REPORT SPRING 2014 As with many high income countries, the UAE is trending toward non-communicable diseases being the number one cause of deaths compared to the disproprtionate number of communicable disease deaths seen a few decades ago.
UNITED ARAB EMIRATES Saleh Fares, president of the Emirate Society of Emergency Medicine, talks about the opportunities and challenges facing EM in the Emirates. Total Health Expenditure per Capita*
interview by logan plaster
EPI: How is EM uniquely challenging in the UAE? DR. SALEH FARES: The most pressing challenge for EM in the UAE is the limited number of emergency physicians (EPs) in the country. Furthermore, out of this limited number there are many trained EPs whose sights are primarily on larger cities. Another challenge is the difficult coordination between the multiple stakeholders within the emergency medical sector. There are different governing bodies in many areas within the country and trying to set the tone can be a challenge at times. EPI: What exciting opportunities do you see for EM in the UAE in coming years? FARES: Over the past few years, emergency medicine in the UAE has experienced very rapid growth. A unique collaboration within the EM community in the country has brought about a series of achievements, including the establishment of an official EM Society (The Emirates Society of Emergency Medicine) in August 2012. This has positively altered the perception of EM in the country. Other successes include hosting internationally recognized medical conferences in UAE. Due to the unique development in the UAE, EM is receiving needed attention from the government. ESEM is working to utilize this attention to boost the field and create state-of-the-art emergency medical care in UAE. The future of emergency medicine in the UAE is promising. As we develop the field, ESEM aims to have an
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impact on the way EM is delivered in the country and across the region. We believe that this can happen in a top-down and bottom-up approach. We need to teach our practitioners the things they need to change within their own local communities (including up-to-date knowledge and clinical skills, administration and flow issues, and research etc). Further, the bigger picture is very important to tackle at a society level, although it may not be very exciting to many practitioners — they feel it’s too big for them. We can address this through inviting policy makers to activities that will feature key people from the Ministry of Health, Health Authorities, and other relevant entities. We think that this will reveal the system-level issues and will yield considerable progress. Furthermore, ESEM plans to be a hub for high quality EM education in our region. We want to offer cutting-edge and innovative lessons that will alter the practice and policy. If we carry out our plan to make the ESEM annual conference (beginning with ESEM 2014) a quality brand, we think that people both in our region and internationally will place it high on their list. EPI: What clinical trends have you noticed in your region? What are the greatest causes of medical emergencies? FARES: As with many high income countries, the UAE is trending toward non-communicable diseases being the number one cause of deaths compared to
Spring 2014 // Emergency Physicians International
Saudi Arabia $901
UAE $1,732
France $4,085 The UAE ranked 34th internationally in total health expenditure per capita in 2011. *Source: The World Health Bank; Intl $, 2011
the disproprtionate number of communicable disease deaths seen a few decades ago. This is reflecting on the population in the EDs locally and regionally. Cardiovascular diseases, trauma, medical emergencies like sepsis, and neurological emergencies are more common than before. Unfortunately, in many parts of the country EDs are still misused by non-urgent cases. ESEM and the EM community are working to solve this chronic issue through structured approaches. EPI: Are there lessons learned in terms of establishing new EDs and programs that are worth sharing with other regions in similar phases of development? FARES: The UAE is undergoing rapid growth and there are several lessons learned that we could share from our experience in developing EM in the country. The most important lesson is the need to prioritize projects within the field. Governments usually focus on projects that directly serve their developmental projects in other sectors. Our ideas need to be in alignment with their projects in order to successfully sell them to the government. Another lesson we have learned is the importance of the team approach — we are utilizing ESEM to be that team. Forming the society in the country helped us standardize our approaches. The openness of the country to invest in numerous international experiences added to our wealth in the EM community. An important lesson we are learning is the need to invest in future generations of EM. By investing in high quality education, we can produce future leaders that will serve the country and continue the development of EM.
l
FIELD REPORT SPRING 2014
Trainees take part in a one week EM course in Kumasi, leaving them better prepared to respond to events like the tragic shopping mall collapse.
GHANA West Africa’s largest A&E has become a regional hub for emergency medicine education. by cian mcdermott, md
O
n November 7, 2012, a multi-story shopping complex collapsed in the capital of Ghana, turning the city’s Achimota neighborhood into a disaster zone. Tragically, 18 people were killed and many more injured. As horrifying as the event was, as I watched it unfold on the news I had to marvel at the timing. I was in Ghana with a team from Irish-based non-profit Global Emergency Care Skills (GECS) and we had just then completed a week-long training course in emergency medicine. I was heart-broken thinking of the lost lives, but encouraged knowing that the first-responders were a little more equipped than they’d been a few days prior. Our course, which took place at Komfo Anokye Teaching Hospital (KATH) in Kumasi, showcased the exciting developments at what has become West Africa’s premier emergency medicine training facility. During our visit, our team was brought to the
A&E resuscitation room where we saw a young lady who had been knocked over by a truck over the previous weekend. She had been immobilized for a cervical spine injury, a flail chest and disruption of the pelvic ring. She had already spent 24 hours in the A&E with her chest drain and pelvic binding in place while waiting for a bed to become available within the hospital. I noted certain similarities in the A&E of KATH and many emergency departments in my home in Ireland. Severe overcrowding and long waiting times are accepted as a routine occurrence. Many patients with serious limb injuries were boarding in the ED corridors making it impossible to assess any other patients due to exit block. However these patients and their families were most thankful for the excellent care they received from the overworked doctors and nurses at the KATH A&E. KATH is one of three university teaching hospitals in Ghana. Today, it is a 1200bed hospital facility, having begun life on this current site in 1952 as Kumasi General Hospital. It was renamed Komfo Anokye Hospital in honour of the 17th century powerful local magician and Ashanti priest Komfo Anokye, and his famous sword is still housed on the hospital premises. The hospital was granted teaching hospital
By the year 2020, it is forecast that vehicle ownership in Ghana will double.
Treatment of the victims of road traffic accidents currently accounts for almost 3% of the national GDP
status in 1975, when it was affiliated with the medical school of Kwame Nkrumah University of Science and Technology (KNUST). In 2009, the 200-bed Accident and Emergency Medicine Unit was built with the aid of government funding and opened in May of that year. The Accident and Emergency unit of KATH, located on the ground floor of the new hospital wing is the largest Accident and Emergency center in the West African region. It houses a 4-bed resuscitation room, major and minor cubicles, operating theatres, radiology rooms, a burns unit and an intensive care unit. There is a designated hospital helipad for emergency aeromedical transfers to and from KATH. The unit cares for between 50 to 95 new patients daily (35,000 per annum). The hospital admission rate from the Accident and Emergency unit approaches 80% partly due to the fact that minor injuries and illnesses are diverted to the KATH Polyclinic, an outpatient facility, also located on the grounds of the hospital. A full range of in-house specialists are available, from surgery to dental to oncology services. Emergency Medicine (EM) in Ghana is a young, emerging specialty. Postgraduate training is growing and is at a very exciting junction. With ongoing collaboration and mentorship from healthcare organizations and specialists in emergency medicine from around the world, Ghana is poised to take a leadership role in the development of EM across Africa. Mortality and morbidity relates mostly to trauma and sepsis. The main causes of death include HIV/AIDS, respiratory infections, malaria, diarrheal disease, tuberculosis and road traffic accidents. Barriers to effective healthcare provision are the same in Ghana as across the continent of Africa, namely, infectious diseases, ruralurban migration with consequent slum formation, natural and man-made disasters and the increase in frequency and severity of road traffic accidents. By the year 2020, it is forecast that vehicle ownership in Ghana will double. Treatment of the victims of road traffic accidents currently accounts for almost 3% of the national gross domestic product. Prehospital emergency medical care is in the early stages of development in Ghana and there is a need for standardization of service provision across the country. www.epijournal.com
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Additional challenges relate to the geographic diversity and limited infrastructure within and between regions of Ghana making patient transportation to higher levels of care a continued challenge. Dr George Oduro is the director of emergency medicine training in KATH and clinical head of the A&E department. Having left Ghana in the 1980s, he undertook specialist training in emergency medicine in the United Kingdom. He returned full time to Ghana in 2011 to take up his current post. He also holds an honorary staff position on the board of the University of Michigan Hospital in the United States. In 2009, the University of Michigan and KNUST joined forces to establish Ghana’s first emergency medicine post-graduate EM training program for physicians. Dr Oduro is responsible for 21 emergency medicine residents in training, which is the largest sub-Saharan EM residency training program outside of South Africa. The first six specialists graduated from this program in October 2012. The importance and influence of KATH on EM training in Africa was clearly visible by the number and quality of research posters from this unit at the inaugural African Conference on Emergency Medicine in Accra. In addition, the Ghanaian Society of Emergency Medicine (GEMS) was established in 2012. Dr Oduro delivered a keynote address at this conference regarding the current status and future of EM in Ghana. He accurately described the challenges that face EM systems in Ghana today. These include financial and economic constraints combined with a lack of governmental support for EM. The physician to population ratio is 0.9 doctors per 10,000 compared with Ghana’s closest neighbor, Nigeria, which
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boasts a total of 4.0 per 10,000 population. On occasion also, there is a barrier to intellectual information exchange in the form of limited access to internet, textbooks and journals. There are common misconceptions regarding emergency care in Ghana. In particular, all physicians, by definition, are assumed to be qualified to practice emergency medicine. In general, specialists focus on diagnoses rather than emergency presentations, processes of care and treatments, a problem that has its roots in medical school training in Ghana. In the hospital in KATH, there is perceived to be an institutional reluctance to invest long-term in EM. Start-up and fixed investment costs are expensive. Inertia is prevalent especially regarding the attitude to ongoing ED overcrowding. There is a general resistance to the concept that EM care is important for the entire population and especially for time sensitive conditions. Planning for the future of EM in Ghana is necessary to develop the specialty. Dr Oduro is keen to identify and address priority areas for training. It is necessary to train more specialist doctors in emergency medicine because they are ideally placed to carry out roles as leaders and educators and to form alliances with public health policy advocates. There are also plans to work closely with all levels of pre-hospital and hospital-based emergency care personnel and to institute community outreach training programs that will train future trainers to rapidly scale up capacity in emergency care practice. Dr. Oduro is keen to accept established care protocols for common conditions but also to tailor these guidelines to suit local resources and disease burdens. Also it will be necessary to design EDs that are locally
Spring 2014 // Emergency Physicians International
PHYSICIANTO-PATIENT RATIOS IN AFRICA
Ghana .9 : 10,000 Kenya 2 : 10,000 Nigeria 4 : 10,000 South Africa 8 : 10,000 Source: The World Bank
fit for purpose that will allow community participation. On a broader scale, Oduro will continue to work with international partners such as the University of Michigan and Global Emergency Care Skills. But there is also a need for national EM coordination in Ghana with increased collaboration. The use of telemedicine has not yet been explored in Ghana and this is an exciting opportunity for EM to make maximum use of online training resources and widen networks of emergency care to remote and deprived areas. Technology transfer and EM-specific medical education and research are vital to the ongoing development of the specialty. These new technologies have the potential to improve the collection, management, analysis, interpretation and dissemination of emergency care data. This will serve to address data gaps in the system and to ensure evidence-based decision making in Ghana. Reflections on our Journey to Ghana As I sat in the hotel lobby in Kumasi, early Wednesday morning in the middle of this lush countryside, watching CNN and listening to US President Barack Obama’s re-election speech, I thought about our journey to Ghana. This country reminds me of an adrenaline-fuelled, intensified version of life at home in Ireland. The colors are deep and intense from the red earth to the bright clothes of Ghanaian people. Smells, sounds and sights confuse and excite the limbic system. Inhabitants are open and honest, ambitious for the future yet realistic about the present. The heat of the sun is ever-present and governs the pace of everyday life. Typical Ghanaian food is spicy and filling, never dull or predictable to the Western palate. It is the wonderful combination of all these senses that make up the complete experience that is Ghanaian life.
