EPI Issue 8 by Logan Plaster

Going global with emergency care research Fergal Hickey reflects on an Irish ICEM Ken Iserson: Building improvised EDs ISSUE 8

JULY 2012

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EMERGENCY PHYSICIANS INTERNATIONAL

BREAKING GROUND From I-beams to iPads, a look at the people, places and ideas influencing the future of global emergency medicine Jim Holliman: ‘We must train the next generation of global EM leaders’

Peter Cameron on preparing for the ED’s growing wave of geriatric patients

Emergency physicians are facing the full brunt of a major shift in the way society views its older citizens. peter cameron, page 38

Remote education: Fiji’s EM residency trials new e-learning platforms

Manuel Hernandez on designing the ED of the future from the ground up. “Planning a new or expanded ED presents a golden opportunity to rethink how care is delivered.”

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EDITOR’S DESK

Physician, Replace Thyself

t the recent Society for Academic Emergency Medicine (SAEM) Annual Meeting in Chicago, Illinois, I was reminded of the importance of developing leadership skills for those interested in international Emergency Medicine (EM) development. I think many of the “originators” of international EM starting in the early 1990s have done a very good job of mentoring and encouraging leadership skill development in the next generation of international EM activists. I am particularly impressed with the enthusiasm, work ethic, knowledge, leadership ability, and vision of the current international EM organization officers in ACEP, SAEM, IFEM, and the African Federation for EM. Also the recent and upcoming officers of the Emergency Medicine Residents Association (EMRA) and the recent and upcoming graduates of the now many international EM fellowship programs are demonstrating remarkable skill and aptitude in leadership. It is essential that leadership skill development be a core training component of both international EM fellowship programs and of the international EM organizations. These organizations, like ACEP’s international section and SAEM’s Global Emergency Medicine Academy, should ensure that their officer positions are filled by new individuals on a regular rotating basis and that these new individuals are well prepared for their leadership roles. After a standard term of office, organization officers should step aside . . . so that more people can obtain leadership experience and exposure. This principle has not been consistently followed by some international EM organizations, much to their detriment. They rob themselves of the future leaders that their emergency medicine societies will inevitably need. So what are some specific things we should do to foster international EM leadership development? EM residents, and of course post-residency fellows, should receive formal didactic instruction in leadership techniques as part of their residency and fellowship program curricula. Residents, fellows, and junior EM faculty (despite their professional time constraints) should be encouraged to serve on committees of state and national EM organizations, and their programs should make allowances for them to be able to attend committee meetings. Extended committee service is often a requirement by EM organizations for a person to then be eligible to run for leadership positions. Residents, fellows, and junior faculty should be included on the planning committees for national and international meetings and conferences. International EM conferences should include leadership training as part of their educational program offering. And finally, those already in leadership positions should formally and closely mentor selected trainees and junior faculty. One of the major difficulties and inefficiencies I had in my own international EM career was the lack of a mentor when I was starting work on international EM development. And to close on a positive note, the near future of international EM looks extremely bright because of the leadership abilities and performance of the current and upcoming international EM organization officers. Keep up the inspiring work.

After a standard term of office, organization officers should step aside . . . so that more people can obtain leadership experience and exposure. This principle has not been consistently followed by some international EM organizations, much to their detriment. They rob themselves of the future leaders that their emergency medicine societies will inevitably need.

Going global with emergency care research Fergal Hickey reflects on an Irish ICEM Ken Iserson: Building improvised EDs ISSUE 8

JULY 2012

WWW.EPIJOURNAL.COM

EMERGENCY PHYSICIANS INTERNATIONAL

Peter Cameron on preparing for the ED’s growing wave of geriatric patients

Emergency physicians are facing the full brunt of a major shift in the way society views its older citizens. peter cameron, page 38

Remote education: Fiji’s EM residency trials new e-learning platforms.

Manuel Hernandez on designing the ED of the future from the ground up. “Planning a new or expanded ED presents a golden opportunity to rethink how care is delivered.”

C. James Holliman, MD, FACEP, FIFEM editorial director

ABOUT EPI With a quarterly print and digital distribution and an online network of more than 1,600 members, EPI is the new hub connecting global emergency care, sparking dialogue and creating a space for new collaborations. Find copies of the print magazine at international EM conferences around the world, or read it online at www.epijournal.com

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LETTER FROM THE PUBLISHER

A Vision for the Future

lying from JFK to Dubai International in January, I looked forward to recovering from the deep chill known as winter in New York. The first hot blast of dry desert air off the tarmac let me know that I’d come to the right place. The reason for the trip was the inaugural Global Network Conference on Emergency Medicine, a meeting that brought together hundreds of EPs from the Middle East and beyond, and garnered the attention of high level Emirate government ministers. While attending the conference, I witnessed firsthand the gleaming, vertiginous skyline, the ultramodern metro, and the endless shopping malls complete with indoor skiing. But the scale of infrastructure wasn’t the only thing on display. So was the youth and enthusiasm of the burgeoning leadership within the Middle East emergency medicine community. Visionary leaders like Saleh Fares, the Canadian-trained founding president of the Emirate Society for Emergency Medicine (ESEM), give one a glimpse of what is to come. And energetic residents gathering from all over the Middle East suggest the potential that exists when a region comes together . . . and has the funds to execute grand plans. That’s what this, EPI’s 8th edition, is all about: looking to the future. In his quarterly editorial, Peter Cameron discusses the patient population that’s around the corner – patients aged 65+ are the fastest growing population in ED attendance – and the important role that EPs play in the management of their care [page 38]. Then Manuel Hernandez breaks down the ED of the future, and explains how good design can help burdened emergency departments do more with less [page 30]. In our Fiji report, we get a glimpse of what’s next in resident education as physicians on some of the world’s most remote islands reboot a residency with little more than iPads, solar panels, and a WiFi network [page 18]. And finally, Jim Holliman discusses the need for greater leadership development if global EM is to have a future at all [page 3]. After all, says Jim, if current EM leaders don’t mentor the next generation and replace themselves, there won’t be anyone ready to carry forward the torch of emergency medicine development. While this edition of EPI is being distributed in print at the International Conference on Emergency Medicine (ICEM) in Dublin, that’s only the beginning of the conversation. Continue the dialogue on the EPI Network [www.epijournal.com], where you can engage with more than 1,600 colleagues on what the future of EM should look like. There’s never been a better time than the present to cast a vision for the future.

Logan Plaster Publisher

on the web

CONNECT WITH INTERNATIONAL COLLEAGUES ON EMERGENCY MEDICINE’S LARGEST PROFESSIONAL NETWORK www.epijourn a l .co m

publisher LOGAN PLASTER logan@epijournal.com editorial director C. JAMES HOLLIMAN, MD executive editors PETER CAMERON, MD TERRY MULLIGAN, DO, MPH LEE WALLIS, MD MARK PLASTER, MD associate editor LONNIE STOLTZFOOS editorial interns PEREL BERAL DR. RASHMI SHARMA regional corespondents CONRAD BUCKLE, MD MARCIO RODRIGUES, MD CARLOS RISSA, MD KATRIN HRUSKA, MD SUBROTO DAS, MD MOHAMED AL-ASFOOR, MD JIRAPORN SRI-ON, MD editorial advisors ARIF ALPER CEVIK, MD KATE DOUGLASS, MD HAYWOOD HALL, MD CHAK-WAH KAM, MD GREG LARKIN, MD PROF. DONGPILL LEE SAM-BEOM LEE, MD ALBERTO MACHADO, MD JORGE OTERO, MD print advertising LOGAN PLASTER logan@epijournal.com EPI Global Briefing Sponsorships JAMES COLLINS jcollins@multibriefs.com

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July 2012 // Emergency Physicians International

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EVENT CALENDAR

African Conference of Emergency Medicine // Ghana, Africa

12 MONTHS OF INTERNATIONAL EM CONFERENCES

4th World Congress in Emergency Medicine // Mayan Riviera, Mexico

07/12–06/13

October 30 - November 1, 2012 www.afcem2012.com

NOVEMBER

November 15-17, 2012 www.urgenciasmexico.org

AUGUST

9th Annual NY Symposium on International Emergency Medicine // New York City, USA August 22-23, 2012 contact: dgurr@nshs.edu

SEPTEMBER

7th Annual Meeting of the German Association for Emergency Medicine // Berlin, Germany September 20-22, 2012 www.dgina.de

3rd EurAsian Congress on Emergency Medicine (EACEM 2012) // Antalya, Turkey September 19 – 22, 2012 www.eacem2012.org

OCTOBER EuSEM 2012 // Antalya, Turkey

October 3 – 6, 2012 www.eusem.org

5th International Conference of SPMED // Lima, Peru October 4-6, 2012 www.spmed.org.pe

The ACEP Scientific Assembly // Denver, Colorado, USA October 8 – 1, 2012 www.acep.org/sa

Pan-Pacific Emergency Medicine Congress 2012 (PEMC 2012) // Seoul, Korea October 23 – 26, 2012 www.pemc2012.org

03 | Editor’s Desk 04 | Publisher’s Letter 08 | Research

November 16-18, 2012 www.semi.org.in

09 | Interview

JANUARY/2013

2nd Global Network on Emergency Medicine Conference // Dubai, United Arab Emirates January 13-17, 2013 www.emergencymedicineme.com

FEBRUARY

19th Annual AAEM Scientific Assembly // Las Vegas, USA February 9-13, 2013 www.aaem.org

APRIL

Manchester Critical Care // Manchester, UK

Tim Coats: Going global with your next emergency medicine research project Fergal Hickey: Raising a pint to an Irish ICEM

11 | Research In Greece, victims of abuse are falling through the ED’s cracks

12 | Education One Nepali physician’s quest to gain emergency medicine training abroad

Source 16 | Dispatches Poll: What makes EM unique in your country?

18 | Fiji 19 | Sri Lanka 20 | Rwanda

April 25-26, 2013 www.critcaresymposium.co.uk

21 | Society News

SAE Conference // Buenos Aires, Argentina

22 | Global Research Review

MAY

May, 2013 www.emergencias.org

Reports Adam Levine et al cover telesimulation, rehydration, and comparative mortality

24 | Disaster Medicine

SAEM Annual Meeting // Atlanta, Georgia, USA

Ken Iserson: How to construct a makeshift ED in the wake of a disaster

May 15-19, 2013 www.saem.org

30 | Design

JUNE

Central European Congress of Emergency and Disaster Medicine // Karpacz, Poland

L I S T YO U R N E X T I N T E R N AT I O N A L E V E N T F O R F R E E O N T H E E P I N E T W O R K – W W W. E P I J O U R N A L .C O M July 2012 // Emergency Physicians International

www.epijournal.com

14th Annual Conference for Society for Emergency Medicine in India // New Delhi, India

June, 2013 www.kongresum.sk

IN THIS ISSUE

Manuel Hernandez on how smart design can make an ED punch above its weight

33 | Photo Essay Photos from Dubai’s Global Network Conference on EM, plus a Q&A with Dr. Saleh Fares, founding president of the Emirate Society of Emergency Medicine.