IN THE FIELD
In Rwanda, Data Collection Project Fuels Innovation at the Point of Care
Rwandan fellowship project gives insight into the value for reliable data and the need for experienced local partners. by jonathan hills
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round the world, International Emergency Medicine (IEM) Fellowship programs provide unique opportunities for research and evaluation of emergency care systems. Last year, EP Craig Spencer, an IEM fellow from Columbia University in New York City, completed multiple projects in East Africa including a teaching curriculum and a patient monitoring program. The work gave Spencer an inside look at the importance of
gathering reliable data, and of working with knowledgeable local partners. A large part of Spencer’s work in Burundi was the routine care of sick patients, which was as eye-opening as it was frustrating. He was presented with a patient population where malnutrition caused daily complications and seemingly routine health concerns turned into emergencies because of a lack of supplies and follow-up. Spencer worked alongside NGO ‘Village Health Works’ (VHW) founded by another of Columbia’s 2013 IEM fellows, Dziwe Ntaba. The VHW clinic was one of the few places in South Burundi with access to oxygen. As a result it was often inundated with patents, forcing physicians to prioritise patient care. “Many clinics would send their patients with pneumonia or anaemia to the VHW clinic for oxygen. We only had a few canisters, so in the US five
patients would have been given oxygen, a facemask or even intubated or on life support. In Burundi you had to choose which two of the same five patients needed it most. “In one case we gave oxygen to a child with pneumonia over a woman who was very anaemic from malaria.” Spencer learned that in such difficult cases it was the experience of the Burundian and Congolese doctors that made all the difference. “The physicians in Burundi are some of the best I’ve ever come across, I couldn’t have triaged and treated patients as well,” he says. “I don’t think I would have had the same success in deciding who needed oxygen to survive and who didn’t. But they had experience. They’d seen it before.” While Spencer was able to introduce cutting edge empirical medical knowledge to many of his East African counterparts – in particular emergencies
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arising from long-term illnesses such as diabetes or stroke – he found that without adequate medical supplies, his impact was limited. “You can make a diagnosis but you can’t do much with it,” he says. Sometimes there was nothing to be done for stroke patients. “Sometimes even aspirin just weren’t available.”
Surveying on the Ground In addition to Spencer’s clinical work, he worked alongside renowned epidemiologist Les Roberts and VHW’s Ntaba to conduct an epidemiological fieldwork survey in South Burundi. He made a startling find which led him to an unorthodox conclusion. “It was a household survey,” he explains. “We went into 30 different geographical locations chosen proportional to size, but otherwise randomly selected.” After conducting epidemiology work in the eastern DRC, Roberts found that more children were dying from uvulectomy complications than from war-related conditions, so proposed including a similar assessment in South Burundi. “In addition to asking questions concerning mortality rate, we asked about uvulectomy. The practice is still active there but what we found was staggering – over 85% of children surveyed had had a voluntary, ‘therapeutic’ uvulectomy.” Furthermore patients who had undergone the procedure themselves were denying subjecting their children to the practice when questioned among procedural weight, vaccination and HIV discussions at VHW’s clinic discussions. “It was strange,” says Spencer. “People were willing to accept vaccinations and western care, they were unwilling to give
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up uvulectomy – a potentially dangerous and fatal procedure. They knew that they shouldn’t be doing it but they did it anyway.” Though he admits the idea isn’t an appealing one, Spencer tentatively questioned whether western medicine may be better being incrementally introduced in the region. “Would it make more sense for us to do uvulectomies in safe, sterile environments where people don’t have to pay? Would we be better off doing ‘A’ to get to ‘B’ rather than just heading to ‘B’ directly?” “Long term change is going to be dependent on outside institutions being pragmatic for on-the-ground solutions. Future IEM success will depend on community education, covering topics like domestic violence, uvulectomies and HIV. For example, a lot of people thought seizures were contagious or caused by a bad spirit.” Emphasising the importance of surveys and local knowledge, Spencer also learned to be sceptical about existing information and feedback from the local population. “During a birth survey in the DRC we asked women where they gave birth. They usually said a clinic or hospital as that is the law. The numbers didn’t seem to add up so we went to various clinics and asked to see birth registers, finding they were over-reported. So, we established an ongoing surveillance system for continuous data collection in addition to the one-off survey, using a local monitor from the community. Then we triangulated the data with model predictions to get more accurate, 3D picture.”
NGO Benchmarking Spencer believes it is not only patients who can give inaccurate information,
Spring 2014 // Emergency Physicians International
expressing concern about the potential implications of health NGOs and initiatives in IEM after his experiences in East Africa. “There needs to be a measure and proof that a program is working and serving the population, not only for financial donors. The financing problem is a real one, many organisations just demand statistics for performance-based financing and people can end up cooking the books, adding names and naming people that aren’t actually treated.” “Without someone on-the-ground who knows the area and its people collecting information, the likelihood that you are going to do more harm than good is pretty high.”
01 Survey training in Burundi 02 Intore war dance 03 Uvula assessment
CURIOUS CASES
A Strange Case of Nausea, Vomiting, And Dizziness
recalled a rare form of poisoning. The literature confirmed cyanide poisoning from bamboo. Galvanized into action, a call to the night pharmacist revealed that all Cyanide Antidote kits were expired and disposed. This led to an all department search for Vitamin B12. Normal antidote dose is 5 grams, but all we were able to muster is 117 mg, or 117 vials. While the IV infusion was being prepared a Cyanide level was drawn, time to result: two weeks. Following infusion, the result was near miraculous as weakness, and all other symptoms resolved, and the patient, like the rest of the family were smiling as the patient was transferred to the ICU. The following day a Cyanide Antidote Kit was air lifted from Puerto Rico to complete the therapy, and the patient was discharged after an uneventful clinical course two days later.
While working in the Virgin Islands I came across a case of apparent food poisoning that drove me back to the books for answers. by keith a. raymond, md
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t 2300, a middle aged patient that owned the local Chinese restaurant arrived with their extended family in the ED. The patient complained of nausea, dizziness, mild generalized non-pulsatile headache, vomiting, and weakness that began several hours after eating bamboo soup. The patient also reported minimal epigastric upset, but no diarrhea. They denied fever, chills, but had mild chest discomfort. The bamboo soup came from a bag found in the stockroom with a Chinese label only, and was composed primarily of water, bamboo and garlic. To this the patient added soy sauce to taste. No one else in the family had partaken of the soup, and all were asymptomatic. The patient’s spouse was very concerned and suspicious, providing the above history in broken English. Past Medical History was significant for Hypertension, and diet controlled Diabetes. Medications included Metoprolol 50 mg daily and Baby aspirin. On Physical exam, the patient was afebrile, mildly dehydrated with a pulse of 117, respiratory rate of 24, and a mildly elevated blood pressure of 142/92. The patient was a well-nourished, well developed and pale, non-English speaking only. HEENT was unremarkable. Neck supple, non-tender, no lymphadenopathy. Cardiac auscultation was tachycardic, and without murmur, rubs nor gallop. Lungs were clear. There was hyperactive bowel sounds with minimal epigastric tenderness, without rebound nor guarding and no organomegaly. The rest of the physical exam was non-contributory, except a reduction of deep tendon reflexes throughout to 1+. Blood sugar was 123 mg/dl, EKG was
DISCUSSION
REFERENCES 1. Nahrstedt, A., 1993: Cyanogenesis and foodplants.
DON’T TRY THIS AT HOME Unlike the carniverous panda, which survives on a diet that is 99% bamboo, humans can suffer from cyanide poisoning by injesting the cyanogenic glycosides in bamboo shoots.
Chapter 7 IN: Phytochemistry and Agriculture. 1993, 107-129; Proceedings of the Phytochemical Society of Europe vol. 34.
sinus tachycardia without ischemic change. CBC, Comprehensive metabolic panel, amylase, lipase, urinalysis, and cardiac markers were ordered, and all were essentially normal. The patient was treated initially as food poisoning with supportive measures including IV normal saline 2 liter bolus, Ondansetron 4 mg IV, Meclizine 25 mg by mouth, and observation. However, on the completion of therapy the patient had failed to improve and in fact was reporting greater weakness. By 0200, the hectic pace of a Friday night in the ED was slowing and it gave me a chance to ponder the case. An alarm bell began to ring distantly and in the back of my memory. This drove me to the literature. Having seen Vietnamese and Chinese patients during residency, I faintly
2. Borron SW, Baud FJ, Mégarbane B, Bismuth C. Hydroxocobalamin for severe acute cyanide poisoning by ingestion or inhalation. Am J Emerg Med. Jun 2007;25(5):551-8. 3. http://www.dartmouth.edu/~janl/ dartmouth.emt.b/ lectures/cyanide.pdf
Taxiphyllin, a cyanogenic glycoside, is the predominant glycoside found in bamboo, as well as certain African cassava species, bitter almonds, and another two thousand plant species.(1) During hepatic hydrolysis by glucosidase, taxiphyllin releases hydrogen cyanide and aldehyde into the blood stream. The antidote Hydroxocobolamin (Vitamin B12) combines with cyanide to form cyanocobolamin which is renally excreted. (2) The Cyanide Antidote Kit contains amyl nitrite pearls, sodium nitrite, and sodium thiosulfate. Amyl and sodium nitrites induce methemoglobin in red blood cells, which combines with cyanide, thus releasing cytochrome oxidase enzyme. Inhaling crushed amyl nitrite pearls is a temporizing measure before IV administration of sodium nitrite. Sodium thiosulfate enhances the conversion of cyanide to thiocyanate, which is renally excreted. Thiosulfate has a somewhat delayed effect and thus is typically used with sodium nitrite for faster antidote action. (3) Both Hydroxocobolamin and the Cyanide Antidote Kit are recognized by the FDA for treatment of cyanide or suspected cyanide poisoning. This case illustrates an important but rarely considered cause for cyanide poisoning.
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journal // africa
The Best of AfJEM by Steven Bruijns, MD A review of recent research from the African Journal of Emergency Medicine
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Ambulance or taxi? High acuity prehospital transports in the Ashanti region of Ghana by Mould-Millman, et al. is an observational study analysing the mode of, and illness/injury severity of patients arriving at a Ghanaian emergency centre (EC). The study included all consenting attendees to the EC for a month in July/August 2011 and excluded those that were unable to be consented, did not speak English, Twi or Fante, had an altered level of consciousness or required resuscitation on arrival. The main gist of the study is described in Table 1. Essentially the majority of patients, regardless of illness or injury severity, tend to make their own way to hospital making use of public transport or a private vehicle (76.6%). Ambulance transported patients did tend to be sicker - odds ratio of 1.5 (95% confidence intervals 1.0-2.3) - although this is hardly reassuring given that only 15% of patients were ambulance transported, with the majority of high acuity patient making their way through other means. The authors quote five barriers to ambulance use which include: lack of availability, poor accessibility, non-affordability, inadequacy and poor acceptance of ambulances. They correctly point out that further research is needed to specifically look at which of these barriers contributed to their findings. One wonders how many never made it to the EC. On the upside, the Ghanaian government did introduce paramedics to the national ambulance service a few years ago to complement the existing basic life support crews. As with any new service, especially an inexperienced one that delivers a national service in a resource challenging environment, it would take time to develop to its full potential. When this study is repeated in another decade, it’ll most likely tell a whole different story.
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Descriptive study of an emergency centre in Western Kenya: Challenges and opportunities by House, et al. is an observational cohort study describing the demographics of attendance at a single Kenyan EC during 2011. The authors utilised attendance and admission records as a data source and only patients with insufficient record keeping were excluded. Data were anonymised to protect patient identity and consent was not individually sought. Almost half of attendees were between the ages of 15 and 30 (47%) with a mean age of 36 years. Interestingly daily attendance variation appeared pretty similar to what would be expected in Western ECs suggesting a universal diurnal cycle. The majority of patients attended during the day with a steep peak around midday, a plateau till around 1800, which then tapered off slowly towards the morning hours (Figure 1). The top ten findings for chief com-
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Spring 2014 // Emergency Physicians International
Table 1: Main findings from ‘Ambulance or taxi?’ High acuity prehospital transports in the Ashanti region of Ghana paper (excluding missing data).
Triage
Arrived by ambulance (n/%)
Total (n/%)
Green
0
3
Yellow
81 / 55%
637 / 65%
Orange
49 / 34%
276 / 28%
Red
16 / 11%
67 / 7%
Total
146
983
Fig. 1: Daily attendance and admissions. Reproduced from House DR, et al. AfJEM 2014;4(1):19-24)
10
Patients Seen
8
Percent (%)
I
n terms of acute care, Africa remains the dark horse of international emergency medicine. Its reputation as the continent with some of the world’s highest injury and acute illness mortality figures is starkly contrasted by its almost non-existent acute care infrastructure, low staffing and lack of equipment. Not surprisingly, very few publications come out of this continent and those that do mainly report on its failures rather than successes. Of course this is not all bad, as understanding the problems allows us to lay the foundation for improvements. This was the theme of the most recent issue of the African Journal on Emergency Medicine (volume 4, issue 1). The following are highlights from three of the most accessed original research papers in this issue.
Admissions 6 4 2 0
0.00
06:00
12:00
18:00
24:00
Time plaints, EC and admission diagnoses could however not be more different (Table 2). In addition to more commonly seen diagnoses in Western ECs, early pregnancy complaints, organophosphate poisoning and psychosis’ ranking suggests regional inadequacies in public health priorities. Furthermore HIV does not feature on any of the top ten lists, a fact which is in keeping with reports that Sub-Saharan Africa has at least achieved control of the epidemic. It is noteworthy that patients pay around a day’s wage to be attended to at this public sector EC. This is beyond a doubt a barrier to acute care access. The authors rightfully point out that there are many challenges faced within a resource limited acute care setting and their paper goes a long way to expose some of these.
3
Assessment of knowledge and skills of triage amongst nurses working in the emergency centres in Dar es Salaam, Tanzania by Aloyce, et al. evaluates the triage skills of 66 EC nurses in four different ECs in Dar es Salaam, a city of 1.36 million. There were three parts to the study; the first evaluated nurses’ knowledge of triage, the second concerned the ECs triage service and the third the equipment available to triage. The majority of nurses (78%) had no acute care training beyond their basic training and most were only
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YOUR PATIENTS ARE ON THE CUTTING EDGE...ARE YOU?
HIV does not feature on any of the top ten lists, a fact whichis in keeping with reports that Sub-Saharan Africa has at least achieved control of the epidemic.
Table 2 Main findings from Descriptive study of an emergency centre in Western Kenya: Challenges and opportunities paper
Chief Complaints
EC Diagnoses
Admission Diagnoses
Road traffic accidents
Soft tissue injury
Incomplete abortion
Vaginal bleeding
Incomplete abortion
Pneumonia
Altered mental status
Acute psychosis
Head injury
Abdominal pain
Pneumonia
Acute psychosis
Difficulty breathing
Head injury
Gastritis
Assault
Gastritis
Femur fracture
Headache
Organophosphate poisoning
Meningitis
Vomiting
Cerebrovascular accident
Organophosphate poisoning
Fever
Femur fracture
Cerebrovascular accident
Poisoning
Pulmonary tuberculosis
Soft tissue injury
recent graduates (47% graduated in the last year). Triage was not addressed or minimally addressed in in-service training which only half of nurses had attended. Not surprisingly, only 48% of nurses were able to triage scenario-based cases to the correct priority. Only one EC had a dedicated triage service. The other units essentially divided patients into ambulatory and non-ambulatory streams (the latter which was afforded a higher priority). Vital signs were performed as far as mechanical devices allowed (a brief history, respiratory rate and pain assessment were omitted by most). The ED with a dedicated triage service was also the one with the most appropriate equipment available. Whilst I appreciate that most Western ECs are currently moving away from using triage (due to better staffing levels, lower acuity and the introduction of rapid assessment services) a comparison with an under-resourced African EC couldn’t be more different. Long waiting times due a predominantly junior work force, understaffing and lack of appropriate training, in addition to high volumes, high acuity pathology as well as the lack of an efficient prehospital service should be enough to motivate the role of triage as a basic acute care skill in any
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journal // global
Global Research Review by Torben K. Becker, MD on behalf of the Global Emergency Medicine Literature Review Group
CHINA_Developing injury prevention strategies for developing countries requires knowledge that urban and rural areas have distinct injury patterns.
GHANA_A new decision tree for the diagnosis of P. Falciparum
Liu Q, Zhang L, Li J, Zuo D, Kong D, Shen X, Guo Y, and Zhang Q. The gap in injury mortality rates between urban and rural residents of Hubei province, China. BMC Public Health 2012; 12:180-190.
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uilding on previous studies that exposed rural-urban injury disparities but were limited by detailed (gender, age and injury category) demographic data collection, the current study uses data from the Hubei Province Disease Surveillance (DSP) system to demonstrate not only clear urban-rural injury mortality rate disparities but also differences in injury type, age and gender. The DSP collected detailed demographic and injury mortality data from a representative sample of the population (approximately 6 million people) from government-designated rural and urban areas using a multi-stage cluster probability sampling. Health officials checked district (urban) or municipal (rural) reported deaths daily and deaths that occurred at home were corroborated with a standardized verbal autopsy or clinical evidence. For hospital deaths, health officials verified death certificate details. These officials entered cause of death in to the database weekly, and coded cause of death based on the International Classification of Disease-10th Revision (ICD-10). The study calculated crude and adjusted injury mortality rates and 95% confidence intervals; the Chi-square or Fischerâ&#x20AC;&#x2122;s exact test examined rural-urban differences with a significance of p<0.01. Injury death rates for both sexes were approximately two-fold higher in rural than urban areas with crude and adjusted rates reaching significance. Overall, age-adjusted death rates for males and females, suicide, traffic-related injuries, drowning and crush injuries were significantly higher in rural areas. Furthermore, the rural residents >55years had an injury death rate three times their urban counterparts and those >65years had higher injury death rates for suicide, traffic-related injuries and drowning. Death rates for falls, poisoning, and suffocation did not differ between urban and rural residents. This study confirms the results of previous studies that found higher injury mortality rates in rural compared to urban areas in developing and developed countries. The striking differences in injury death rates from suicide in the rural elderly versus urban elderly population, and the traffic-related injury mortality rate in rural compared to urban residents are important findings of this study. Increased risk taking behaviors, access to pesticides, decreased social welfare in rural areas, and a large urban-rural income gap are proposed by the authors as possible reasons for these disparities. This study is limited by unreported death rate of 15% and 13% in rural and urban areas respectively, possible misclassification of deaths (specifically in the area of falls), and sparse demographic data (past medical history, occupational history or socio-economic data). However, the results from this study have important implications for injury prevention policy in China. -KP, TB
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Vinnemeier CD, Schwarz NG, Sarpong N, et al. Predictive value of fever and palmar pallor for P. falciparum parasitaemia in children from an endemic area. PLoS One. 2012;7(5):e36678.
his article aimed to create a clinical decision algorithm for the diagnosis of P. falciparum malaria in endemic areas. The study evaluated all children between 2-60 months of age who attended an outpatient department in Ghana. They obtained data regarding over 30 clinical symptoms, a blood count, and a thick smear. A Classification and Regression Tree (CART) model was created to create a decision tree that could be utilized to predict malaria. Palmar pallor was the most indicative with an Odds Radio (OR) of 3.06 in children, while body temperature had an OR of 2.82 and reported fever had an OR of 4.62. Two CART models were created for children 2-12months and older children including these variables among others. The CART model in younger children had a high sensitivity (97.2%), but a low specificity (22.2%) compared to the current Integrated Management of Infectious Disease (IMCI) guidelines with sensitivity and specificities of 6.7% and 99.6% respectively. In the older population, the CART model was 37.7% sensitive and 91.4% specific, compared to the editors IMCI-model with 55.6% and 73.4%. The CART-model had KP: Kimberly Pringle, MD higher specificities and positive TB: Torben K. Becker, MD predictive values, while the IMPM: Payal Modi, MD CI-model had higher sensitivities and negative predictive values. MF: Mark Foran, MD, MPH The main strength of the study includes the large number of variables analyzed in the preliminary analysis to help create the CART model. Additionally, the gold standard of malaria smears in all patients provided an objective measure of parasitemia. The large sample size, prospective analysis, and statistical analysis all increased the validity of the study. However, limitations include the CART model which is inherently a controversial tool and the use of subjective clinical indicators which might be biased by the providers recording the data. Nonetheless, this study further validates the IMCI guidelines and highlights the importance of clinical signs such as palmar pallor which tested well on univariate analysis. -PM, MF
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// pan-asia
Pan-Asian Network Promotes Regional Cardiac Arrest Research The PAROS collaborative research group has collected invaluable data on regional emergency medicine trends and is publishing literature that will lay the groundwork for the future of Asian emergency medicine.
by drs. marcus ong eng hock, pek pin pin & munawar alhoda
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he PAROS CRN is a collaborative research group that was formed in 2010 by dedicated Pre-hospital and Emergency Care (PEC) providers conducting PEC research in the Asia-Pacific region. The network now represents a population base of more than 89 million in 11 countries, including Japan, Korea, Taiwan, Thailand, Dubai, Singapore, Malaysia, Indonesia, China, Qatar and Pakistan. The large size and international nature of the network provides a unique opportunity for analysis of the preventable risk factors and systemic predictors of survival for Out of Hospital Cardiac Arrest (OHCA). The network has published close to 20 articles in peer-reviewed journals since its establishment in 2010. The database that the group has been working on in the past 3 years has grown to include over 60,000 cardiac arrest cases. For 2013, the focus of the network was to develop and implement a Dispatcher-Assisted cardiopulmonary resuscitation (DA-CPR) program. An implementation package consisting of a DACPR protocol, training program and quality improvement toolkit are currently being developed in collaboration with the Save Hearts in Arizona Registry & Education (SHARE; Arizona, USA).
OHCA is a Global Disease OHCA is a global health concern. The incidence of OHCA is estimated at between 50 to 60 per 100,000 person-years globally1. Early initiation of treatment has an important effect on outcomes and survival2. In the Asia-Pacific region, the incidence of OHCA has been rising, due to the advent of lifestyle diseases, increasing and progressively aging population. Survival rates from OHCA are generally low (2-11%)3 and significantly below the best survival rate of 16.3% reported for Seattle, USA1.
We believe that establishing a resuscitation outcomes network in the Asia Pacific will give valuable information regarding OHCA in Asia Pacific countries, and will help to develop an understanding of the variations among different emergency medical systems in the Asia Pacific. Such a network can provide a platform to support and stimulate research into the most effective strategies to improve survival from sudden cardiac arrest and other prehospital emergency conditions. It can also inform the healthcare community/ policy makers on the relative importance of modifiable factors that can affect OHCA survival outcomes (e.g. increasing bystander CPR rate, investing in public access defibrillation, etc.).
Overview of PAROS The PAROS CRN promotes collaboration by bringing together like-minded individuals to share experiences and develop joint initiatives for the betterment of PEC. Similar research groups such as the Resuscitation Outcomes Consortium (ROC) and the European Registry of Cardiac Arrest (EuReCA) exist in the USA and Europe. Currently, research into PEC in the Asia-Pacific region is largely inadequate and poorly coordinated owing to the marked variations in Emergency Medical Services (EMS) systems and outcomes reporting. With OHCA being one of the leading causes of death worldwide, the dearth in the understanding of trends and research in PEC underscores the urgent need for more collaboration and highquality intervention. PAROS CRN is unique in its ability to reach out to countries across the Asia-Pacific region, allowing the network to adopt a multi-pronged strategy that targets key stakeholders such as the community, EMS and hospitals. By offering practical ways of monitoring and meaningful measurement of PEC outcomes, PAROS CRN has an enormous
potential to contribute significantly to PEC research, regardless of whether they are epidemiological studies or clinical trials. PAROS CRN has a Trial Coordinating Centre based in Singapore which is managed by the Singapore Clinical Research Institute (SCRI). The mission of the PAROS clinical network is to “improve outcomes from Pre-hospital and Emergency Care across the Asia-Pacific region by promoting high quality research into resuscitation”. PAROS CRN endeavors to answer important questions for the development and revisions of Pre-hospital and Emergency Care (PEC) policies. It will also help to further develop the necessary research infrastructure and strengthen the Emergency Medical Services (EMS) treatment capability in the region. Set to be the driving force for PEC research and development in the Asia-Pacific region, PAROS will act as a networking hub and as a contact point for interested research partners. PAROS CRN has forged ties with CARES in the USA, and is also affiliated with the Asian EMS Council and the Asian Relations Ad Hoc Committee of the National Association of EMS Physicians (NAEMSP).