38 | Grand Rounds IFEM President Peter Cameron on how EPs bear a unique responsibility towards caring for the vulnerable elderly

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RESEARCH

Going Global with EM Research

International EM research is not ‘doing research abroad’ - it is collaborating research efforts across national boundaries

Vital emergency medicine research need no longer be confined to a specific hospital or region; taking this work beyond your borders is now both manageable and powerful. by tim coats, md

s a relatively new and rapidly evolving specialty, emergency medicine is still defining its scope of practice. Along with that evolution comes a delay between specialty formation and the development of an academic foundation. While academic units of emergency medicine have been formed and there are established programs for training academic emergency physicians, academic emergency medicine is still looking for its identity. After all, what exactly is emergency medicine research? One of the characteristics that makes emergency medicine unique is the huge numbers and diversity of patients that we care for. With collaboration between emergency physicians it is possible to enroll large numbers of patients in a clinical trial. For research questions where even a small difference in outcome is clinically significant, very large numbers of patients – thousands or even tens of thousands of patients – need to be recruited. This requires international collaboration. A good example is the CRASH trials, the first of which showed that steroids are harmful in head injury and the second of which showed that tranexamic acid is beneficial in reducing mortality after injury. From experience with the CRASH2 trial, we’ve discovered a number of important considerations for international emergency medicine research. Getting buy in from clinicians is crucial to the successful delivery of the trial. Recruiting large numbers of patients requires enthusiasm and commitment. Creation of a ‘feeling’ within the trial that inspires clinicians to want to collaborate is the most important part of success. In a large clinical trial there will be no per-patient payment or other financial inducement for clinicians and there will be little academic reward (too many investigators for all the names to be on the paper). They will have to give their time and effort for free, so they must really feel the value of the trial, that it is “their” trial, rather than feeling like just another foot soldier working towards someone else’s academic reward. The question must be relevant to emer-

gency physicians across the different participating countries. This is easier than it might first seem, as although we all work in different contexts, the similarities between emergency care systems are greater than the differences. This sort of research fits best with a pragmatic methodology, and does not really suit highly explanatory trials. The design needs to be as simple as possible, and all decisions in trial design need to reflect this. On an international scale, attempting studies which have multiple arms or complex inclusion criteria makes failure very likely. It is difficult to avoid an enthusiasm for complexity, especially as those leading the trial will want to get the maximum return. However, obtaining a definitive answer to a simple question is much better than getting “interesting” data from a complex question. As the emergency physicians participating in the trial will be doing so in their own time it is essential to make the trial data collection as easy as possible. The CRASH2 trial had one single sheet, one side for data for trial entry/ intervention and the other for outcome data collection. Limiting data to the “must have” requires an iron discipline in the design, as it is so, so tempting to put in the “nice-to-have” questions. Every data point that is added makes it more likely that the trial will fail. Emergency physicians do not have time to do a lot of trial administration, so it is essential that both national and local administrative processes are completed as far as possible by the central trial team rather than relying on the local investigator. For the CRASH2

July 2012 // Emergency Physicians International

trial this central support was provided by the Clinical Trials Unit of the London School of Hygiene and Tropical Medicine, a university which specialises in international medicine. The ability to work across international boundaries, meet the varying regulatory and ethical requirements of different countries and produce trial materials in the appropriate languages is a specialist set of skills, and has a significant cost (time, translation, international phone calls, travel for site monitoring visits, collaborators meetings etc) which must be planned for in the initial grant application. In an international collaborative trial the leaders must be willing to give up their personal status for the greater good of the trial. A degree of control is lost and academic credit (authorship, etc...) becomes a group rather than individual credit. Some university systems have difficulty in dealing with this. However, the emergency physicians involved with the trial need to feel that it is theirs, and the tone of communication and the actions of the trial leaders must reflect this. This is also reflected in authorship of the published article; crediting “The CRASH2 Collaborators” as the authors, for instance, gives a very different feeling than simply putting in a few names of the trial leaders. The single most important way to deliver success is to be skilled at communication. The central trial administration must be rapidly responsive to email or phone. The senior investigators must be accessible and supportive. Regular updates, both country specific and for the whole trial, are best done as a regular newsletter. This needs to reasonably-sized email as in many countries emergency physicians have low bandwidth email access at work. Featuring success, team photos, and recruitment league tables work well. A well-designed website (again with bandwidth in mind), in key languages is essential. A system in which each county or region has its own local lead seems to work very well, as it is much better for local opinion leaders to be pushing the trial rather than doing this from a far distant country. Making the local lead role as easy as possible by providing high quality communications materials (such as lecture materials or newsletters) is very effective. The costs of travel to national meetings, so that all the local leads in a particular country or region can meet, should be included in the initial grant application. Small rewards can be powerful motivators. Featuring a team in a monthly newsletter, distributing trial branded materials (such as pens), or simply a personal email from one of the trial leaders can greatly encourage a local team. However many emergency physicians have told me that their main reward for participation is the feeling of belonging to the wider emergency medicine community, a feeling that seems particularly strong from emergency physicians in rather isolated practice. continued on page 37 4

INTERVIEW

Raising a Pint to an Irish ICEM ICEM chair Dr. Fergal Hickey talks conference innovation, IFEM guidelines, and how Irish emergency medicine punches above its weight. interview by logan plaster

In an emergency, there’s no substitute for your time. //

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:10

EPI: What unexpected challenges did you face while organizing ICEM in Dublin? Fergal Hickey: Realistically, the biggest issue is the size or our organization. It’s the smallest organization to host an ICEM conference. There are about 66 consultants in emergency medicine in Ireland, and a similar number of trainees. For a small organization, this is a very large undertaking. Fortunately, we’ve had a large percentage of our organization stepping up to help. People have obliged us, done work, chased down speakers. So far, to give you some milestones, we had 1,030 abstracts submitted, which is a record for any ICEM. That all bodes well for the conference.

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EPI: Can you describe the abstract review process? FH: There is a group of EPs who have systematically gone through to score abstracts. We set a scoring system, but most of them met our requirements for being presented. We had two imperatives. One was to insure that the submissions were of a high enough academic quality that they were worth sharing with people. The second was to, where possible, encourage people. But there was clearly a group that didn’t meet the minimum standard. The notices – around 900 – went out to the successful abstract submitters by the end of March. The vast majority of those people who were successful in their submissions will be attending the conference. EPI: What makes Ireland a unique setting for ICEM? FH: Irish medicine is very well known internationally. There are Irish doctors working all over the world. We’ve been a nation that has exported a lot of medical talent, therefore people in other countries all over the world will have experience working with Irish doctors. If you look back at the names associated with different conditions, many are named after the Irish doctors who first discovered them. The Irish are also a gregarious group, by their nature, so what we hope to be able to provide people is a combination of good science and a convivial environment. It’s not just a question of coming to learn something, it’s also about meeting people, having a good time, and seeing a bit of beautiful Ireland.

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EPI: How are you working to build this convivial attitude into the conference itself? FH: We’ve tried to be a bit more innovative. We’ve tried to restructure the talks so that they mirror the patient’s pathway through the emergency department. We’re also hoping that people will enjoy the social program we’ve set up. The conference center itself is state of the art, with fabulous views of the Wicklow Mountains, the Dublin Bay, and the River Liffey. So we hope that the general ambience will encourage a convivial atmosphere. continued on page 10 4

INTERVIEW 3 continued

from page 9

EPI: What’s new about the ICEM academic program, compared to past conferences

DR. FERGAL HICKEY ICEM Chair

FH: What is particularly special about this ICEM is that IFEM will be publicizing certain landmark developments in EM, such as the quality framework and curriculum development. IFEM has actually created quite a portfolio of these guidelines, working behind the scenes. IFEM’s new pediatric guidelines might not be essential to countries like the United States and Ireland, but for countries in which emergency medicine is early in development, these become important benchmarks to negotiate better standards of care. There’s going to be something for everybody. Most of the sessions are intended to be international – not merely the perspective of a single country – which I think is important. The fact is, people show up with ischemic heart disease all over the world, and our care needs to gradually move towards standardization. There are practices going on in parts of the world that others can learn from, and vice versa. EPI: Who are the rising leaders in global EM? FH: The broadness of the research submissions was what really impressed me. We received submissions from over 40 countries, which I suspect is a record. We’ve had submissions from nations which previously were not a part of the global emergency medicine conversation. In many ways, the development of EM tends to start on the shop floor. People try to improve clinical care in the department, and then, as sys-

tems mature, academic medicine develops secondarily. So the fact that we’re getting research submissions from countries that are relatively new to emergency medicine reflects that they’re moving forward. That’s good news for the future. EPI: Why are meetings like ICEM important? FH: EPs tend to be affable, gregarious individuals who benefit from the communal nature of social networks and conferences. We come together to gain a better understanding of how the problems we face are truly global problems. Take, for instance, ED overcrowding. We’re having a significant session on this because it’s a problem that effects every country. Different countries have different ways of dealing with it, and we can all learn each other’s experiences. The solutions are going to come from a broad range of interventions rather than one single intervention. For the new, aspiring countries in emergency medicine, they can come and actually see how developed nations are handling the problems they’re facing. They can then bring practical solutions home and actually begin to change their healthcare systems. The hope is that at some time in the future, the basic care that one would receive in the emergency department would be pretty much the same the world over. Clearly, some countries have greater access to high tech equipment, but the basic stuff should be standardized. (It should be possible, if you present with ischemic chest pain, to get an aspirin anywhere in the world. Whether or not you get PCI may well vary depending on where you are.) A conference such as ICEM achieves a strong step in that direction. I’ve been to the British conference, and the ACEP Scientific Assembly, and clearly continued on page 37 4

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July 2012 // Emergency Physicians International

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RESEARCH

Greece: Victims of Abuse Falling Through the Cracks A new study suggests that Greek emergency physicians need considerably more institutional support in handling “victims of abuse.” by fotis papaspyros, md

3.0% 1.5% 0.75% 0

0 – 18

36 – 50

66 – 80

fig. 1: Relative frequency of abuse, by age, per year

he economy isn’t the only thing playing catch-up in Greece. Emergency departments – which take turns covering 24-hour shifts for entire cities – are overcrowded, overwhelmed and their physicians are underpaid. Meanwhile, emergency medicine still isn’t a recognized specialty, so these marathon shifts are covered by doctors specializing in

anything from general surgery to microbiology. Within this limping system, acute patients get seen quickly and effectively; it’s the more subtle findings which can fall through the cracks. For the sake of this article we’ve taken up the issue of “victims of abuse” in Greek emergency departments, in the hopes of learning how emergency physicians can help prevent future harm in a vulnerable population. To this end, I and two of my colleagues, all of us resident anesthesiologists working in the ED of Hippokrateio General Hospital of Thessaloniki (HGHT), addressed a series of questions regarding patients presenting in the ED as “victims of abuse” during a 24-hour shift of our hospital. These questions were: • What is the frequency of patients presenting as “victims of abuse” out of all cases examined in the ED during that specific 24-hour period that HGHT is on duty? • What are the characteristics regarding age and sex of this specific population of patients? • What percentage of these patients was diagnosed to be in a critical condition, mandating hospitalization? • Is there an established network of health professionals for the further referral of obvious and suspected cases of victims of abuse (child abuse, intimate partner abuse, elderly abuse) once they are treated for the physical problems? In order to answer these questions we focused on the registered cases in the medical records of two surgical wards/clinics that

admitted, examined and treated in the ED environment all acute “surgical” cases. We gathered statistics on patients presenting as “victims of abuse”. In addition we conducted personal interviews with the head of the social service of the hospital and with several resident surgeons. The Data On a total of 6,496 patients that were examined in the “surgical ED” during 18 months, 263 (4%) presented with the complaint as being a “victim of abuse.” 42% were women and 58% were men. The relative frequencies when analyzed by age group were: 9.8% for children and teenagers (0-18 years old), 42,9% for people aging from 19-35 years, 27,1% for those from 36-50 years, 14,2% for ages 51-65 and 6% for people over 65. Relative frequencies by year are presented on table 1. With regards to how critical the presentation, 81,7% of them were discharged under instructions and/ or medication, 11.8% were considered serious and were hospitalized, 3.8% were judged as needing hospitalization but were discharged “on their own responsibility” and 2.7% fled the department without a complete medical examination. An important finding was that among the cases treated no clear distinction was made between whether these were assaulted by a third person or by someone they knew, like their partner, a caretaker or a relative of theirs. Thus, despite the fact that more than the 15% of them were categorized as belonging to vulnerable populations (under 18 or over 65

years old) it was impossible to document in retrospect whether they had been victims of domestic abuse or not. When we addressed this issue with the resident surgeons, they agreed that they did not put to record whether they suspected their patient to be abused from an intimate person or not. They explained however that in case the person treated admits being abused by a parent, a son, a partner, or if by themselves they suspect this to be happening, they follow a standard, albeit unofficial, procedure. Their aim is to institute primary protection as the best measure for reducing further morbidity and mortality, hence they suggest that the person to be admitted to a ward until the social service or the police are notified to take the necessary measures. This is not always feasible since either the patient rejects this suggestion or there are no beds available. With regards to the social service of the hospital, as the head of the department explained in a personal interview, this is only available during normal working hours. She agreed that the “therapeutic process” in such cases should involve a team of health workers in addition to the ED medical care. Hence, in case they are contacted for a suspected case of abuse, they notify the psychiatrist to verify that the victim’s allegations are plausible and then the police. She suggested that beyond this, there should actually be a team of professionals on 24-hour duty, in order to handle such cases with the appropriate discretion and efficacy, in collaboration with the doctors working in the ED. In sum we concluded that regarding cases of abuse, the ED physician in HGHT is not as supported as he/she should have been in order to provide the best possible treatment. Although we do the best we can, this is not always enough, especially within Greece’s current financially unstable environment. In addition, very little evidence exists in the current literature to recommend for or against universal screening for abuse, despite recommendations of several medical organizations. Interventions have been poorly studied but, anecdotally, all emergency physicians understand the importance of handling such challenging cases efficiently. We need more studies in order to form evidence-based protocols on how to treat such patients holistically.

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EDUCATION

The Long Road from Kathmandu A Nepali physician faces the uphill challenge of obtaining advanced EM training abroad by dr. rashmi sharma

was born and raised in Nepal. The daughter of a doctor, I always knew I’d follow my father’s footsteps into medicine. I grew up watching as people lined up in my house every morning, my father knowing all his patients by name, including their complicated ailments and histories. It was a curious combination of medical treatment, therapy, and socializing. The dream came to fruition when I completed my medical degree in 2009 from Kathmandu University, having graduated in the top ten of my class. And yet, three years later, I stand caught between two systems. Like many emergency physicians trained in the second and third world, I’ve sought advanced training abroad only to find doors closing behind and before. This is my story. I knew that I wanted to be an emergency physician after my first day as an intern. An old lady was brought in with acute respiratory distress. Her file stated her as a known case of chronic obstructive pulmonary disease. I remember her straining muscles, her labored breathing, the typical posture associated with COPD. Her vitals signs and oxygen saturations were worsening. A quick clinical exam led to a suspicion of tension pneumothorax. There was no time to waste. My ER supervisor immediately inserted a large gauge cannula in the right second intercostal space, and the air escaped with a hiss. Subsequently, a chest drain was placed. Within minutes, the patient looked significantly better. Following up on her an hour later, the patient gave me a great smile. We’d saved a life, and I’d found my calling. On a medical elective in Linkoping University in Sweden I began to appreciate the advancements in Western emergency departments, and I saw Nepal’s training and infrastructure in a new light. There were staggering differences in the skill of providers as well as the expectations of patients. Shortages of gloves, syringes, cannula, IV sets, saline – even electricity – are the norms in Kathmandu. Many EDs in Nepal can’t even afford to have fixed protocols regarding management of acute cases due to shortages of skilled personnel, and the necessary equipments that such protocols require. As a medical officer in an ER in Kathmandu, I was faced with a common dilemma.

I would ask the patient why they were there, write down what was needed, and then wonder, “can the patient really afford an extra pair of latex gloves for my use?” Nepal is among the poorest and least developed countries in the world, with almost one-quarter of its population living below the poverty line. If the patient couldn’t afford the gloves, I don’t order them. Once I’d made my recommendation, I’d wait until the patient’s family ran to the nearest pharmacy, bought the medicine I ordered – IV cannula and all – and handed them to me in a black polyethylene bag. The hospital policy doesn’t allow free investigation on every patient who walks in, so there is a constant weighing of which treatments are financially feasible. While practicing emergency medicine in this environment allowed me to experience a wide spectrum of cases and gain experience, the mediocre care never felt right. Without an organized approach to many emergencies, pivotal elements got overlooked. I couldn’t shake the knowledge that there were times when I could have served my patients better had I had more specialized training. Ideally, I would have found the advanced training I desired in my home country. But while there are ample medical schools in Nepal, the number of post-graduate residency seats have not increased to meet demand. Competition is fierce, and every year there are several reports of nepotism, rigged exams, and corruption in post-graduate candidate selection. For whatever reason, this system

July 2012 // Emergency Physicians International

would not have me, so back to Sweden I went. I applied to Linkoping University for a post-graduate training, but despite the hospital wanting to hire me as a locum physician, the complicated European Union laws ruled against my non-swede, non-european, non-immigrant, nonrefugee, non European-partner status. After a year of trying to sort out post-graduate training in Sweden, I gave up. The process was long and the bureaucracy too complicated. Next I turned to the United States, quickly learning that American post-graduate residencies are quite welcoming of foreign medical graduates; the USA relies heavily on foreigners to supply health care to Americans. For several decades, there have not been enough U.S. medical school graduates to fill the slots available in domestic residency programs, and those that are left over go to international medical graduates, or IMGs. In 2010, more than 20 percent of graduates who were matched to first-year residency positions had graduated from foreign schools. Other elements which make the United States a popular choice for foreign docs include a comparatively short training period (3-4 years), English as the language of communication and a centralized application system (ERAS). Cost is also an issue. In countries such as India, China, Pakistan and Bangladesh, many residents have to pay full tuition – up to 50 hundred thousand rupees (around $45,000 USD) – for a three-year program. As many have documented, the problem with migrating to the United States for training is that it results in a drain on qualified professionals in the developing world. Formally called “brain drain,” but now more often referred to as “resource migration,” the trend has left Nepal with acute shortages of trained medical personnel – one doctor is available for every 20 thousand people. According to NRMP data of this year’s match, out of the 6,828 IMG participants who were not U.S. citizens, 2,775 (40.6%) obtained first-year positions. The Nepali government has shown little initiative to retain the workforce within the country, who have to contend with political strife, poverty, and an unemployment rate of 68%. Many developing nations suffer the same fate, and unless radical action is taken, such as the provision of higher pay or more training opportunities, the trend will continue. I recently asked a group of Nepalese immigrants why they’d moved to the United States. Common reasons were: seeking equal opportunities, living in a politically stable country, possibility of earning more, living more comfortably, using proper equipment, having reliable amenities such as electricity, transportation, running water, and simply having a shot at getting into a speciality of their choice. When I asked the same group what would have convinced them to stay in Nepal, the only consistent answer was to be near family and friends.

Emergency Medicine Training Opportunities Around the World by Terrence Mulligan, DO, MPH Nepal

Obstacles to Success The first hurdle for any foreigners seeking post-graduate medical education in the United States is money. Although most Nepalis don’t have the kind of school debt held by many American medical students, there is often some debt to pay off, whether it is to the bank or to family members. The bigger monetary problem is that a junior doctor in Nepal only makes around 20 thousand rupees per month (approximately $250 USD). That’s not a lot if you’re saving up for the $800 USMLE step 1 exam. Taking the necessary exams to enter the States is quite an investment – the overall cost of the entire steps 1, 2 CS and CK and step 3 could run up to $4,000. If the fees weren’t enough, add to this the higher cost of living, a bad exchange rate, plane tickets, and hotels during residency interviews. Even the applications cost money. While applying through ERAS, it costs $85 for the first 10 programs you apply to, and then the cost progressively increases as you apply to more programs. I applied to 143 programs and the cost mounted to $2,500 dollars. Most Nepali doctors that I know made the decision to come to America once they had graduated and worked for a few years as medical officers. The trouble is that if there is a gap post medical school, the entrance exams in the United States will only get more difficult. The dilemma faced by so many is whether to quit work and focus on studying the basics for a few months, take the exam immediately (and risk getting a lower score), or try to study while continuing to work. Whatever approach, it takes a lot of effort and commitment for anyone to go back to basics and open those textbooks again. Even after a foreign doctor has raised the funds, taken the tests, and scored above the 90th percentile, there is still the question of obtaining a visa. While my initial entrance was smooth, many of my friends were denied visas for unclear reasons. In spite of preparing all the paperwork scrupulously and proving that they had sufficient funds to travel, taking the exam and return home, not all doctors wanting to come to U.S. can do so. In most cases, IMGs travel to the US on a visitor visa or a tourist visa, and upon arrival, can stay up to six months at a stretch and then apply for another six months extension for a fee of $290. Otherwise, one must leave the country and re-apply. The U.S. currently grants many foreign doctors a J-1 visa, which allows them to do a medical residency training in the US, but then requires them to return to their home country for at least two years before applying to become a permanent US resident. Through various government programs, however, that requirement is often waived, and some foreign doctors usually choose to practice in the US after completing medical residencies. IMGs who have letters of recommendation from American doctors, or who have clinical/research experience are said to have a stronger ap-