PAROS Events In the past years, the PAROS network has organised meetings in countries such as Dubai, Taiwan, Malaysia and Thailand. In April 2013, the network in collaboration with Society for Emergency Medicine Singapore, Asian EMS Council, and Toxicology Society (Singapore) organised the EMS Asia 2013 in Singapore. PAROS CRN encourages like-minded researchers with interest in resuscitation and prehospital care to participate in PAROS meetings and also welcomes opportunities to collaborate on research studies or explore new strategies/ platforms to improve survival outcomes from diseases such as OHCA. REFERENCES 1. Nichol G, Thomas E, Callaway CW, et al. Regional variation in out-of-hospital cardiac arrest incidence and outcome. Jama. Sep 24 2008;300(12):1423-1431. 2. Cummins RO, Ornato JP, Thies WH, Pepe PE. Improving survival from sudden cardiac arrest: the “chain of survival” concept. A statement for health professionals from the Advanced Cardiac Life Support Subcommittee and the Emergency Cardiac Care Committee, American Heart Association. Circulation. May 1991;83(5):1832-1847. 3. Stiell I, Ong M, Nesbitt L, Jaffey J. Predictors of Survival for Out-of-Hospital Chest Pain Patients in the OPALS Study. Academic Emergency Medicine. 2004;11(5):586.
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// typhoon haiyan
RING OF FIRE The Philippines is an archipelago of 7,107 islands located in the Pacific Ring of Fire. Its geography makes it especially vulnerable to annual earthquakes (about 900), typhoons (about 20, with half making landfall), and active volcanoes. In 2012, Typhoon Bopha was the single deadliest disaster worldwide that killed 1,901 people in the Philippines. In October 2013, a 7.2 magnitude earthquake shook the Visayas islands leaving about 200 dead and tens of thousands of people displaced. Less than a month later, another natural disaster was to bring even more damage. On November 8, 2013 Super Typhoon Haiyan (locally known as Yolanda), a Category 5 superstorm and the strongest in recorded history, made landfall in several regions of the country destroying about 70-80% percent of the areas hit, affecting more than 16 million people and killing more than 6,000 people. More than 28,000 were injured and about 4.1 million people were displaced. The immediate impact of Haiyan led to a Category 3 Disaster classification by the WHO, in the same group with the 2004 Indian Ocean Tsunami and the 2010 Haiti earthquake. Amidst the local and national governmentsâ&#x20AC;&#x2122; conflicting and uncoordinated response, and foreign aid groups bypassing the local governments and going directly to the survivors, there were also individuals who spontaneously organized relief goods and personally went to the worst hit areas. There were several forms of volunteers of physiciansâ&#x20AC;&#x201D;from selforganizing to joining an established aid group. These are their stories.
-maria sannoy-cadiz, md
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How empowered community health workers formed the backbone of disaster relief.
Two local physicians give an on-theground afteraction report.
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Community Health Workers prove the Key to Philippines Relief Efforts After Typhoon Haiyan, relief poured in from around the world. But it was the ongoing work of Barangay Health Workers that made recovery sustainable.
by kevin k.c. hung and satoko otsu
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hilippines is one of the most disaster prone countries in the world [1]. In 2012, according to the International Disaster Database EMDAT from Centre for Research on the Epidemiology of Disasters (CRED), Philippines ranked third by the number of reported disasters. The highest death toll for a single event from a natural disaster in 2012 was also in Philippines caused by tropical cyclone Bopha in December, resulted in 1,901 deaths in total [1]. Typhoons frequently affect the Philippines, however most of the typhoons were responded to locally, rarely requiring external assistance or support. However on November 8th 2013, Philippines was hit by a category 5 hurricane Typhoon Haiyan (local name: Yolanda), and 18 million people were affected [2]. This came after a series of crisis events including the civil unrest in Zamboanga and a 7.1 magnitude earthquake in Bohol. International re-
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lief teams including the International Federation of Red Cross (IFRC) responded soon after the disaster to support the basic needs for the affected population. The Japanese Red Cross Society (JRCS) Basic Health Care Emergency Responses Unit (BHC ERU) was one of the teams deployed to the affected areas on request of the International Federation of Red Cross and Red Crescent (IFRC). Health professionals from other National Societies joined the ERU team including Philippine Red Cross, Hong Kong Red Cross, Australian Red Cross and French Red Cross. The ERU team arrived in Cebu city on the 16th of November and performed rapid assessments on the following day at Daanbantayan district at the northern tip of Cebu island. Total population in Daanbantayan is about 86000 (22000 households) with 20 local government units (LGUs: Local name: barangays) in total. More than 90% of houses were damaged totally or partially. Water and sanitation was a concern as most of latrines in vil-
Spring 2014 // Emergency Physicians International
lages are destroyed and many villagers now practice open defecation. Water source was from deep well or spring, but without electricity supply many water pumps were not functioning. Regarding health, there was one district hospital with only one doctor on duty and two Rural Health Units (RHU) with either a doctor or a nurse. Some community health centers were also damaged and closed due to this disaster. The RHU at barangay Maya was severely damaged and there was no doctor available. Our team opened a fixed clinic at Maya to support the damaged and understaffed RHU, and at the same time to operate a mobile clinic to provide support to other barangays on 20th November. Following the rapid assessment, our team strongly felt that providing preventive support was critical in the affected area as well as ensuring the access to essential healthcare. Therefore, from the beginning of our operation, we emphasized a two pillar approach â&#x20AC;&#x201C; clinical care and community based health support. With the contribution from the team including the community health delegate and psychosocial health delegate, we initiated community based health care support in the mobile clinic and later on in the Maya fixed clinic. The vital role of the community health workers in emergencies was highlighted in the joint statement published by the Global Health Workforce Alliance, IFRC, UNHCR, UNICEF and WHO [3]. The joint statement highlighted the importance of community based actions, the contribution of the community health workforce, and the significance of better preparedness for emergencies. Our team worked closely with community health workers and midwives in the barangays, and therefore understanding their role and function in the health system was one of the initial priorities of the ERU team. Community health workers are called barangay health workers (BHWs) in the Philippines and are the designated persons in the community to assist the midwife in providing health services. In Northern Cebu, each of the barangays had around 10 BHWs, each responsible for their respective subunits called sitios of around 100 households. The BHWs usually come from the same sitios and have excellent knowledge and relations in the neighborhood. In some barangays, the younger BHWs will partner with the more experienced ones to work in the same sitios so that training and support can be provided. The midwife also has the responsibility to provide direct supervision for the BHWs, and this forms an excellent network and system not only to disseminate essential health information but also to collect health information. Based on the results of the assessment and the public health risks post typhoons [4], a comprehensive approach in community health training and emergency support was used to control the po-
01 Volunteers
and children participating in the dental hygiene campaign 02 Dental hygiene
campaign for children at Maya ERU clinic 03 A barangay health
worker with a health message post typhoon 02
04 Training for
midwives on psychosocial support for typhoon survivors
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tential exacerbation of communicable diseases. The support was provided to different tiers of the community health structure including the midwives, the BHWs and also directly to the communities including the vulnerable groups. Our team focused initially on community management of communicable diseases, providing knowledge to the prevention activities that were being carried out including a mass vaccination campaign. This was important to increase the confidence and morale of BHWs to perform prevention and promotional tasks. Our team met with midwives from all barangays regularly every week to share health knowledge. Workshops and scenarios for psychosocial support for survivors was conducted, and the management of chronic diseases discussed in meetings. Overall, the trainings and support were very well received and the health workers valued the opportunity to learn about the key interventions and to discuss REFERENCES 1. Guha-Sapir D, Hoyois P, Below R (2013) Annual Disaster Statistical Review 2012. Available at: http://cred. be/sites/default/files/ADSR_2012.pdf Accessed 14 January 2014 2. World Health Organization (2013) Public health risk assessment and interventions: Typhoon Haiyan, Philippines. Available at: http://www.wpro. who.int/philippines/typhoon_haiyan/
the challenges of the program implementation. It was observed that the interest and awareness of the community interventions were raised, and the confidence of the health workers were also increased. Whilst the risk of disease outbreak and public health concerns was significant, there were a number of challenges for the community health programs and also for our ERU team to support, especially with the competing priorities for the tasks for BHWs. It was observed that the BHWs were assigned multiple tasks after the typhoon, with some that were non health related. They had to support relief teams to provide logistical and administrative support, assist with relief material distribution, collect household information on shelter and damages and many other tasks. While the BHWs proved to be valuable for the community and provided an effective means for relief distribution and administrative tasks, by over-utilizing them, communities were robbed of valuable healthcare recourses. Secondly, the roles of BHWs in disasters were poorly defined, and they were often not adequately equipped to perform necessary tasks. Individual BHWs shared their experience that during the typhoon when they were faced with injured victims, they did not know how to help and they were frustrated and felt ashamed. According to Epidemic Control for Volunteers, in emergency situations it was suggested that community health workers have
media/Philippines_typhoon_haiyan_ ph_risk_assessment_16Nov2013_FINAL.pdf Accessed 14 January 2014 3. Global Health Workforce Alliance, WHO, IFRC, UNICEF, UNHCR (2011) Scaling-up the Community-Based Health Workforce for Emergencies: Joint Statement by the Global Health Workforce Alliance, WHO, IFRC, UNICEF, UNHCR. Available at http:// www.who.int/workforcealliance/ knowledge/publications/alliance/
three major groups of actions including health promotion, prevention activities and case management and referral [5]. Preparedness for these health workers can be much improved given adequate training and resources for future disasters. The long-term commitment and the effort of BHWs in Daanbantayan was commendable. They provided invaluable assistance in ensuring the health of the affected population, and their resilience and capabilities to support the recovery is the best proof for the vital role played by community health workers in emergencies, and the need to reinforce the community health workforce. The Global Disaster Preparedness Center shed light into preparedness issues in Typhoon Haiyan recovery [6]. In summary, the JRCS BHC ERU team successfully provided support and increased the capacity of community health workers under a very limited time period in the emergency phase. The importance of working in close collaboration with and building resilience for community health workers in emergency cannot be over emphasized. Even though circumstances in individual disasters will never be the same, the best model for collaborating with community health workers in emergency health relief should be carefully considered in future disasters.
jointstatement_chwemergency_ en.pdf Accessed 14 January 2014 4. The Assessment Capacities Project (ACAPS) (2011) Disaster Summary Sheet: Tropical Cyclones. Available at http://www.acaps.org/ resourcescats/downloader/disaster_summary_sheet_tropical_cyclones/52 Access 19 January 2014 5. International Federation of the Red Cross and Red Crescent Societies
(2008) Epidemic control for volunteers: A training manual. Available at http://www.ifrc.org/Global/Publications/Health/epidemic-control-en.pdf Accessed 14 January 2014 6. Global Disaster Preparedness Center. Preparedness issues in Philippines Typhoon Haiyan recovery. Available at http://preparecenter. org/topics/preparedness-issuesphilippines-typhoon-haiyan-recovery Accessed 19 January 2014.
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EPI: Did you have any doubts when you made the decision to volunteer and organize your team? DR. CUA: “None. I started calling DOH (Department of Health) and the (Philippine) Red Cross to ask for volunteer opportunities starting on the 2nd day after typhoon Yolanda”. DR. ALCIDO: “There was no doubt as to the team’s safety or whether the team goes or not. There was a pressing need to go on the ground but it was just a matter of when and where. People were more than willing to volunteer, but they need to be informed beforehand as to the dates involved and as to what they need to prepare.” EPI: Were there any the barriers or hindrances while preparing for and during the actual mission?
After Action Report: Local Physicians Give First-Hand Findings
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The devistation left in the wake of Typhoon Haiyan was unprecedented. To get a sense for how successful healthcare relief efforts fared on the ground, EPI sat down with two physicians from the initial wave. Dr. Evangeline “Banggi” C. Cua is a general surgeon from Iloilo, Philippines and Dr. Ma. Rowena Alcido worked as a general practitioner in a remote municipality in Samar Island.
interview by maria salud loreen sannoy-cadiz, md EPI: What were your first thoughts or feelings upon hearing about the storm’s devastation? DR. CUA: “I feared for the safety of my siblings and relatives who were residents of Tacloban. My mother decided to go there and look for my siblings when we didn’t hear from them a day after Typhoon Yolanda. Imagine my 65-year old mother walking alone from San Juanico Bridge to my aunt’s place, which was about 16 kilometers away! I was crying the whole time because my brother’s last message was he was on duty in an evacuation center (he’s a policeman) then I heard in the news that all the evacuees in an evacuation center drowned during the typhoon surge. I never felt so helpless in my whole life. When I talked with my mother, after 3 days of not hearing anything from them about the
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devastation, and that they were all okay, I decided to go there and do something. My sister initially asked me to abort my plans of volunteering in Tacloban because of security issues but I felt guilty. I mean, how could I go on with my life when I know that people are suffering and I could actually do something to help and not go there? I thought, at that time, that it’s our moral obligation as a human being to extend help.” DR. ALCIDO: “A chill ran down my spine. This was a major disaster and it happened in a place very familiar to me, where I spent growing up and where I chose to serve as a remote area physician. I knew I just couldn’t stay glued to the TV watching how slow [the] relief efforts were. There was a pull to be on the ground.”
Spring 2014 // Emergency Physicians International
DR. CUA: “There was total lack of coordination among organizations involved in the relief and rescue missions. I called Red Cross and they were asking me to submit a CV, updated Professional License ID and my board certificate! I was asked to call a certain number only to be told that they’ll call me at a later time. I emailed someone from PRC and they just told me to be in Tacloban and bring my own resources. The DOH central office also did the same. I was referred back to the provincial DOH but I was so angry I didn’t bother to call again. When I was arranging for transportation, the AFP personnel in charge of the C130 plane manifesto in Cebu could not give me assurance that my team could get a ride on the plane even if I told them that we are a medical team. We were given the round about between Cebu and Villamor Airbase. I only had 4 volunteers at this time because almost all the people I’ve asked to go with me were afraid of the security issues in Tacloban at that time and they thought it was too dangerous for a medical mission. Three doctors who initially volunteered backed out at the last minute. I had to promise one volunteer that I’d pay for her fare so she would go with the team. I only had one day of preparation for the mission - from collecting funds to buying medicines and picking up donated medical supplies from donors’ homes. We had limited medical supplies. Airlines who were supposed to give free cargo allowance containing medical teams asked us to pay enormous amounts for our cargo. We ran out of supplies while in Tacloban because half of our supplies got lost in Cebu during transit. The [government] red tape was worse. One retired AFP [military] general asked us to pay for “consultancy fee” for arranging our inclusion in the list of people who could ride the C130 plane and this was not an AFP plane, but for a Sweden C130 plane.”
01 Dr Banggi Cua (in blue scrubs) directs
her team of volunteers with distribution of medical supplies in Tacloban City. 02 Dr Alcido (2nd from left) and her fellow
physician-volunteers who joined a local NGO-Agape Rural Program to serve the remote and less-known affected areas. 03 With no electric power, Tacloban
survivors assist the Team Banggi volunteers with flashlights to continue giving medical treatment into the night.
02
DR. ALCIDO: “Contact on the ground was difficult to establish especially in Samar areas so we skipped that area. Then transportation problems ensued, the contact we had with the C-130 plane bailed us out on the day of the trip [sic]. We anticipated this by psyching ourselves into spending for plane fares even before our slot was cancelled. Then there was the issue of how much cargo we could carry on board or whether we should transport the supplies ahead. There was also the challenge of how much food and water we could carry with us. Eventually we arrived in Ormoc and all our challenges were put to rest when our host contact on the ground took care of our food & lodgings. We had a roof, beds (we stayed at the hospital ICU), electricity from the hospital standby generator and a bathroom. “ EPI: What about the foreign aid organizations? International media reports said they bypassed the local government and went directly to the people? DR. CUA: Some of the foreign aid went directly to the people because the organizations that brought them were the ones who distributed the goods. Those that were directed to the local government didn’t reach the people. We were able to enter one of their warehouses while we were looking for our missing supplies; there was so much waste [translated]. Mineral water bottles were on the floor while people outside the streets were asking strangers to give them water. EPI: Where did you first set up? How did you choose the location? DR. CUA: “Outside the Redemptorist church in Tacloban City. We were given 5 tables and a tarpaulin. A Redemptorist priest asked me to consider having the mission in their church in Tacloban where they had 2,000 refugees. “
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DR. ALCIDO: “The team that went to Ormoc was composed of remote area physicians previously affiliated with the Doctor to the Barrios program of the Department of Health (DOH). Through our tie-up with Agape Rural Program, we did a 5-day mission covering a private Ormoc hospital, and some towns of Isabel, Tacloban and Basey. After that, half of the team worked with an international humanitarian NGO (MSF-Holland) which provided medical and psychosocial services extensively in the towns of Leyte.” EPI: Were there other individuals or groups that helped you and the team? DR. CUA: “Mostly, my Facebook friends who were able to read my post(s). One friend introduced me to his photographer friends in Thailand and Japan who, in turn, sent money. The Redemptorist community who provided our food and ac-
commodation while we were in Tacloban.” EPI: What other social media besides Facebook helped? Twitter? DR. CUA: Just Facebook, I didn’t tweet at that time. I think most Filipinos use Facebook more because I saw some of my posts would be shared sometimes 300-500 times. EPI: How did the mission trips affect your regular or daily responsibilities and those of your team members? DR. CUA: “I took a leave from work. I had to arrange the follow-up consult and elective surgery of my private patients to fall on dates that I am in Iloilo.” DR. ALCIDO: “Half of the team committed www.epijournal.com
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to a 5-day mission and went back to their usual business after the mission. The other half stayed in Ormoc to work for the international humanitarian relief group that was in need of doctors for 6 weeks.” EPI: What were the common conditions that you saw during the missions? DR. CUA: “(On our) first mission (5-9 days after Yolanda)—mostly infected wounds. For the second mission (2 weeks after Yolanda)—respiratory and GI infections. On the third mission (6 weeks after Yolanda)—skin lesions (fungal), upper respiratory tract infections (URTIs)”. DR. ALCIDO: “URTIs, wounds suturing, skin diseases-scabies, impetigo and fungal infections, hypertension, acute watery diarrhea, a few bloody diarrhea, chronic malnutrition, parasitic worms, otitis media/externa.” EPI: How consistent has the support been for your missions? DR. CUA: Donations from friends and strangers (continue to come in). DR. ALCIDO: We always had the help of our partner NGOs for the supplies and transportation. EPI: What factors (besides social media and contacts) have also helped your team? DR. CUA: “(The) willingness of the members to go to remote places. There were 9 members for our first mission (only 3 are MDs, one chef, 1 law student,1 PT,1 nurse , 1 midwife and 1 social worker). The subsequent missions were composed of almost the same group of people- mostly MDs and nurses. We have scheduled medical missions until May 2014.” DR. ALCIDO: “We have been fortunate to work with NGOs with a good track record and extensive experience in doing disaster work.” EPI: Who pays for the team’s travel and other expenses during the trips? DR. CUA: The arrangement is for first time members [who] pay a one-way fare. The rest of the expenses are shouldered by the team. After that, everything is free. I have to consider, too, that they will not have their usual income or salary if they are with us during missions.
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EPI: From the beginning of the recovery effort, how have your responsibilities evolved? Was it all medical/surgical? DR. CUA: During the first mission, I was doing everything - supervision, marketing, accounting, etc., on top of medical consults- from general medicine to surgery. There were only three MDs in the team. Now I mostly supervise. (Later) I was able to recruit my med school classmate, an ophthalmologist, to the team. Beginning in March we will include cataract surgeries. EPI: So the responsibilities have evolved beyond the disaster-related problems? DR. CUA: Yes, and we will also include places outside those affected by Typhoon Haiyan. We have one mission scheduled in April in Banaue (Northern Luzon). EPI: What are your final thoughts on the overall disaster response? DR. CUA: I’d like to see a better system during disasters. Better coordination between departments involved in the relief and rescue is needed as well as more involvement from the private sector. Perhaps they could enlist MDs for mandatory service during disasters as they do in the army. DR. ALCIDO: We had almost everything: the basic medications, emergency drugs, access to emergency transport, emergency/transport assistance, referral center for acute, life threatening/ emergency cases, a water-sanitation team for access to potable water, and a psychosocial team for the mentally distressed. We covered areas with no doctors, assisted rehabilitation of some structures, reached far-flung villages through mobile clinics, and distributed non food-item kits. For an emergency disaster response we have covered the essential and given more. But we have seen also the limitations of emergency disaster efforts. The problems we were seeing towards the latter part of the missions were poor access to health facilities, chronic medical conditions, surgical conditions requiring elective surgery, poor health-seeking behavior, problems in water access and sanitation, and lack of a psychiatric program in the region – all of which are problems inherent to the health system even prior to the disaster.
Spring 2014 // Emergency Physicians International
-----------------Evangeline “Banggi” C. Cua, MD, FPCS is a general surgeon practicing in Western Visayas. She feared for her siblings and relatives who were living in Tacloban City (several islands away in Eastern Visayas), an area with major damage and loss from the Typhoon. Dr Cua spontaneously organized her team members through colleagues and Facebook posts. Her eponymous “Team Banggi” group continues to organize medical missions to other affected areas. -----------------MA. ROWENA ALCIDO, MD, MPM, had just finished serving two years as a general practitioner in a remote, underserved municipality in Samar Island for the Department of Health when the Typhoon hit. Dr Alcido volunteered with two groups: a local nongovernment organization that works with rural communities and an international humanitarian relief group. -----------------MARIA SALUD LOREEN SANNOYCADIZ, MD, works in the Department of Radiology, Diagnostic Imaging Center, Negros Oriental Provincial Hospital, Philippines
The response to the devastation left by Typhoon Haiyan from volunteers and aids like Doctors Cua and Alcido is impressive and should be lauded. Their stories emphasize that there is work to be done. As the most pressing needs presented by the typhoon are met, it is important to note these existing ‘problems inherent to the health system’, and their alleviation should be the ultimate goal.
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// global consensus
Consensus Conference Helps EM Build Towards Global Goals In May of 2013, the Academic Emergency Medicine Annual Consensus Conference brought together over 125 emergency care researchers and practitioners with the aim of advancing the cause of global emergency medicine. The following report explains key findings of that meeting.
by drs. stephen hargarten, adam levine, nicholas risko & jon mark hirshon
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wo days after the earthquake, an elderly woman presents to a humanitarian field hospital outside Port-au-Prince her right leg mangled by falling debris. She is feverish from the infection that has already begun to take hold in her wound. Across the planet in rural Rwanda, a young mother carries her small infant several kilometers to a local health center, worried about his rapid breathing and lack of appetite. Meanwhile in Dhaka, a young man is struck by a lorry while trying to cross a crowded intersection – bystanders rush to his side, uncertain how to respond to his injuries or safely transport him to a hospital. Acute care, comprised of both urgent and emergent care, is a critical component of health systems yet it is frequently overlooked in many countries during health care system development. The list of unmet needs in global emergency care is significant: infectious diseases which still claim the lives of millions of children each year, exacerbations of chronic diseases such as heart failure or diabetes, injuries sustained in events ranging from road traffic crashes to earthquakes or floods; and the list will only grow in the coming years. In order to meet this growing demand for improved emergency care in both an effective and efficient manner, high quality research is needed, especially in resource-limited settings. The requirements for evidence based emergency care are growing. On May 15, 2013, the Academic Emergency Medicine annual Consensus Conference brought together over 125 emergency care researchers and practitioners including emergency medicine specialists, to advance global health, emergency care, and research. The Conference title was: Global Health and Emergency Care: A Research Agenda. Critical input was obtained from colleagues from across the
globe who attended this historic meeting. The meeting began with a review of the current state of global emergency care research, accompanied by a discussion of the boundaries of the field. Evidence from the Global Emergency Medicine Literature Review (www.gemlr.org) suggests that both the number and quality of global emergency care publications have been increasing in recent years, though significant gaps still remain in the
“Global health emphasizes transnational health issues, determinants and solutions; involves many disciplines within and beyond the health sciences and promotes interdisciplinary collaborations; and is a synthesis of population-based prevention with individual-level clinical care.” Lancet 2009; 373: 1993–95 current evidence base. The primary goal of the consensus conference was to clearly define the gaps in our understanding of how to provide high quality emergency care in resource-limited and disaster settings and develop a coordinated plan for filling those knowledge gaps through novel, well-designed research studies. The conference breakout sessions focused on specific areas of global emergency care research including education research, clinical and translational research, resuscitation research, and health systems research. Other groups focused on the significant challenges of conducting emergency care research in resource-limited settings, including obtaining grant funds and the management of complex ethical issues involved.