Full EM Residency Abroad Obtaining full EM specialty training in another country offers the works, from qualified supervision to system exposure to interaction with senior faculty and mentors. The hurdles are many: funding, years of testing (USMLE 1-2-3), multi-year commitment and language. Plus, the foreign residency track also increases “brain drain.” Many residencies exist, but are focused in places where EM has been around the longest (USA, Canada, UK, Ireland, Australia,New Zealand, Hong Kong, Singapore). Observational Fellowships Foreign medical graduates have the option of obtaining partial EM specialty or subspecialty training in host country through observerships. These pogroms, which accept applicants as visiting fellows rather than official residents, cover a range of topics (exposure level varies). Program lengths vary from weeks to years. Typically, observerships are shorter than residencies, and can be offered to multiple faculty members from same foreign program at once. They are less expensive than full residencies, but rarely offer practice rights or specialty status upon completion. Observerships can be expensive, and most programs are located within EM residencies that have International EM departments. Foreign Consultants One option for global education is for an EP to simply move to a host country and learn through working in the field. The time frame for these stints can range from weeks to years. While “outsider” status can be a benefit in these scenarios – helping overcome certain barriers to development – it can also be a burden. As can be language barriers and differences in training. Countries like the Netherlands and South Africa are known to host foreign consultants. Educational Courses Trained EM faculty travel to foreign countries for short, focused courses on specific areas of emergency medicine. Alternatively, EM faculty can travel to a

host country to obtain focused training as a team. This can be an economical option for advanced training, and can help jump start larger programs. Downside: short courses are limited in scope and can convey a false sense of competency. Certain aspects of EM simply cannot be taught in a shortened format. Conferences A good way to get exposure to global emergency medicine is to attend a national, regional or global conference. Given the number of countries with EM as a recognized specialty, there is an EM meeting somewhere in the world nearly every month. While these meetings are great for networking, and are often where policy decisions get made, their educational impact is questionable. Like short courses, they can give a false sense of competency. In addition, conferences can be subject to local politics, and can be expensive. Publications When not attending a course or conference, a great way to stay up to date is with an emergency medicine publication. More than 15 national and regional journals are published, providing up-to-date, peer-reviewed content tailored to the emergency medicine audience. While these publications gain in impact each year, they have the difficulty of being region-specific, and access can be cost-prohibitive. To find a journal, start by contacting the EM society of your choice; many will have either a journal or a dedicated international section. On-line Resources Every day, more EM educational, testing and instructional material are being made available on-line, some even for free. The material is available instantly, usually at a low cost, covering a wide range of topics. However, content is often disorganized, and it can be difficult to gauge credibility. Many EM societies have begun collaborating on online educational materials, so look for more in this arena in coming months and years.

To learn more, connect with Dr. Mulligan on the EPI Network –www.epijournal.com/profile/terrencemulligan–

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EDUCATION

3 continued

from page 13

plication, so such opportunities are highly sought-after. Although there are some hospitals offering clinical observerships for free, there are an equal number of hospitals who allow IMGs to shadow a senior doctor for a few weeks for a fixed fee. This means even more expenses. I decided to come to the USA because residency in emergency medicine is still in its infancy in Nepal. I want to train in the States and then work in a humanitarian field five years from now. I’m inspired to continue by the patients I encountered while working in Kathmandu, patients like Lobsang Sherpa, a 52-year-old man brought in from a small village more than 2,000 meters up into the mountains. His son, Dawa Tschering, had carried him down the mountains on his back in a traditional wicker-basket called a doko, trekking about 12 hours in total. Lobsang, his face furrowed, concentrating on his pain, had fallen off a cliff while looking for firewood. He rolled a short Tibetan prayer bead round and round his fingers, unable to explain anything in Nepali, a language he didn’t speak. This patient had traveled such a vast distance because there were no X-ray machines in his village, nor were there any medical professionals. His diagnosis: A fractured femur. If more doctors aren’t trained, if more health care professionals aren’t produced, then I believe more patients like Lobsang Sherpa will continue to suffer meaninglessly. In Nepal, only 65 percent of the population in rural communities are within one hour of a public health centre and only one in ten are within an hour of a hospital. The probability of dying between birth and age 5 is 50% – one of the highest in Asia. Finally, there is no organized ambulance system in Nepal. Its diverse topography and climate, high level of illiteracy and political instability only make matters more difficult. I believe that if the door is opened for more foreign doctors to train in countries like the United States, many will walk away with the skills and knowledge they need to invest back in the developing world. Doing so will help win “the hearts and minds” of the global community and will begin to fill critical physician shortages.

July 2012 // Emergency Physicians International

SOURCE FIRSTHAND REPORTS OF EM SPECIALTY DEVELOPMENT AROUND THE GLOBE

In order to provide EM residents on Fiji with more continuous internet access in a region where WiFi service and power outages are frequent, each trainee has been provided with a solar panel charger, and internet access via satellite cellular service.

Fiji report on page 18

DISPATCHES 16 FIJI 18 SRI LANKA 19 RWANDA 20 SOCIETY NEWS 21

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

04 05 06 07 08 09

Q. What makes emergency medicine unique in your country/region? ______________________

01 UNITED STATES “The fact that we are still fee-for-service (we are not usually penalized for ordering unnecessary tests). In fact, we might put ourselves at medicolegal risk by not ordering it or risk that the patient not be satisfied, which is also not desirable when hospitals actually compete for patients.” -Scott Weiner ---------“Corporate exploitation” -Jerry Jamison ______________________

MEXICO “Unfortunatelly there are big differences in outcomes based more on the

03 COLOMBIA “Our country has a high rate of violence, so many patients are daily injured by sharp weapons, firearms and landmines – not only soldiers, but also civilians. There’s also a lot of severe blunt and penetrating trauma from other sources (assault or traffic accidents).” -Diana Cardenas ______________________

economic status of the patient than the seriousness of the illness.” -Carlos Risa ______________________

SWEDEN “We are definitely less invasive than in many other countries. Our thresh-

July 2012 // Emergency Physicians International

old for intubation or central lines is much higher.” -Katrin Hruska ---------“In 12 years we’ve gone from a small group of enthusiasts to approximately 300 doctors in some stage of EM training.” -Pia Malmquist ______________________

05 DENMARK “The most junior doctors are no longer alone dealing with the most sick and undifferentiated patients.” -Dan Brun Petersen ______________________

06 UNITED KINGDOM “[EM is] totally free at the point of

care (not even nominal fee) for all people resident in our country” -Ffion Davies ______________________

07 FRANCE “Mountain SAR with Emergency Physicians’ staffing Helicopter EMS” -Nicolas Peschanski ---------“The prehospital EMS with emergency physicians in ambulances everywhere in the country. An EP on the phone 24 hours a day 365 days/ year. It is a unique EMS and particularly usefull for the management of the MI: taking care the ACS direct to the cathlab in 90 min.” -Eric Revue ______________________

08 NETHERLANDS “What is unique is the speed of the development of EM nationally, and

______________________

18 19 20 21 22

SOUTH AFRICA “High prevalence of TB and HIV” -Niel van Hoving ______________________

12 KENYA “Time to receipt of care is usually extremely long because of lack of reliable EMS. Patient conditions have significantly deteriorated before ED arrival, even in major cities where EMS is available. What is unique in Kenya is that this situation has become increasingly more critical and events more sudden for both natural and man-made mass disasters over the past 4 years.” -L. Kamau ______________________

the enthusiasm most young EPs work with to establish EM as a full specialty in the near future.” -Menno I. Gaakeer ______________________

09 GERMANY “Even though Germany is one of the most professional working environments for prehospital EM, wellworking EDs are still scarce, thanks to the political pressure against EM´s professionalisation attempts. Germany´s quality gap between prehospital and hospital EM is unique, unfortunately.” -Lars Lomberg ______________________

10 ROMANIA “Maybe the schedule: 24 hours per shift is very exhausting. ” -Angelica Amarande

YEMEN “EM is still seen by patients and doctors as a first aid area until the specialist sees the patient. Nurses and doctors, though, know from TV that there can be a higher standard and are keen to learn.” -Brendan Webb ______________________

14 SUDAN “In Sudan, its always brutal in the ED. We lack a lot of essential tools for running good service, so all aspects of care are a real challenge, from prehospital until disposition.” -Hussain Abdelgadir ______________________

15 INDIA “The Indian government does not have the vision of EM for next 50 years. Private hospitals play an important role in recognizing the emergency department.” -Rahat Farid ---------“Volume of patients and that most are not covered by insurance and many cannot afford proper payment” -Saptarshi Saha

______________________

16 UNITED ARAB EMIRATES “The practice in the primary care does not follow any standards and they refer patients (children in my case) when thay are a little bit complicated (not simple GE, colds, rash). The challenge is that the patient is upset and the case is masked with improper treatment. Your role is not only to treat but to verify and correct the previous management.” -Tameem Shoukih ______________________

17 QATER “Extreme volume of patients per year” -Mohamed Al-Asfoor ---------“The number of patient who are seen each day avrage 1800, or 54000 per month, or 648,000 per year. And stil we can survive.” -Galal Alessai ______________________

18 TURKEY “The only specialty that can take care of a patient from top to toe and manage the patient according to guidelines, from the life threatening conditions to simple ones.” -Ahmet Demircan ---------“Dynamism of interaction with other disciplines” -Suha Turkmen ______________________

19 IRAQ “Because of the high number of casualties due to terrorist attacks(explosions), violence caused by conflicts and road accidents, Iraqi EPs become experts in trauma care, rapid response and professionalism.” -Shakir Rubayi ---------“Those who work in our emergency hospitals are those who run the other parts of the health system. We don’t have a single doctor or paramedical

staff who holds degree in emergency medicine.” -Harman Maaroof ______________________

20 RUSSIA “medical guidelines for the mass admission of patients.” -Yuri Tkachenko ______________________

21 AUSTRALIA “We run retrieval, hyperbaric and disaster services almost exclusively, and are the acknowledged experts in resuscitation and the early management of trauma.” -Robyn Parker ---------“A well developed Retrieval sector for the many remote areas of Australia” -Titiosibina Adegbija ______________________

22 NEW ZEALAND “New Zealand medical budget is limited. The attitude of patients and family is much more realistic than the “do everything” attitude in places like the US.” -David DuBois ---------“If you practice reasonable medicine within the framework of how other similarly trained physicians do, the system has your back. They realize that bad things occasionally happen to good people but it is not always someone else’s fault. When accidents occur, the government – through an entity called the Accident Compensation Corporation – covers all costs, including loss of wages. You cannot sue someone for personal injury which includes what is referred to as “medical misadventure”. That means less use of unnecessary CT scans and less unnecessary admissions.” -Brad Ellington

SOURCE

FIJI

The remote nation’s innovative post-graduate EM training program embraces e-learning solutions by michelle daniel, md; ajita shah, md mika ah kuoi, md; craig adams, md

he nation states of the Pacific are made up of more than 25,000 islands, geographically dispersed over nearly 1/3 of the world’s total surface. Not surprisingly, this is a challenging environment for medical education and healthcare delivery. Additional hurdles include low socio-economic status, marked cultural diversity, and political instability–all of which have contributed to an exodus of senior trained medical staff. Throughout the Pacific Islands there are only a total of eight practicing specialty-trained emergency physicians, most of whom are expatriates. The only post-graduate EM training program in the region is in Papua New Guinea, an area where security issues preclude most other Pacific Islanders from pursuing the 5-year masters in EM. In Fiji, one of the most developed nations in the Pacific Islands, no EM training program or EM trained physicians currently exist or practice. Under the current training system, medical students progress through a 6-year program. The first 3 years focus on the

basic and clinical sciences using a problembased learning curriculum. The last 3 years are spent doing clinical rotations. After graduation, students do a 1-2 year rotating internship at one of two major divisional hospitals. They are then sent out into clinical practice. Some students return for specialty training in internal medicine, pediatrics, or surgery, but those who practice in emergency departments or rural clinics do so with no EM specialty training. All of that, however, may be about to change. With the aid of a visionary dean, a supportive minister of health, and a core group of international emergency medicine physicians, the island nation of Fiji is striving to set an example for the development of emergency medicine in the region. This year, 17 individuals are embarking on a pioneering journey in a 1-year post-graduate EM diplomate program. The goal of the program is to help the diplomates develop the necessary knowledge, attitudes, and skills to practice emergency medicine in their diverse settings, and to assist in the development of accredited emergency