Participants came to consensus around a number of critical actions for advancing global emergency care, including: 1) promoting and partnering the sciences of multiple disciplines ranging from the cellular responses to inflammation and injury to the public health fields of population health management and systems development, 2) developing sustainable international partnerships between researchers and institutions in multiple different countries in order to ensure local leadership and input into study design, 3) pushing the research envelope from simply reporting on what was done to tracking measurable outputs and outcomes; 4) encouraging funders to develop innovative new mechanisms for funding acute care and disaster research in resource-limited settings while also addressing the unique ethical issues involved in these types of studies and 5) promoting creative ideas and projects to encourage the development of a robust research infrastructure alongside the development of emergency care systems in low and middle-income countries. The consensus documents from this meeting with the fully developed thoughts and ideas about developing and promoting acute care research were published in the December issue of Academic Emergency Medicine. We present a summary guide to this special consensus issue below. It is our hope that this outline summary will act as the primary blueprint for building a global emergency care research infrastructure over the coming decade. Emergency physicians are emerging as global health leaders, dedicated to advancing acute care in partnership with colleagues in other disciplines across multiple health care sectors and in multiple communities. This historic meeting of emergency care global health leaders was an essential step in creating a research agenda for the next 5 to 10 years that can inform colleagues across disciplines about how to address and reduce the burdens of acute disease throughout our communities and the globe. The participants of this meeting realized that in order to advance emergency care, training, standardized data, ethics, funding streams, and long term commitment need to occur across the globe. The challenges of developing valued acute care systems that address time sensitive illnesses and injuries require dedicated multidisciplinary investigations with partners across high, middle, and low resourced settings that are based on respectful bilateral and multilateral collaborations. The science of global health is advancing across universities worldwide. The science of acute care is a subset of global health and requires equally rigorous attention so that the health of communities can grow and the burdens of acute illness and injury can decrease. www.epijournal.com
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Global Health & Emergency Care A Brief Guide to the 2013 AEM Consensus Papers MEDICAL EDUCATION Many trainees now desire opportunities at the medical undergraduate, graduate, and postgraduate levels. Despite rapid growth of educational experiences at all these levels, little is known about the effects of these experiences on the trainees and the patients they serve. The following consensus papers assess the scope of global health EM education at these various levels, present research agendas for each level, and discuss future steps towards further development. Global Health and Emergency Care: A Postgraduate Medical Education Consensus based Research Agenda Ian B.K. Martin, MD, et al
There are now at least 83 global health related fellowship programs, 34 of which are in EM. The International Emergency Medicine Fellowship Consortium (IEMFC) fosters collaboration and a uniform application process for these programs. At the moment, this fellowship continues to lack ACGME accreditation. The SAEM Fellowship Credentialing Task Forceâ&#x20AC;&#x2122;s global EM work group is in the process of developing a voluntary credentialing process. The Role of Graduate Medical Education in Global Health: Proceedings From the 2013 Academic Emergency Medicine Consensus Conference Janis P. Tupesis, MD, et al
The authors discuss future research questions surrounding bridging the gap of GME and global health. The article characterizes GME level global health education within four categories and provides recommendations for each category. Global Health and Emergency Care: An Undergraduate Medical Education Consensus based Research Agenda Ian B. K. Martin, MD, et al
A research agenda, along with proposed metrics and methods, is presented highlighting five priority areas of study related to global health education at the undergraduate medical level. Creating Change Through Collaboration: A Twinning Partnership to Strengthen Emergency Medicine at Addis Ababa University/Tikur Anbessa Specialized
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Hospitalâ&#x20AC;&#x201D;A Model for International Medical Education Partnerships Heidi Busse, MPH, et al
This paper provides a real-world example as a companion to the consensus pieces. The twinning partnership has so far resulted in the training of six Ethiopian physicians as EM faculty, two as EM pediatric faculty, the development of nine locally applicable training modules, the initiation of two academic training programs, and the opening of a training center that has trained over 4,000 Ethiopian medical professionals. HEALTH SYSTEMS, SERVICE DELIVERY, AND DATA COLLECTION & MANAGEMENT These consensus documents summarize the current state of scholarship related to emergency health systems, covering all levels of the emergency care system, from pre-hospital care to presentation at health services with a chief complaint, to the data collection systems and feedback mechanisms for quality improvement, to the place of acute care in the function of the entire health system. Emergency Care and Health Systems: Consensus-based Recommendations and Future Research Priorities Emilie J. B. Calvello, MD, MPH, et al
The authors lay out a lexicon for describing and discussing emergency medicine, acute care and health systems. The paper adapts existing health systems concepts to the needs of emergency and acute care. A research agenda is proposed highlighting key questions related to the six health systems building blocks: leadership/governance; health care financing; health workforce; medical products, technologies and vaccines; information research; and service delivery A Research Agenda for Acute Care Services Delivery in Low- and Middle-income Countries Rachel T. Moresky, MD, MPH, et al
In response to World Health Assembly mandates for affordable and accessible acute care services, the aim of this paper is to set forth research priorities focused along central themes, including: infrastructure, implementation, and sustainable provision of acute care services. Close attention is
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paid towards appropriate development of service delivery with regards to local disease burden and the level of existing capacity, particularly concerning human resources. Research Priorities for Data Collection and Management Within Global Acute and Emergency Care Systems Teri A. Reynolds, MD, MS, PhD, et al
Barriers to global emergency care development include a critical lack of data in several areas, including limited documentation of the acute disease burden, lack of agreement on essential components of acute care systems, and a lack of consensus on key analytic elements, such as diagnostic classification schemes and regionally appropriate metrics for impact evaluation. A research agenda is presented based upon a framework of five target areas to improve data collection: burden of acute diseases; acute care in the global setting; classification of acute care system interventions; and metrics to evaluate acute care interventions. Making Recording and Analysis of Chief Complaint a Priority for Global Emergency Care Research in Low-income Countries Hani Mowafi, MD, MPH, et al
Although recording chief complaints has been found to be valuable and is widely accepted in highly developed emergency care systems, no standards have been established to identify minimum effective sets of chief complaints for use in resource limited settings. This presents a major barrier to epidemiology, training, and the development of emergency care systems across the globe. An agenda for addressing this issue is put forth. Prehospital Research in Sub-Saharan Africa: Establishing Research Tenets Nee-Kofi Mould-Millman, MD, et al
There is limited consensus guiding research needed to improve the delivery of prehospital care in sub-Saharan Africa. The authors propose a research agenda, emphasizing the following tenets: (1) the paucity of epidemiologic data specific to emergency conditions in sub-Saharan Africa; (2) the lack of facility based emergency care in many sub-Saharan nations and the tension between focusing resources on this or prehospital care; (3) CONTINUED ON PAGE 32
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The New Psych ED Behavioral health patients present a unique set of challenges for emergency departments across the globe. Dr. Manuel Hernandez explains how ED design can decrease the stress and anxiety for these patients while increasing the efficiency of their care.
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cross emergency departments globally, no patient population can be more challenging to safely and efficiently manage than those presenting for evaluation and management of acute behavioral health conditions. Whether its presentation is simply for medical clearance or for medical clearance, assessment, and disposition to the appropriate site of care, behavioral health patients present unique challenges with respect to ensuring the safety of patients and staff, protecting patient dignity and privacy, and providing a milieu in the emergency department that is acceptable to all patients. It is well known across many health systems that behavioral health patients represent a growing portion of overall emergency department visits while also utilizing emergency services at a higher frequency than the general population. Various studies show that the issue is global. A 2008 ACEP survey found that 99 percent of emergency physicians reported admitting pschiatric patients daily. In the Netherlands, behavioral health patients were more likely to be high utilizers of emergency department services (van der Linden) and similar findings have been seen in other national health systems as well (Minassian, Lunksy). Presentation of pediatric behavioral health patients also continues to climb. The initial assessment of stabilization and deposition of behavioral health patientsfrequently results in longer lengths of stay and longer boarding times in the ED. One academic medical center in the United States determined that the average length of stay for behavioral health patients awaiting inpatient admission was 3.2 times longer than non-psychiatric patients (Nicks). The impact of crowding in the ED has also resulted in increased risk of agitation and use of restraints for behavioral health patients (El-Mallakh). A frequent area of dissatisfaction for behavioral health patients can also be found with respect to the privacy afforded during the care process in the ED. As with many
parts of the world, an Australian study examining patient perspectives on behavioral health management in the ED demonstrated dissatisfaction with waiting times, lack of privacy, and the attitudes of the ED staff (Summers). As emergency departments are developing an understanding of the unique challenges faced in caring for patients presenting with behavioral health emergencies, manyare turning toward innovative care models that blend accelerated diagnostic protocols, early psychiatric intervention, and dedicated physicals environments custom designed to the needs of behavioral health patients. The combination of these solutions has begun to show early promise in enhancing clinical quality, reducing the use of restraints and seclusion, and lowering the overall cost of care. As a result, the psychiatric and non-psychiatric patient experience in the emergency department is enhanced.
Planning for the Behavioral Health Patient There are multiple organizational constructs for behavioral health care . The options vary based on national health care system, frequency of behavioral health attendances, and the role the general emergency department plays in providing acute assessment and management of behavioral health patients. A Canadian study of mental health services provided in pediatric emergency departments reported that ED-based metal health services ranged from coverage by a social worker to services as comprehensive as an entire crisis intervention team (Leon). Similarly, in the United Kingdom, management of acute behavioral health emergencies can be variable. A study of 32 hospitals in the UK demonstrated considerable variability in presentation and management of patients with self-harm. (Cooper). As with planning any clinical environment, developing clinical and operational models to support optimized behavioral health care in the emergency
The living room concept (illustrated above) is a recent design innovation in emergency psychiatric units that provides a calm, deescalating environment for stable behavioral health patients awaiting evaluation and disposition separate from the activity of the main emergency department.
department mandates consideration of processes, staffing models, use of technology and ultimately, facility design to create an optimized environment.
Process Understanding how behavioral patients will flow through the emergency department is an important first step in planning psychiatric emergency services. As referenced earlier, the role of the emergency department can range from simple medical clearance to medical clearance, evaluation, stabilization and disposition to the appropriate inpatient or outpatient setting. Regardless of the scope of care in the emergency department, the patient throughput? model should focus on the following key attributes: immediate triage and identification of a behavioral health emergency, rapid medical clearance, early psychiatric assessment and stabilization, and quick transfer to an appropriate site of care. The medical clearance process can be a significant factor in delaying the initiation of psychiatric assessment and disposition. While this process can take many forms, a number of studies are doubting the viability of a one-size-fits-all approach to providing medical clearance for behavioral health patients. Evidence is pointing to the fact that many diagnostics routinely performed as part of the medical clearance are of low diagnostic yield and have an even lower impact on management and disposition decisions (Donofrio, Parmar, Shihabuddin).
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reduced patient anxiety, and increases in outpatient follow-up (Blumstein, Wand). In facilities with a dedicated psychiatric emergency department, the areas are typically staffed with a cohort of behavioral health personnel including psychiatric nurses, technicians, and psychiatrists or other advanced practice providers. The theory behind this staffing model is tied to the skills set possessed by the staff which aid in behavioral de-escalation and restraint avoidance during the acute assessment and stabilization phase.
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Staffing Models Emergency departments in Australia, Canada, the United Kingdom and the United States have been the most aggressive in experimenting with different staffing models for behavioral health patients. The models are wide ranging and include on-call crisis response teams that report to the emergency department for acute assessment, a dedicated psychiatric emergency department within or adjacent to the main emergency department, and off-site assessment units that require patient transfer once medical clearance has been completed. Co-management models consisting of medical support from emergency medicine with parallel assessment by a psychiatric team in the eED has been shown to reduce length of stay for behavioral health patients. A study conducted at an academic medical center without inpatient psychiatric services demonstrated a 22% reduction in length of stay for behavioral health patients cared for under the co-management model (Polevoi). Similarly, instituting psychiatry rounds in the eED also results in an appreciable reduction in the length of stay,
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Technology Psychiatric telemedicine services are gaining in popularity among many healthcare systems with limited availability of acute psychiatric services. This is particularly the case in rural communities where transfer to a behavioral health receiving center may be unnecessary for some patients and presents a hardship for others. Early studies into the efficacy of telemedicine services indicate that there is no significant difference in diagnosis or disposition recommendation between in-person assessment and tele-consultation assessments (Seidel). Similar analysis in rural areas of Scandinavia are also showing potential benefit to the use of telemedicine services for behavioral health emergencies (Trondsen). Across Europe, transnational psychiatric telemedicine models are beginning to take shape, linking patients in areas with limited access to acute psychiatric services to behavioral health professionals in other parts of Europe in a manner not dissimilar to teleradiology services.