July 2012 // Emergency Physicians International

Pediatric patient in Sigatoka, a town on the island of Viti Levu, the largest island in the Republic of Fiji

01 Currently the only EKG machine available on Fiji, where many patients present with ACS (Acute Coronary Syndrome)/CP. 02 The Fiji School of Medicine launched the new post-graduate EM diplomate program. Previously, no EM training program existed in Fiji. Before the Fiji School of Medicine launched the new EM diplomate program, no EM training program existed in Fiji. 03 One of the 17 diplomate candidates developing her EM skills. “I have been waiting for years for a training program like this.”

medicine care masters programs in their own Pacific nations. To overcome the geographic distribution of the region, the predominate learning and assessment is taking place in an E-learning environment. The diplomate candidates have all been distributed iPads on which they can access medical applications, including a resident handbook, the program website, and a blog about hot topics and cases. In order to provide residents with more continuous internet access in a region where WiFi service and power outages are frequent, each trainee has been provided with a solar panel charger, and internet access via satellite cellular service. The “resident handbook” for the program was developed using a unique emergency medicine approach that focuses first on the life/limb threatening problems, followed by the most common causes of those symptoms in the region and their management. The handbook is chief complaint based. The management protocols are all modified to accommodate the limited resources available in the region. Local diplomates identified the 30 most common EM presentations in the region and contributed to the book’s development. The handbook is not meant to be comprehensive, but rather focuses on the region’s life threatening and common treatable diseases. It only covers the high-impact material diplomates can be expected to learn in a one-year

SRI LANKA

program. Ultimately, the goal is to extend the training to a more comprehensive 3-4 year masters program. Currently there is a lack of clinical leadership in EM in Fiji. To address this issue, telemedicine will be used (via email and video-conferencing) for trainees to access international EM physicians at remote locations for advice on clinical cases in real time, or at scheduled intervals according to an â&#x20AC;&#x153;on-callâ&#x20AC;? schedule. Additional clinical support will be provided via resident and attending locums physicians rotating from the United States and Australia. A series of short courses (ACLS, PALS, ATLS, ultrasound, cardiac critical care, procedures, etc...) will be offered to augment the online curriculum and clinical teaching. The use of technology (E-learning, iPads, telemedicine, solar powered chargers) may serve as a model for other international programs facing similar challenges of geographic dispersion, and lack of local clinical support for trainees. The technology exists to make this feasible. Now we need the vision and financial resources to make it sustainable. With the continued support of the Fijian government and international universities, the enthusiastic diplomate candidates in this fledgling EM program have the potential to alter the face of emergency healthcare delivery in the Pacific, and to become the clinical leaders of tomorrow.

How the 2006 tsunami lead to significant developments within emergency medicine COMMUNICATING IN SRI LANKA Official Language Sinhalese and Tamil are the two official languages The Link The Constitution defines English as the link language. Education/Commerce English is widely used for education, scientific and commercial purposes. Dialects Members of the Burgher community speak different dialects of Portuguese Creole and Dutch. Members of the Malay community speak a unique form of Creole Malay.

by chula goonasekera, president of ssccem

he tsunami in 2006 triggered focused emergency care training in Sri Lanka. It highlighted the need for development of coordinated emergency responses by trained personnel at the national level. In this context, various activities took place such as the establishment of emergency ambulance services and emergency call numbers in some cities (e.g. Colombo), the inauguration of a new ministry for disaster management, higher focus for training in emergency care (CPR programs) designed for all categories of staff including doctors, nurses, and ambulance personnel, the initiation of disaster management training centers (e.g. Peradeniya), and construction of dedicated emergency care units (eg Karapitiya). There were also initiatives to improve emergency response thorough ambulance services, fire brigade and outreach care (e.g. Colombo, Galle). Many international organizations and governments helped these developments especially the Government of Victoria, Australia. The tsunami brought about substantial changes in hospitals as well. Several existing outpatient care models were upgraded to ETUs (emergency treatment units), PCUs (Preliminary Care Units), and Accident centers (Colombo NHSL).

In order to initiate a specialist training program, the Post Graduate Institute of Medicine, University of Colombo Sri Lanka, formulated a multidisciplinary specialty board in emergency medicine in the year 2011. This board has already developed a comprehensive 6 year training curriculum with the assistance and advice from members of the Australasian College of Emergency Physicians. The Ministry of Health of Sri Lanka has also officially considered the need to develop emergency medicine as a separate specialty and has agreed to assist a specialist training program and create the necessary cadre in its hospitals. The first batch of emergency medicine trainees is due for recruitment in mid 2012 following a selection examination. The Sri Lankan Society of Critical Care and Emergency Medicine (SSCCEM â&#x20AC;&#x201C; www. ssccem.com) has already initiated an Emergency Life Care training program, a modified course suitable for Sri Lanka based on the principles of Emergency Life Support PLC course in Australia. The first ELC Sri Lanka course was conducted in November 2011 and the second is due to take place in mid 2012. A two day workshop on emergency medicine was also held in war stricken Batticaloa in late 2011 with the participation of several emergency physicians from Australia. www.epijournal.com

SOURCE

In Rwanda, there are about 2.4 physicians for every 100,000 people (2005) and about 1.6 beds for every 1,000 people (2007).

TOP 10 CAUSES OF DEATH IN RWANDA Malaria 15.1%

RWANDA

A global collaborative forms to establish Rwanda’s first emergency medicine residency by dr antoine bahati kabeza, mmed

resently, there are no practicing emergency physicians in Rwanda. While many of the referral hospitals have emergency departments, they are staffed by recently graduated general practitioners with minimal training or exposure to acute care or trauma. Rwanda does have a rapidly growing EMS system, but there is a significant need for improved physician direction and oversight in order to maximize its effectiveness.

In order to address the needs outlined above, Rwanda is embarking on an ambitious plan to develop its first emergency medicine residency. The planning phase involved the collaboration of representatives from several US medical schools and the Rwandan Ministry of Health (RMH) as part of the Human Resources for Health (HRH) strengthening plan, which envisions a 7-year scale up of specialty physician capacity within Rwanda. Made possible by a large grant from USAID, the HRH strengthening plan involves a consortium of 17 US medical,

nursing, and dental schools working directly with the government of Rwanda to establish the first sustainable, large scale specialty training programs in the country. In addition to advanced nursing, public health, and dentistry programs, the first phase of HRH will include the establishment of six new Masters in Medicine (residency) programs, including internal medicine, surgery, anesthesia, obstetrics/gynecology, pediatrics, and emergency medicine. There will also be new one-year diploma courses in emergency medicine/critical care and in family medicine. The Department of Emergency Medicine at Brown University has taken the lead for establishment of the emergency medicine training programs under the HRH grant, and will support two full time U.S. emergency physicians to work on the ground in Rwanda as the first faculty for the new EM training programs. In February 2012, an EM Sub-Committee

July 2012 // Emergency Physicians International

Acute respiratory infections 13.7% HIV/AIDS 8.0 % Diarrheal diseases 7.2% Premature birth 6.3% Cerebrovascular disease 5.9% Tuberculosis 3.8% Malnutrition 3.3% Physical trauma 3.2% All other diseases 33.5%

(CDC, 2008)

of the HRH program was established by the Rwanda Ministry of Health and was tasked with the development of the curriculum for both the one-year Emergency Medicine/ Critical Care Diploma Course (slated to being in fall 2012) and the full four-year Masters in Medicine in Emergency Medicine (slated to begin in fall 2013). The EM SubCommittee includes representatives from the Rwanda Ministry of Health; from CHUK, the primary teaching hospital in Kigali (the capitol of Rwanda) and site of the planned EM residency; from the National University of Rwanda Faculty of Medicine; from Brown University Department of Emergency Medicine; and from sidHARTe, a US-based organization that has worked in both Ghana and Rwanda to develop emergency care systems. The program is expecting to begin matriculating 15 post-graduate students for the Emergency Medicine/Critical Care Diploma Course in August 2012. It is expected that about 10 of these will stop at the diploma level – returning to cover the emergency departments at rural district hospitals across Rwanda – while around five will continue on in the Masters in Medicine in Emergency Medicine. This latter group will eventually become the first fully trained emergency physicians in Rwanda. With this rate of training, in four years we hope to have four fully trained emergency physicians who will be retained at CHUK in order to begin replacing the American emergency medicine faculty. We’ll also have more than 40 general practice physicians with diplomas in EM and critical care who can work at the district hospital level to stabilize and manage acute medical and surgical patients before transferring them to one of the referral hospitals. Like many other low-resource countries, Rwanda has recognized the need for specialty training in emergency medicine in order to produce a cadre of physicians who can meet the growing need for rapid and cost-effective acute medical and trauma care. The effort to establish Rwanda’s first EM residency program is an example of the type of academic medical collaboration that can help developing countries rapidly increase their numbers of EM specialists.

IFEM

SOCIETY NEWS

AFEM The African Federation for Emergency Medicine is excited to report on the upsurge of activity following the EMSSA 2011 Conference in Cape Town. Prof. Lee Wallis was elected to continue as president of the federation and in 2012 will focus the organization on increasing membership and consolidating the information network of emergency care related activities in Africa. Emergency care in Africa is growing rapidly through the establishment of residency programs, nurse and pre-hosptial training programs. The residency programs in Botswana and Sudan are maturing and the first residents start in Rwanda and Madagascar soon. AFEM is working on developing a 1-year Emergency Care Diploma course. EMAT (The Emergency Medicine Association of Tanzania) and the EM training program at Muhumbili are embarking on a national survey of emergency care resources, training, access and disaster preparedness in every district. The Abbott-funded ED at Muhimbili National Hospital is involved in emergency preparedness exercises and emergency nurse and health care assistant training. EMAT’s challenges for 2012 are to improve the quality of primary trauma care, improve access to care by improving referral pathways, and increase awareness of EM as a specialty. In South Africa, the Emergency Medicine Society of South Africa (EMSSA) is preparing for its biennual symposium to be held in Johannesburg in October 2012. In October, AFEM will be hosting its first conference in Ghana, bringing together EM leaders from across the continent. Given the financial challenge of traveling across Africa, AFEM is actively looking at ways to make the conference digitally accessible via the web. The adopt-a-delegate program will once again try to raise sponsorship for delegates from emerging economies. Details of the program are at www.afcem2012.com. AFEM now has individual membership from over 14 countries and society membership from 4 countries in Africa.

ICEM is bringing together EPs from every region to discuss the hot topics in EM in Dublin. The conference tackles controversial areas such as overcrowding, funding, training and how different regions have improved emergency care. The ability of a truly global voice to bring about improvements should not be underestimated. Of note, IFEM is progressing on several important fronts: EDUCATION: Building on our existing curricula by establishing an international curriculum on continuing professional development, and identifying basic principles for assessment methods. Paramedic curriculum under consideration. SPECIALTY IMPLEMENTATION: Assessing the needs and resources of IFEM member countries, assisting collaborations in countries with developing emergency medicine. BUILDING INTERNATIONAL RELATIONSHIPS: With the Paediatric Emergency Research Network, the Guidelines International Network, the Global Sepsis Alliance, and the International Federation of Medical School Associations. RESEARCH COLLABORATION: Our new Research Committee will consider research proposals, explore and potentially develop global research collaboration, and aims to develop a research agenda and assist in prioritization of research internationally. PROFESSIONAL RESOURCES: Utilizing the excellent collaborations at the London Symposium to develop a consensus on Quality Indicators; and the creation of Special Interest Groups in Disaster Medicine, Ultrasound, Triage and Paediatric Emergency Medicine. Going forward, the election of a new 12 person Board will increase proper representation of all geographical and cultural aspects of members into Submit news from your the future. There are now 45 national emergency medicine socimembers and 5 regional organizations, representing organizations that provide ety for publication. Email emergency care for the most of the Logan@EPIJournal.com planet.

IEDLI

International Emergency Department Leadership Institute

22-26 October, 2012 Leuven, Belgium As the number of interdisciplinary emergency departments grows internationally, where can ED leaders acquire the administrative skills they need to build and sustain successful emergency departments? The International Emergency Department Leadership Institute (IEDLI) was created by Harvard Medical School faculty and other international experts in order to provide ED leaders with the skills and knowledge they need to successfully operate emergency departments in any part of the world. In this one-week course of over 35 hours of interactive lectures and workshops, leaders will explore strategies to: • Establish the ED’s role within the hospital • Improve efficiency and control costs • Decrease overcrowding • Develop quality improvement programs • Educate and motivate ED doctors and nurses • Develop an emergency medicine training program • Form a strong administrative structure This program is designed for doctors, nurses and administrators.

Come celebrate the 20th anniversary of the LOGO Club of Leuven at IEDLI 2012 IEDLI 2012 is officially endorsed by EuSEM, The European Society of Emergency Medicine

The International Emergency Department Leadership Institute is a collaboration between www.epijournal.com 21 Harvard Medical Faculty Physicians at BIDMC and Brigham and Women’s Hospital.

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Global Research Review by Adam C. Levine, MD, MPH on behalf of the Global Emergency Medicine Literature Review Group

Botswana/Canada_Using Telesimulation to Train Providers in Resource-Limited Settings Mikrogianakis A, et al. Telesimulation: An Innovative and Effective Tool for Teaching Novel Intraosseous Insertion Techniques in Developing Countries. Academic Emergency Medicine 2011; 18:420-427.

uilding on previous work in which surgeons demonstrated that laparoscopic skills improved when using telesimulation compared to self-practice, Mikrogianakis et al. demonstrate successful teaching of intraosseous (IO) needle insertion using telesimulation. Using the internet, telesimulation connects an instructor and trainee allowing them to see and speak to each other as well as see within each other’s simulators. In this study, Canadian physicians taught 22 volunteer Botswanan physicians from a variety of specialties IO insertion using matching simulation rooms located at both sites. To learn IO insertion, the Botswanan physicians underwent two training sessions: one 60 minute didactic session, and one 15 minute individual telesimulation instruction session. Participants underwent three evaluations: 1) A 15 item pre- and post intervention- knowledge test, which was pilot tested on Canadian pediatric residents; 2) An eight item pre- and post-simulation survey evaluating knowledge, comfort and confidence; 3) A practical exam scored both remotely and on site. On the knowledge exam test, means improved by 5 points (95% CI = 3.9 - 6.3). For the simulation survey, which evaluated physicians’ knowledge, comfort and confidence, a chi-squared test compared binary “high” or “low” categories with all categories having a p<0.05. Finally, the simulation score showed no significant difference as to whether it was scored in person or over the internet. This study combines two relatively recent developments, teleconferencing and medical simulation, into ‘telesimulation,’ which is utilized in this study to teach a specific technical skill to medical professionals in a developing country. The most important potential strength of telesimulation is lower cost compared to international travel of educators from developed countries to developing countries, which requires flights, visas, accommodation, and time away from work. Telesimulation could also facilitate re-assessment and re-enforcement of skills over long periods of time, a known weakness of one-time educational interventions. Despite these potential strengths, telesimulation may not be suitable for countries with poor internet connections, locations with unreliable electricity, or facilities with poor information technology support or technological literacy. An important weakness of the study is that the primary method of evaluation of impact is pre and post tests, with no demonstration of retention of the skill over time, or more importantly improvement in health outcomes. Before either telesimulation or training of physicians in resource limited settings on IO utilization can be recommended for broader implementation or scale-up, skill retention, positive clinical impact, and relative cost-effectiveness compared to other interventions must be demonstrated.

-AL, KP

Global_Rehydration Reconsidered Rouhani S, Meloney L, Ahn R, Nelson BD, Burke TF. Alternative rehydration methods: a systematic review and lessons for resource-limited care. Pediatrics 2011 Mar;127(3):e748-57. Epub 2011 Feb 14.

ith significant research available on the efficacy of oral and intravenous rehydration, this review focuses on alternative methods for rehydration in dehydrated children. The literature review explored articles addressing dehydration in children through December 2009. In those articles that met inclusion criteria, nasogastric hydration was found in multiple cases to be as effective as intravenous hydration in children with moderate to severe dehydration. Intraosseus hydration was also found to be effective, though few randomized control trials exist. Intraperitoneal rehydration has some benefit, while there is limited data on subcutaneous rehydration. This article explores the various alternatives to traditional oral or intravenous hydration, and finds that nasogastric and intraosseous rehydration are effecThis review tive alternatives to oral and intravenous rehydration. provides cliWhile oral rehydration should remain first line thernicians with apy for children with mild-moderate dehydration, in children with moderate-severe dehydration or those the evidence refusing oral rehydration, nasogastric or intraosseous necessary to rehydration are safe and effective alternatives to inrapidly inititravenous hydration, especially in resource-limited settings. The authors of this review both highlight ate alternathe key articles studying each different method and tive rehydrareport on the deficiencies in the current research on tion methods alternate methods of rehydration in children. This subject is very pertinent to international emergency when standard medicine as it provides clinicians with the evidence practices are necessary to rapidly initiate alternative rehydration unsuccessful methods when standard practices are unsuccessful or unavailable. or unavailable. -AL, PM

Uganda/United States_Comparing Injury Mortality in San Francisco and Kampala Jayaraman S, Ozgediz D, Miyamoto J, et al. Disparities in injury mortality between Uganda and the United States: comparative analysis of a neglected disease. World J Surg. 2011 Mar;35(3):505-511.

he burden of injury-related deaths disproportionately affects developing countries, and according to estimates, will continue to grow, outpacing many other high priority diseases. However, little is known about injury patterns in developing countries and how they compare to developed countries. In this article, Jayaraman

A L : A D A M L E V I N E , M D , M P H ; K P : K I M B E R LY P R I N G L E , M D ; H D : H E R B I E D U B E R , M D ; P M : P A Y A L M O D I , M D

July 2012 // Emergency Physicians International

PMPH-USA A Comparative Look at Trauma in the Developing World

Critical Books and iPad Apps in

Emergency Medicine from PMPH-USA

Kampala, Rwanda

San Francisco, USA

percentage of deaths due to injury

25%

the odds of dying of injury

{five time higher in kampala}

mean age of injury-related death

and colleagues compare injury-related mortality patterns in Kampala, Uganda to San Francisco, California and the United States more broadly. They utilized vital registry, mortuary and trauma center data to calculate death rates and odds ratios, and then analyzed those results by age, cause-specific death and affected body region. The authors found that during the 6 months of data analyzed, 25% of all deaths in Kampala were due to injury, versus 6% in San Francisco. Furthermore, they calculated the odds of dying of injury in Kampala were five times that of San Francisco. The mean age of injury-related death in Kampala was significantly lower than in San Francisco (29 vs. 44 yrs), and the odds of dying from a given cause (e.g. motor-vehicle collision) or affected body region (e.g. head and neck injury) was higher in Kampala. Much of the epidemiologic information we have from developing countries is inadequate due to poor record keeping and missing information. In this article, the authors use three different sources to collect as much data as possible on injury-related deaths in Kampala, Uganda. The result is a robust analysis of the disparities in death rates and causes of death from injury when comparing Kampala, Uganda to San Francisco, California. However, as the authors note, there is still the possibility of missing data when deaths are not recorded, a common phenomenon in many developing countries, although usually less so in urban settings. In addition, injury severity is not recorded, making comparisons between death rates limited, and assertions that improved trauma systems could improve outcomes speculative. Despite these limitations, this article reinforces that injury-related death in developing countries should be a key public health priority moving forward. -AL, HD

Books are available at pmph-usa.com, amazon.com, or your local bookseller. Prehospital Care and EMS book apps are available through Appleâ&#x20AC;&#x2122;s iTunes. Attending the ICEM Meeting in Dublin? www.epijournal.com 23 View and order these books at Wisepress - stand C3a

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Making Do When the ED is Down When disaster strikes, local healthcare facilities can quickly become overwelmed, necesitating the organized creation of alternative care sites (ACS). Whether this takes place in a school, arena or church, there are a few important things to remember – lessons learned in some of the world’s worst medical disasters.

by kenneth iserson, md, mba

hen an institution’s systems fail—or when a local or regional disaster occurs—the limited surge capacity of the health care system will quickly be overwhelmed. When this happens, it will require using one or more alternative care site (ACS). Situated in a variety of non-health care structures, ACS’s may be used for ambulatory, acute, subacute, or chronic care. Developing alternative care facilities is the one disaster-planning step that moves communities from talking to doing. This commitment pays real dividends if a disaster of any magnitude strikes. Any available site may initially be used to provide health care after a disaster. After a massive earthquake in Turkey in 1999, for example, makeshift medical centers were set up on street corners and in ruined buildings.(1) Five months after Hurricane Katrina, when the media spotlight had dimmed, the New Orleans Convention Center still housed a makeshift medical center. The “emergency rooms” consisted of six military-surplus tents in which about 5,000 patients, many of them uninsured poor, were treated each month.(2) After 9/11, Canadian emergency medicine residents used a New York City high school as a medical facility. They later wrote, When we arrived at Stuyvesant High School, we found that there was limited electrical power because many local power grids were knocked out . . . Thus, many of the more intricate procedures, such as suturing, needed to be performed under the illumination of hand-held flashlights. The layout of the triage was very simple. In the main foyer of the school were approximately eight stretchers clustered together in a makeshift patient care area. Surrounding the cots were

dozens of large boxes of unorganized medical equipment, many unopened. The injured arrived either by ambulance or were ambulatory, and promptly triaged. Each stretcher, when possible, was staffed with two nurses, an attending physician, a resident and a medical student. As there were few survivors of the direct disaster, all patients we assessed were emergency response personnel and volunteer rescue workers.(3) Issues in Establishing an ACS A number of inter-related issues must be resolved when establishing a viable ACS. These include the following: • Who will decide to open the facility? Under whose authority will the site be established and run? This should normally be decided at a regional level. • Who will direct the facility’s operations? • What types of patients will the facility house and treat? Will the ACS be used to decompress hospitals or nursing homes, or to provide primary care? What patient acuity will it accept? Will it accept oxygendependent patients? • Which available facility will be used for this type of medical care? What will be the selection criteria? How will approval for use be gained? What will be the infrastructure dependencies? Or will the site be a previously designated portable/temporary shelter? • Who will staff the ACS, including medical support and volunteer staff? • What durable and disposable supplies and equipment will be available? In what quantities? • What operational support (meals, sanitation needs, and infrastructure) will be required? • What policies and what patient documentation will

July 2012 // Emergency Physicians International

01 A large ACS at a sports facility that was opened after the Joplin, MO, tornado in 2011. This ACS had a special (staffed) section for bedridden medical patients, a cafeteria, and a playroom for children. 02 A makeshift ED – housed in a grocery store’s former meat locker – in an ACS following Hurricane Ike in 2008

This is how an ACS looked as it was about to get its first occupants. They were “special needs” evacuees in advance of Hurricane Ike hitting the Texas coast. The structure housing this ACS was a former grocery store that was converted into a large church. Extra electrical outlets were installed to accommodate medical equipment for the occupants.