Design Considerations There is limited evidence-based design research supporting the appropriate design characteristics of behavioral health environments in the emergency department. Much of what has been gathered has
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occurred through anecdotal evidence and trial and error approaches based on the care model in place at the emergency department in question. While patient and staff responses to the built environment can vary based on culture and model of care, evidence does support that design modifications tied to changes in process and human capital models can yield improvements in perceptions regarding privacy and satisfaction in the care process (Lin). Figure 1 illustrates a pod emergency department design with treatment stations dedicated to behavioral health patients in an area adjacent to both walk-in and ambulance entry. The largest consideration will be to assess whether behavioral health patient volumes justify a dedicated area within or adjacent to the larger emergency department. Justifiable volumes will vary by emergency department and country and should be based on total volumes, average length of stay, availability of behavioral health staffing resources and the cost model. In emergency departments that cannot support a dedicated psychiatric care area, minor modifications can be made to individual treatment stations to make them psychiatric safe. This reduces potential harm to patients, visitors, and staff. Since treatment stations are not always used by behavioral health patients, many emergency departments have turned to designing convertible stations that can be used for general medical patients and when necessary, can be converted to a psychiatric safe treatment station in less than one minute. This is accomplished by placing all fixed equipment along a temporary floor-to-ceiling wall than can be used to cover and lock all medical equipment. These rooms are also fitted with doors that have an unbreakable window and often, video link to the central nursing station for continuous monitoring. When volumes and model of care support a dedicated behavioral health area within the ED, a relatively simple design solution can be developed. The
01 A dedicated psychiatric
emergency department that is located immediately adjacent to the main emergency. 02 This dedicated
psychiatric ED is separated from the main ED by secured doors that promote patient safety, prevent elopement, and allow easy access to the unit for the general ED staff.
dedicated behavioral health zone should be located in an area that is separate from the main emergency department yet easily accessible. Separation allows for segregation of medical and psychiatric patients. Figure 1 illustrates a dedicated psychiatric emergency department that is located immediately adjacent to the main emergency department. In this model, the psychiatric emergency department is separated by secured doors that promote patient safety, prevent elopement, and allow easy access to the unit for the general emergency department staff to facilitate smooth patient transfer and response to any emergencies. Further detail regarding the design of the psychiatric emergency department is shown in Figure 2. Dedicated behavioral health zones also facilitate the creations of an internal waiting area that can be designed to reduce agitation while also providing consultation and treatment rooms for patient interviews and therapeutic interventions. Features
REFERENCES Blumstein H, Singleton AH, Suttenfield CW, Hiestand BC. Weekday psychiatry faculty rounds on emergency department psychiatric patients reduces length of stay. Acad Emerg Med. 2013 May;20(5):498-502. Cooper J, Steeg S, Bennewith O, Lowe M, Gunnell D, House A, Hawton K, Kapur N. Are hospital services for self-harm getting better? An observational study examining management, service provision and temporal trends in England. BMJ Open. 2013 Nov 19;3(11):e003444. Donofrio JJ, Santillanes G, McCammack BD, Lam CN, Menchine MD, Kaji AH, Claudius IA. Clinical Utility of Screening Laboratory Tests in Pediatric Psychiatric Patients Presenting to the Emergency Department for Medical Clearance. Ann Emerg Med. 2013 Nov 9;(13):1485-6.
of the internal waiting area include psychiatric-safe interior furniture, a de-escalating design, and visual distractions such as video and reading materials. An example of an internal psychiatric waiting area is shown on page 29.
Conclusion Planning a new emergency department presents the unique opportunity to consider design solutions that can support caring for behavioral health patients in an environment that mitigates the stress and anxiety psychiatric patients commonly experience in the emergency department. In addition, careful planning and design can enable best-inclass models of care that promote greater collaboration between emergency medicine and psychiatry while reducing the overall length of stay for behavioral health patients in the emergency department.
Pittsenbarger ZE, Mannix R. Trends in pediatric visits to the emergency department for psychiatric illnesses. Acad Emerg Med. 2014 Jan;21(1):25-30. Polevoi SK, Jewel Shim J, McCulloch CE, Grimes B, Govindarajan P. Marked reduction in length of stay for patients with psychiatric emergencies after implementation of a comanagement model. Acad Emerg Med. 2013 Apr;20(4):338-43. Seidel RW, Kilgus MD. Agreement between telepsychiatry assessment and face-to-face assessment for Emergency Department psychiatry patients. J Telemed Telecare. 2014 Jan 10. Epub. Shihabuddin BS, Hack CM, Sivitz AB. Role of urine drug screening in the medical clearance of pediatric psychiatric patients: is there one? Pediatr Emerg Care. 2013 Aug;29(8):903-6.
El-Mallakh RS, Whiteley A, Wozniak T, Ashby M, Brown S, Colbert-Trowel D, Pennington T, Thompson M, Tasnin R, Terrell CL. Waiting room crowding and agitation in a dedicated psychiatric emergency service. Ann Clin Psychiatry. 2012 May;24(2):140-2.
Sigfusdottir ID, Asgeirsdottir BB, Sigurdsson JF, Gudjonsson GH. Trends in depressive symptoms, anxiety symptoms and visits to healthcare specialists: a national study among Icelandic adolescents. Scand J Public Health. 2008 Jun;36(4):361-8.
Leon SL, Cappelli M, Ali S, Craig W, Curran J, Gokiert R, Klassen T, Osmond M, Scott SD, Newton AS. The current state of mental health services in Canadaâ&#x20AC;&#x2122;s paediatric emergency departments. Paediatr Child Health. 2013 Feb;18(2):81-5.
Summers M, Happell B. The quality of psychiatric services provided by an Australian tertiary hospital emergency department: a client perspective. Accid Emerg Nurs. 2002 Oct;10(4):205-13.
Lin YK, Lee WC, Kuo LC, Cheng YC, Lin CJ, Lin HL, Chen CW, Lin TY. Building an ethical environment improves patient privacy and satisfaction in the crowded emergency department: a quasi-experimental study. BMC Med Ethics. 2013 Feb 20;14:8. Lunsky Y, Lin E, Balogh R, Klein-Geltink J, Wilton AS, Kurdyak P. Emergency department visits and use of outpatient physician services by adults with developmental disability and psychiatric disorder. Can J Psychiatry. 2012 Oct;57(10):601-7.
Trondsen MV, Bolle SR, Stensland GĂ&#x2DC;, Tjora A. VIDEOCARE: decentralised psychiatric emergency care through videoconferencing. BMC Health Serv Res. 2012 Dec 20;12:470. van der Linden MC, van den Brand CL, van der Linden N, Rambach AA, Brumsen C. Rate, characteristics, and factors associated with high emergency department utilization. Int J Emerg Med. 2014 Feb 5;7(1):9. Wand T, White K, Patching J, Dixon J, Green T. Outcomes from the evaluation of an emergency department-based mental health nurse practitioner outpatient service in Australia. J Am Acad Nurse Pract. 2012 Mar;24(3):149-59.
Minassian A1, Vilke GM, Wilson MP. Frequent emergency department visits are more prevalent in psychiatric, alcohol abuse, and dual diagnosis conditions than in chronic viral illnesses such as hepatitis and human immunodeficiency virus. J Emerg Med. 2013 Oct;45(4):520-5. Nicks BA, Manthey DM. The impact of psychiatric patient boarding in emergency departments. Emerg Med Int. 2012. Epub 2012 Jul 22. Parmar P, Goolsby CA, Udompanyanan K, Matesick LD, Burgamy KP, Mower WR. Value of mandatory screening studies in emergency department patients cleared for psychiatric admission. West J Emerg Med. 2012 Nov;13(5):388-93.
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CONT’D FROM PAGE 17
resource poor setting. Commentary All these issues undeniably impact negatively on acute care. They cost not just patient lives, but also the simple ability to return to work after an injury or acute illness. It is therefore imperative that African acute care workers consider less expensive, lower resource consuming, innovative short-cut solutions. Instead of providing a fleet of ambulances that will require roads, fuel, and staff why not train taxi drivers or communities to provide a basic proxy. Simple triage systems such as the South African Triage Scale requires very little training to be effectively used by even the most junior nursing staff members for prioritising
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the need for clarification, delineation, and research skill development surrounding prehospital scholarship; and (4) a focus on local systems and local innovations. RESUSCITATION This sweeping analysis of the global resuscitation landscape highlights important gaps and suggests areas for future focus. Global Health and Emergency Care: A Resuscitation Research Agenda—Part 1 Tom P. Aufderheide, MD, MS, et al
This paper provides important background on global resuscitation issues, including: the existing disease burden; cost-effectiveness; infrastructure and capacity; and current trends in resuscitation research, funding, and ethics by region. Global Health and Emergency Care: A Resuscitation Research Agenda—Part 2 Marcus Eng Hock Ong, MBBS, MPH, et al
The second article focuses on data collection and management, the regionalization of post-resuscitation care, and strategies to strengthen resuscitation research.
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acute care. And acute care workers can continue to come up with new equipment and procedure hacks such as described in the practical pearl feature (Ujuzi). Of course in most other settings such solutions would be viewed as temporary, a sticking plaster to cover a leaky pipe. Sadly, in Africa much depends on the effectiveness of such sticking plaster solutions and all too often these are relied upon as permanent solutions. Real solutions will require sheer determination aimed at several levels of government (local and national), specifically targeting those in leadership positions with a real passion for improving acute care and changing the way they view acute healthcare provision. It will also require the private sector to contribute (as they did with the HIV epidemic), but this will need proof of benefit to get private cash in the mix. This proof is most likely present in all shapes and forms in Africa, but since much of this activity remains unreported, a mighty private sector solution remains dormant. It is the AfJEM’s niche
to report on evidence based solutions in resource constrained settings as it will be this information that will drive the local acute care knowledge economy, putting theory into practice on a larger scale and ensuring safe, accessible acute care for all Africans. If you wish to contribute to the AfJEM please visit our official website for more information (www.afjem.com).
RESEARCH, FUNDING AND ETHICS
infrastructure; and studying the long-term effects of clinical research programs on health care systems.
These consensus documents round up the state of clinical and translational research, the funding landscape in the global health context, and important considerations in ethics. Emergency Care Research Funding in the Global Health Context: Trends, Priorities, and Future Directions Alexander Vu, DO, MPH, et al
Although there has been a steady growth in funding for global health over the past few decades, there is a lack of evidence available to determine funding priorities, quantities, and barriers in global emergency care research. This consensus statement lays out key areas of focus for researchers to better understand the funding landscape and advocate for the resources needed to increase global access to high quality emergency care. Clinical and Translational Research in Global Health and Emergency Care: A Research Agenda Michael S. Runyon, MD, et al
The authors define key considerations in global EM clinical and translational research, emphasizing the importance of the local context in the planning, implementation and interpretation of research. Principle areas of discussing are: including clinical and translational research in initial emergency care development plans; defining the local burden of acute diseases; assessing the appropriateness and effectiveness of global guidelines in the local setting; building sustainable research
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REFERENCES 1. Mould-Millman CN, Rominski S, Oteng R. Ambulance or taxi? High acuity prehospital transports in the Ashanti region of Ghana. African Journal of Emergency Medicine. 2012;4(1):8-13 2. Aloyce R, Leshabari S, Brysiewicz P. Assessment of knowledge and skills of triage amongst nurses working in the emergency centres in Dar es Salaam, Tanzania. African Journal of Emergency Medicine. 2012;4(1):14-18 3. House DR, Nyabera SL, Yusi K, Rusyniak DE. Descriptive study of an emergency centre in Western Kenya: Challenges and opportunities. African Journal of Emergency Medicine. 2012;4(1):19-24
Ethics in Acute Care Research: A Global Perspective and Research Agenda Jon Mark Hirshon, MD, MPH, PhD, et al
While there are widely accepted ethical principles related to human subjects research, the interpretation of these principles requires specific local knowledge and expertise to ensure research is conducted ethically and within the societal and cultural norms. Utilizing case studies, this article delves into the complexities of determining and applying socially and culturally appropriate ethical principles. The authors present a consensus driven research agenda well framed by the history and modern development of medical ethics. Society for Academic Emergency Medicine’s Global Emergency Medicine Academy: Global Health Elective Code of Conduct Bhakti Hansoti, MBChB, MPH, et al
As the number of emergency medical trainees participating in international experiences grows, so has the need to develop acceptable standards of behavior for these settings. The authors propose a set of guidelines to be adopted by institutions as part of the global health preparation for their trainees. The proposed code of conduct was developed using consensus methodology and supported by extensive systematic literature review.