Table 1: Buildings/Structures Typically Used as Alternative Care Sites. Adult detention facility

Trailer/tent (military or other)

Shuttered hospital

Community/recreation center

Aircraft hanger

Church

Government building

Convalescent care facility

Fairground

Military facility

Hotel/motel

Meeting hall

School

National Guard armory

Same-day surgical clinic

Sports facility/stadium From Cantrill, Bonnett, and Pons.(7)

be used? • Who will decide to close the ACS? What criteria will be used? Implementation Difficulties Planning for an ACS is difficult, and takes personnel time, financial resources, and political capital. For these reasons, most regions have abandoned any real ACS planning. Rather, they use a conceptual model, such as “we can use the stadium,” without any further thought. Only when a disaster strikes do they find that the “planning” was woefully inadequate. (Go ahead, ask your emergency medical services [EMS] and disaster planners what they have done.) In addition to a lack of finances and leadership, another major stumbling block is that, to be effective, multiple groups, who traditionally have not done so, must work together. Who Controls, Opens, and Closes the Alternative Care Site?

The single most important issue for the successful establishment of an ACS is determining its ownership, command, and control. These are political issues that should be decided at a local or regional (as opposed to institutional) level. Decisions must be made about the individual(s) who can decide whether, when, and where an ACS should be opened, as well as about who has the authority to operate the site.(4) Deciding to open an ACS is bound up with bureaucratic and financial implications. While an individual hospital can make the decision alone, the decision will usually be regional, with support from many sources, especially the government. If a hospital decides to open an ACS as part of their emergency operations plan, they assume an enormous burden that few except the largest institutions can manage. This includes the need to find an acceptable facility; to staff and equip it; to establish policies and manage it; to coordinate operations with the EMS, Red Cross, and other community emergency assets; and, lastly, to finance it. While there may be many

fewer bureaucratic obstacles to “going it alone,” the sheer magnitude of such an operation presents formidable barriers. In some cases, where the need is obvious and no leadership has either prepared for or is willing to support establishing an ACS, individual clinicians and support staff may need to open an ACS on their own. That was the case in St. Bernard Parish after Hurricane Katrina, when three family practitioners opened the only medical facility in two counties (parishes) in what had been the lobby of the ExxonMobil refinery—located on the highest point in the parish. Using whatever equipment and supplies they could salvage from the flood water (with the help of the local sheriff’s department), they provided care for a week after the storm. They recruited nurses who were willing to stay and help, as well as two family practice residents from a nearby state (one was a relative). Eventually, a Disaster Medical Assistance Team (DMAT) (AZ-1, from Arizona) assumed responsibility for that ACS. An exit strategy and exit criteria should be built into the initial plan. The decision to close an ACS is much easier if preset and widely understood guidelines control the process. How Will the ACS be Used? Most of the decisions about an ACS (staffing, equipment, supplies, and type of structure) flow from the manner in which it will be used. Therefore, that is the first major decision that must be made. Possible uses are as follows (5): • Facility to house low-acuity patients from hospitals and nursing homes • Ambulatory care/vaccination clinic • Primary triage point to decide where and how patients can best be treated • Acute care inpatient facility • Facility in which to quarantine or isolate patients • Place to provide palliative care for hospitalized patients • Facility to house patients discharged from hospitals so that they can be released earlier than usual Note that many alternative care facilities have multiple functions. Some develop as the situation progresses, although the facility should not exceed its www.epijournal.com

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structural, staffing, or logistical capabilities. Picking a Facility Selecting facilities to serve as an ACS is an imprecise science and varies with the event. Most commonly used are facilities of opportunity, or “buildings of convenience,” which are non-medical buildings that can be adapted into an ACS.(6) The building selection process works best if there is first a clear idea of the role planned for the ACS. Buildings typically used as an ACS are listed in table 1. An often forgotten fact is that if an ACS can accommodate patients from nursing home/long-term care facilities, those beds can be converted for acute care use (often with an existing oxygen supply). If there are options when selecting an ACS, especially if it is being selected in advance of a disaster, some basic questions must be answered to get the best possible facility. Of course, even the best facility will still need lots of improvisation to make it work well (table 2). Structure Selection Criteria Rate possible alternative care facilities using preset criteria (table 3). Give each criterion a 1 to 5 rating based on how close it comes to the same criterion in a hospital, “5” being “equal to a hospital.” Once in use, facilities should be laid out in an organized fashion. A grid system allows clinicians to make “rounds” and know exactly where to find a patient (e.g., bed A4). Public health issues are critical (e.g., safe food and water supply, sanitation, latrine resources). (11) Staffing and Security Once a suitable facility is found, staffing becomes an issue. Emergency privileging of health care professionals can be a knotty issue. Staff may be volunteers, off-duty providers from the primary facility, military personnel, or designated members of disaster response teams (e.g., DMAT). Table 4 lists the ideal staffing for each 12-hour shift in a 50-bed inpatient ACS. Staff members face several issues, including that of arranging for provisions to house and feed the patients. If volunteers are used (as they should be), they should have their own coordinator. Understand that volunteers may not want to do certain tasks (e.g., colostomy care, diaper changes). Establish who is going to do what. Note that placing an ACS near a college or university enlarges the potential workforce (e.g., football team) to help carry patients, set up equipment, and so forth.(11) In chaotic situations, security becomes an extremely

Table 2: Questions to Ask When Selecting an ACS Will the structure accommodate expected number of patients and staff, and the planned activities? Is the structure located in a relatively safe area (culturally and geographically)? Is it structurally sound? Is it easily accessible by ambulance, foot, and automobile/public transportation? Is there adequate electrical power (plus back-up power or the capacity to tie-in to large portable generators)? Are there adequate potable water, ventilation, refrigeration, and lighting? Are the ventilation and lighting systems on the back-up generator? Are there also other back-up electrical outlets for critical equipment, such as ventilators? Are there kitchen facilities adequate for the number of people expected (patients, staff, visitors)? Is the entire patient care area wheelchair/stretcher accessible? If elevators are needed, are they on the back-up power system? Will there be separate space for other necessary functions, such as staff sleeping/rest areas, communications center, command center, waiting area, security office, pharmacy, equipment supply and storage areas, chapel/family counseling area, and a morgue? Can the building be secured? Can you control patient and staff traffic? Are there phone and computer access lines? Will cellular phones and radios (two-way, ambulance, public sector, and ham) work within the building without interference? Can lights be dimmed in sleeping and patient care areas? Are the doors >33 inches wide to permit ambulance stretchers to move through them? Are there areas to load and unload patients and supplies? Ideally, these will accommodate forklifts. Is there parking for patients, staff, and visitors? Are toilet and shower facilities adequate for the anticipated number of patients, staff, and visitors?(*) Does the facility have oxygen or will it be readily available? (*) Is the facility easy to clean for patient use? Note: (*) Important and often overlooked in planning alternative care sites.

July 2012 // Emergency Physicians International

Table 3: Criteria to Consider in Alternative Care Site Selection infrastructure

Door sizes and stairways adequate for gurneys

Floors

Parking for staff and visitors

Roof

Ventilation

Walls

Toilet facilities/showers (number of)

Loading dock

total space and layout

Auxiliary spaces (pharmacy, counselors, chapel)

Staff areas

Lab specimen handling area

Equipment/supply storage area

Mortuary holding area

Family area

Patient decontamination areas

Food supply and prep area

Pharmacy area

Patient care/ward areas

utilities

Electrical power (Backup present? Adequate for anticipated equipment?)

Air conditioning (Sufficient for the number of people?)

Lighting

Heating

Refrigeration

Water (Hot?)

communications

Communication (number of phones, local/long distance, intercom)

Wired for information technology and Internet access

Two-way radio capability to main facility

Other services

other factors

01 Red Cross client shelter in Joplin, Missouri, 10 days post disaster

Ability to lock down facility

Laundry

Oxygen delivery capability

Biohazard and other waste disposal

Ownership/other uses during disaster

Proximity to hospitals

Accessibility/proximity to public transportation

Liability insurance coverage

02 ACS in former church/grocery store 03 In 2005, the Louisiana Superdome was used as a large ACS for Hurricane Katrina survivors

important concern, especially since local law enforcement will be stretched thin. Establish a system to identify staff members, patients, and their families. “Planners must develop robust security plans. It is helpful if security personnel have previous experience in dealing with patients, especially those with behavior disorders. The best potential source of security staff would be offduty hospital security personnel, but these individuals may not be available. Other potential sources would include on- or off-duty police officers, activated members of the National Guard, or volunteers.”(12) “Security makes patients and staff members feel safe and

keeps out troublemakers. Having uniformed people on site (even Reserve Officer Training Corps [ROTC] cadets) makes a real difference.”(11) In reality, many positions are interchangeable. For the ACS to function optimally, everyone must be willing to do any job for which they are qualified. Supplies and Equipment Supplies and equipment for an ACS will vary with its mission and range from extremely primitive to similar to those found in the basic hospital (not including the operating rooms or radiology). Conversely, the lack of specific items, such as oxygen, may limit an ACS’s role. Oxygen and pharmaceuticals are often difficult to obtain during a disaster. Oxygen While generally taken for granted in modern

(developed-world) hospitals, oxygen is an expensive, difficult-to-acquire commodity. Table 5 lists the costs, power requirements, and flow rates for some typical portable oxygen delivery systems. In the least-developed countries the solution is often to use oxygen concentrators, although facility-size units are not commonly available unless purchased in advance. The most common solution is to not accept oxygen-dependent patients in an ACS. Obtaining oxygen from industrial sources may also solve the problem in resource-poor situations. Reducing oxygen use in patients who may not really need it may also be necessary. Pharmaceuticals The nature of the ACS responsibilities (acute and chronic care) and the patient population will determine what pharmaceuticals are needed. In St. Bernard Parish after Hurricane Katrina, for example, the ACS www.epijournal.com

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Table 4: Ideal Staffing for a 50-Bed ACS per 12-Hour Shift

pharmacy (that Sheriff’s officers scrounged from the non-flooded shelves in local pharmacies) was used primarily to supply chronic medications to members of the military and rescue teams. Most ACS will also need to stock medications to provide acute respiratory therapy, acute hemodynamic support, pain control, anxiolytics, antibiotic coverage, and behavioral health maintenance.(15)