Grand Rounds
PETER CAMERON, MD // PRESIDENT OF IFEM
Getting Beyond Turf Wars Emergency medicine progress in Europe is going to require emergency physicians to put aside turf battles and work hand in hand with intrenched groups of specialists.
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Around the world similar dramas unfold. Healthcare needs shift and then entrenched specialties feel threatened by advances in emergency care. Dr. Peter Cameron explains that the way forward is simple common sense. Crunch the numbers, follow the money and play nice.
they come in and have the income distributed in different ways. They can either get nothing or everything. Either the inpatient specialist guys upstairs say: “Well, we look after the patients ultimately, so we get all the money,” or the ER docs determine where they go and how much money is distributed after the encounter. At one particular hospital, the emergency department said to the administrators, “We’ll take the money and then we’ll determine what’s left after that.” This has the potential to leave a lot of people unhappy. It also depends on the model of care. If the model of care is based on billing, then the way the billing occurs is fundamental to the power struggles that occur. If you can reassure people they’re not going to miss out on income, then they’re usually pretty happy. If you can’t do that and they feel a threat to their livelihood, you’ll have trouble getting buy-in.
EPI: I understand that you’ve recently spoken at a meeting of anaesthetists in the UK. What is the relationship currently between anesthesia and emergency medicine in Europe? EPI: On a practical level, how do you go about reassuring an entire specialty that they’re not going to get cut out on income? PETER CAMERON: Within each country there are varying relationships between the anesthetists and the CAMERON: I think the money always follows where emergency guys. In some of the European countries, the If you’re going to the work is. If you can work with the specialty group and anesthetists basically do the emergency work. In a few have a new group of say: “We’re all doctors. We’re all working together towards countries, there’s a bit of a schism between the professional people working in an ultimate outcome, which is better patient care,” you groups. And in other countries, it’s a good relationship. So the system, they’ve can agree on the essential facts. Despite what an anestheit varies quite a lot. In the continental European context got to be funded tists group or a surgeon group might say about getting the issue has been that the anaesthetists have traditionally appropriately. I guess less money, the individuals are actually getting the same controlled critical care, operating theaters, and pre-hospithe easiest way is if amount. It’s just that some are now relabeled, if you like, tal care. They see the specialty of emergency medicine as a it comes from above. as emergency physicians. I think it’s this sort of external sort of threat to them. Despite this, some anesthetists just But sometimes that is threat and the threat of the unknown that makes it most want to do operating theaters and they actually quite like too slow. difficult. The problem in some of these European countries having some professional help so that they don’t keep getis that the professor, the academic head at the top of the ting distracted by emergencies. It’s very much dependent traditional specialties, is most threatened: they’ve got a big on the location. empire which might well shrink. EPI: Is Europe unique in this regard? EPI: Given that model, how do you recommend that physicians go forward trying to find a common ground? Do you think it has to happen more at the CAMERON: In continental Europe, there’s a fundamental problem. The prohospital level? Or more at the system level? fessor (or academic chair) “owns” everything in their clinical discipline. They get all the money and then they distribute it. Therefore a new specialty group CAMERON: You can’t tackle this on the ground. You’ve got to tackle that at on the block might represent a threat to power and also their actual income. On a governmental level. If you’re going to have a new group of people working in the other hand, if you are in Australia or the U.S. it doesn’t really matter that the system, they’ve got to be funded appropriately. I guess the easiest way is if it much. You get paid according to the work you do. And if the work’s easier and comes from above. But sometimes that is too slow. In places like Belgium and not as stressful, then you’re happier. It sort of depends on what your threats and Belize, those guys have tried to do it from within. But I think it’s really too slow motivations are. for what is required. So the only way that’s going to happen is by a change in government policy and a change in the way medical services are funded. EPI: In Europe, or other places where there are competing incentives, how do you turn the turf war into teamwork? EPI: In coming together with the anesthetists in UK for this recent meeting, have you found that there have been any misconceptions about what emergency CAMERON: First you need to understand what the motivation is. And it’s physicians do? not just anesthetists. It’s basically any professional group that feels threatened. I’ve heard stories from some countries where the ER docs see every patient when www.epijournal.com
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Grand Rounds
PETER CAMERON, MD
CAMERON: A lot of anesthetists just have to work and do elective operations and don’t really know much about what happens in the emergency area. But I think – and this is in the U.K. – the anesthetists are under a lot of stress at the moment. They’ve had funding cuts, which has resulted in there being a common external threat. And I think from that point of view, the medical professionals tend to feel more arm-in-arm than caught in hand-to-hand combat. A common external threat always makes people work better together.
EPI: Are there any tips you’d give to practicing docs on the ground about how to address these systems issues?
CAMERON: I think most ER docs are actually pretty switched on to what the issues are. But the ability to influence policy is obviously very tricky, depending on which system you’re in. This is high politics. Just look at what’s in the newspaper. Every day there’s an article about emergency medicine. So, in terms of politics, that makes it very high profile. Politically, governments have to have EPI: Have you noticed any major public misconceptions about emergency quick fixes that the public can understand. But improvements to emergency sysmedicine in Europe? tems are not quick fixes. They are complicated compromises. As doctors on the ground, we can’t afford to let some bureaucrat or administrator determine these CAMERON: There’s been a lot of media about emergency medicine – I mean, policies because they come up with stupid answers. everyone perceives that it’s under threat. You know, it was in the paper today. In terms of practical advice, each jurisdiction is going to be different. And One of the things that’s common is that people tend to blame the overload of you can’t say something that works in Melbourne will work in London. And emergency medicine on the general practice patients and the problems they London’s solution certainly won’t work in Doha, where I am at the moment. cause. But the general practice patients on the whole At a hospital level you can influence policy. In terms of are the easiest group to deal with within emergency influencing politics, there are national organizations medicine. They represent very large numbers but not and lobbying groups which you can use to push the a very high workload. The real issues in emergency agenda. But most of those are local solutions. Work Politically, governments medicine are around the management of the more together with local GPs. Work together with hospihave to have quick fixes seriously ill. But the public gets focused on the mital administrations. Some of these things are actually that the public can nor cases, and then we end up with all these diversion solvable at a local level. But when you get into fundunderstand. But these are strategies in place. Now in the UK there are ‘navigaing mechanisms, obviously there are state and nationnot quick fixes. They are tors’ to take non-emergency cases out of the emergenal jurisdictions which you have to work through. complicated compromises. cy department. They have walk-in clinics. They have As doctors on the GPs. They have all sorts of alternatives. But when you EPI: What does that actually mean on a really granuground, we can’t afford actually look at the cost of the diversion rather than lar level to reach out to GP’s and to try to solve some the cost of actually treating a lot of these simple conof these smaller problems on a hyper-local level? to let some bureaucrat or ditions, turns out they would be better off just treatadministrator determine ing the simple conditions. And that might involve CAMERON: The first thing is to understand what these policies, because nurse practitioners, physicians’ assistants. You know, your numbers are. A lot of this is blown out of prothey come up with stupid a lot of this is very simple stuff: “I’ve got a runny nose. portion. People say: “Oh, we had ten unnecessary visanswers. Should I take antibiotics?” I mean, it takes you two its today.” Well, ten out of a hundred probably doesn’t seconds. “I’ve got a cut finger. Do I need a Band-aid actually matter. Ten out of a thousand certainly or stitches or a plastic surgeon?” These things are redoesn’t matter. You will remember well the things ally very simple and straightforward to someone who is that upset you because they just seem so stupid. But in experienced. And to divert people around the system just because they came terms of the overall impact on the department, they’re not very important. And through the wrong door is actually not very efficient. really you just say: “Oh, well, it was a bit stupid but let’s get on with it.” The things which are actually interfering with the main flow or the main EPI: During your trip to the UK, what conclusions have you drawn about how treatment pathways are the important groups of emergency patients – they’re emergency medicine could be improved? the things you’ve got to tackle. And so getting the numbers right is critical. Once you’ve got that, it helps you work with whoever you need to work with, from CAMERON: In terms of casual observations, it comes down to this very GPs to inpatient units. Then you need to work out what it is that motivates problematic diversionary strategy. Which again comes down to money. The GPs these people to come to you as opposed to some other more appropriate venue. commission services for the hospitals, meaning that they buy hospital services For example, in Doha we have a lot of minor patients. But we actually deal on behalf of their patients from the healthcare trusts. What’s happened is the with them fairly effectively. We see about 800 cases a day that could be dealt with general practitioners say: “Well, these minor cases we can look after,” which is by primary care if that existed. But the patients that cause the most angst actutrue. But what they’re really saying is “We won’t pay you for these minor cases. ally are a small minority, like patients with dependency, for example. So we work We’ll see them.” But because the patients have turned up to the emergency dewith other groups to help manage that special subset of patients. partment, you’ve got to start with spending money on triaging and diverting these patients, which is paid for by the hospital but not by the general practice EPI: You mention data collection and benchmarking. Just how important is trust. And the general practice trusts are not paying the emergency departments benchmarking in emergency medicine’s strategic success? for the cost of the visit. When they operate this way, they say, “Look at how much we’ve saved the emergency department by saving 20 percent of medical CAMERON: It’s the same all over the world. If you haven’t got your numvisits.” Meanwhile, the emergency departments effectively are seeing them bebers straight, you can’t really work out what your strategy should be. Now you’re cause they worked out their minor complaints and then dealt with how to refer never going to get it perfect. You’re never going to get perfect numbers. But even them. But that’s not actually included in their numbers. just sort of very basic numbers – like the total number of attendances, admis-
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Spring 2014 // Emergency Physicians International
sions, total number of patients you can turnaround quickly, and the types of patients – are crucial to understanding where to focus your efforts. And a lot of this is pretty black and white. The thing that emergency physicians do most is blame everyone else. Because we’re in the middle of so much stuff, it’s easy to say: “Well, it’s his fault, it’s her fault.” It’s harder to say: “Well, actually I can manipulate this and get the right outcome.”
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EPI: As a final thought, anything you’re observing now in Doha in terms of new challenges, new trends that are worth mentioning? CAMERON: There’s all the same old problems of patient flow; getting the clinical pathways with in-patient units worked out. I think the business about emergency systems and emergency networks is quite important. Medicine is very specialized and to link up the various specialties, both physically and logistically, is very difficult. And one of the problems we’re dealing with in Doha, which is similar and I’ve noticed in a few places, is actually the physical separation of clinical specialties. You know, it might be cardiac, neuro and trauma in separate institutions and how do you actually, across a region, link up those specialties for emergency patients? Because most patients have more than one organ or specialty involvement. Our job as emergency specialists is to actually work out how to make these emergency networks and systems work well. It’s a real challenge in Doha, where we’ve got a heart hospital and a cancer hospital and a women’s hospital and plans for various other types of hospitals. And it’s even a problem in places like the U.K. where traditionally the older specialties have wanted to have their own hospitals, like a plastics hospital or a heart hospital. What we’re trying to do is work out how to integrate these concepts so that you have bridges between the various powers of knowledge. Emergency is effectively on the bottom, if you like, as the entrance to this vast array of specialization. But the question is: As you progress through, how do you deal with things like radiology and intensive care theaters? And how do you make them an integrated whole? Medicine is becoming so fragmented that specialties like emergency and critical care are going to be like the glue that brings these specialization powers together. But how you actually translate that into a physical whole is quite an interesting thing as well. The physical building we’re looking at in Doha is like a kilometer across. It becomes quite a big entity. That’s the challenge of the future. We’ve got extreme specialization. We’ve got these groups like the “strokologists” telling us we’ve got to get people to have treatments within an hour of arrival. We’ve got cardiologists. We’ve got trauma guys. And then we’ve got all the issues with infectious disease. Everybody’s subspecialty now needs expert attention immediately. So how does that work when you’re on the ground faced with an undifferentiated emergency patient? That’s where emergency medicine is critically important in terms of bringing all this together. EPI: Any final thoughts? CAMERON: There is a tendency to think that you can’t change the system. But if you work at it and you work collaboratively, you can. I think emergency medicine being a fairly nascent specialty has underestimated the influence it can have on developing systems of care. Whether it be trauma or other emergencies, you don’t have to fight the other specialties; you just work with them. It’s basically common sense. I mean, I see my job as providing common sense and stopping silliness. That’s about it, really.
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