1 Physician

1 Physician Extender (PA/Nurse Practitioner)

6 Registered Nurse or Licensed Practical Nurse

4 Health Technician

2 Unit Secretary

1 Respiratory Therapist

1 Case Manager

1 Social Worker

1 Medical Assistant/ Phlebotomist

2 Food Service

1 Chaplain/Pastoral

2 Patient Transporter

4 Volunteer

.25 Engineering/Maintenance

2 Security

2 Housekeeper

.25 Biomedical Engineer 1 Lab

From Cantrill, Bonnett, and Pons.(7)

Table 5: Oxygen Equipment Typically Available Oxygen Flow Rate (L/min)

Power Required (kW)

Oxygen Purity (%)

Expeditionary deployable oxygen concentration system

120

93 ± 3

Portable therapeutic oxygen concentration system

93+

Portable oxygen generation system

93–95

20/20

4.3

93 ± 3

0.2

93 ± 3

Oxygen Generation Systems

Patient ventilation oxygen concentration system Home oxygen compressor

REFERENCES 1. Erri Emergency Services Report. Emergencynet News Service, Wednesday, August 18, 1999. Vol. 3, 229-09:00cdt; Turkey. Death toll from earthquake now exceeds 3,500. 2. CNN. “You are taking your life in your hands.” Posted by Sean Callebs, CNN Correspondent on Tuesday, February 14, 2006 at 8:06 PM ET. http://www.cnn.com/ CNN/Programs/anderson.cooper.360/ blog/2006/02/you-are-taking-your-life-inyour-hands.html. Accessed September 12, 2006. 3. Carvalho AM, Delvin ME, Rosenczweig C, et al. Helping at ground zero: the experience of four Canadian emergency medicine residents and an emergency department nurse. Canadian Assoc Emerg Phys Newsletter. http://www.caep. ca/page.asp?id=96C6D43FBEFF4C1582 6C7ABF3329419D. Accessed September 12, 20069/12/06. 4. Cantrill S, Bonnett C, Pons P. Alternative care sites. In: Phillips SJ, Knebel A (eds.). Providing Mass Medical Care with Scarce Resources: A Community Planning Guide. Rockville, MD: Agency for Healthcare Research and Quality, 2006:82. 5. Cantrill S, Bonnett C, Pons P. Alternative care sites. In: Phillips SJ, Knebel A (eds.). Providing Mass Medical Care with Scarce Resources: A Community

Planning Guide. Rockville, MD: Agency for Healthcare Research and Quality, 2006:74-101. 6. Cantrill S, Bonnett C, Pons P. Alternative care sites. In: Phillips SJ, Knebel A (eds.). Providing Mass Medical Care with Scarce Resources: A Community Planning Guide. Rockville, MD: Agency for Healthcare Research and Quality, 2006:86. 7. Cantrill S, Bonnett C, Pons P. Alternative care sites. In: Phillips SJ, Knebel A (eds.). Providing Mass Medical Care with Scarce Resources: A Community Planning Guide. Rockville, MD: Agency for Healthcare Research and Quality, 2006:85. 8. Capitol Region Metropolitan Medical Response System, Hartford, CT. Selection and Evaluation of Alternate Care Facilities Survey Tool. http://www.crcog.org/publications/HomeSecDocs/ESF%208/Alternate%20Care%20Sites/Survey_Tool_ACF. pdf. Accessed June 2, 2008. 9. Cantrill S, Bonnett C, Pons P. Alternative care sites. In: Phillips SJ, Knebel A (eds.). Providing Mass Medical Care with Scarce Resources: A Community Planning Guide. Rockville, MD: Agency for Healthcare Research and Quality, 2006:100. Also available as an interactive tool at www. ahrq.gov/research/altsites.htm. 10. Shaw JJ, DMD, Program Director, Capitol Region Metropolitan Medical Response System, Hartford, CT, Chair, ESF

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8 [Health and Medical] Capitol Region Emergency Planning Committee, 2007. 11. Cantrill S, Bonnett C, Pons P. Alternative care sites. In: Phillips SJ, Knebel A (eds.). Providing Mass Medical Care with Scarce Resources: A Community Planning Guide. Rockville, MD: Agency for Healthcare Research and Quality, 2006:94. 12. Cantrill S, Bonnett C, Pons P. Alternative care sites. In: Phillips SJ, Knebel A (eds.). Providing Mass Medical Care with Scarce Resources: A Community Planning Guide. Rockville, MD: Agency for Healthcare Research and Quality, 2006:91. 13. Cantrill S, Bonnett C, Pons P. Alternative care sites. In: Phillips SJ, Knebel A (eds.). Providing Mass Medical Care with Scarce Resources: A Community Planning Guide. Rockville, MD: Agency for Healthcare Research and Quality, 2006:89. 14. Berry DK, Shackelford LS, Hewitt II CA. Appendix A: Oxygen supply options. In: Phillips SJ, Knebel A (eds.). Providing Mass Medical Care with Scarce Resources. A Community Planning Guide. Rockville, MD: Agency for Healthcare Research and Quality, 2006. 15. Cantrill S, Bonnett C, Pons P. Alternative care sites. In: Phillips SJ, Knebel A (eds.). Providing Mass Medical Care with Scarce Resources: A Community Planning Guide. Rockville, MD: Agency for Healthcare Research and Quality, 2006:88.

Improvised Medicine:

The Book

Ever need to build your own centrifuge in the field? How comfortable do you feel performing an emergency tracheostomy with a straight razor? Dr. Ken Iserson’s new book Improvised Medicine: Providing Care in Extreme Environments (McGraw-Hill) covers topics from dental emergencies to managing disasters to making your own diagnostic equipment. Emergency Physicians International readers can purchase the book from McGrawHill at the special reduced price of $43.20 (Regularly $54.00) at: www. mhprofessional.com/ promo/index. php?promocode= iserson&cat=39

Bridging the Gap between Evidence and Practice

The Irish Association of Emergency Medicine (IAEM) is proud and honoured as your local hosts to welcome you to Dublin to the 14th International Conference on Emergency Medicine, ICEM 2012. Although by far the smallest organisation to have ever hosted an ICEM Meeting, we have endeavoured to put together a stimulating and innovative scientific programme â&#x20AC;&#x2DC;Bridging the Gap between Evidence and Practiceâ&#x20AC;&#x2122;, featuring a combination of world class speakers and original research. We are also delighted to offer a full and authentically Irish social programme and hope to succeed in creating a genuine platform for discussion, learning and networking amongst the international Emergency Medicine community. We trust you will benefit from your attendance at ICEM 2012, enjoy your stay in Ireland and will carry fond memories of ICEM 2012 with you, for years to come. IAEM would like to acknowledge IFEM for their partnership and support in making ICEM 2012 happen and look forward to seeing you again in Hong Kong for ICEM 2014!

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Designing the ED of Tomorrow In part I of EPI’s new design series, Dr. Manuel Hernandez explains how smart architectural decisions can lead to real improvements in emergency care. 01

“I

f you build it, they will come.” These words have been uttered in movies, by businessmen and women and they form the backbone of revenue-driven healthcare delivery models. While many state-sponsored and single payer healthcare models believe these words don’t apply to their reality, this could not be further from the truth. As acceptance of emergency medicine evolves, history has taught us that utilization rates generally follow an upward trend (10, 12, 14). Eventually, almost every ED will require expansion or replacement. When the time arrives, careful planning during the predesign, design, construction and occupancy phases will play a critical role in determining how successful the new ED will be in meeting community need. Understanding what to build and how to build a new ED requires, to a certain degree, a leap of faith. Most peer-reviewed information on ED design focuses specifically on modifications to processes or overall capacity while little attention has been paid to how the built environment can impact care delivery. To understand this, we must often look to other clinical areas and draw our own conclusions. Alternatively, we can turn to the architectural literature where an emerging discipline known as evidence-based design is beginning to study how the built environment impacts care delivery and vice versa. Regardless of what research is consulted, there are a number of design considerations that should be incorporated into any ED design project. Too numerous and complex to cover in a single review article, the following are key high-level concepts that should be incorporated into any new ED project. Understanding Process and Patient Flow Planning a new or expanded ED presents a golden opportunity to rethink how care is delivered. Every ED design project should begin with an assessment of current operations to understand what processes

work well and where opportunities exist to improve. Leveraging methodologies such as LEAN can yield significant benefits in terms of length of stay, walkout, mitigating access block and has been shown to be effective in both developing and mature emergency medicine systems (3, 11). Regardless of methodology employed, process redesign undertaken in collaboration with architects provides the design team with keen insights into ensuring the built environment is designed to support operations as opposed to hindering them (16). Process standardization has been shown to decrease morbidity and mortality in a range of clinical areas while also reducing overall length of stay (2, 15). From a facility perspective, creation of standardized, or universal, patient care rooms promotes improved efficiency and results in more flexible clinical areas (1, 5). Rethinking departmental layout can also positively impact patient safety as well as improve patient per-

July 2012 // Emergency Physicians International

01 Proper design can create intuitive way-finding for patients and families. The Gates Global Vascular Institute (Buffalo, NY, USA) uses large lettering and bright lighting to ease locating the emergency department entrance. 02 Identical design of trauma rooms as in the case of UMASS Memorial – Lakeside creates an ease of orientation for clinicians providing fast-paced, high-acuity care. Proximity to adjacent departments such as imaging speeds time to diagnostics and reduces overall transport times and time out of department for critically-ill patients.

03 Situational awareness is essential in the ED. Designing departments that ensure a clear line-of-site from staff work areas to all treatment stations promotes patient monitoring and early recognition of clinical decompensation. 04 Access to natural light and the external environment is an important consideration to promote patient and family satisfaction along with a sense of well-being. 05 Open treatment station design promotes patient access and ability for physicians and care team to manage multiple high-acuity patients simultaneously. 06 ED treatment station design with dedicated hand-washing and staff work / documentation stations promote infection control and increased time at bedside. Introduction of entertainment devices such as a TV improves patient satisfaction and distracts from prolonged delays.

ceptions of privacy (8, 13). In both cases, the design of the built environment had a direct impact on the outcomes observed. Technology Planning Technology planning is never more important than at the beginning of a new design project. Careful consideration of the impact of processes and workforce models and vice versa will ensure an informed ED design that places technology in the right places at the right time in the care delivery process. For example, point-of-care testing (POCT) has been a proven technology with respect to accelerating time-to-diagnosis and reducing overall length of stay (17). Planning for POCT requires consideration regarding the location of analyzers, reagents and quality control materials as well as planning for appropriate wireless bandwidth to facilitate seamless interface with existing electronic health records. Another important facility planning consideration is the impact of computerized physician order entry (CPOE) on processes. When planned properly, CPOE has been shown to have a meaningful impact on over-

all length-of-stay while reducing incidence of medical errors and overall mortality (9, 18). As with POCT, planning for the location of CPOE stations, IT bandwidth and the point in the care process where order entry may occur are all important when considering potential design solutions. Inter and Intra-Departmental Adjacencies As the front door to many hospitals, the EDâ&#x20AC;&#x2122;s location relative to other clinical, diagnostics and therapeutic areas becomes an important consideration. Similarly, the location of different components of the ED itself become important considerations in planning and design. A 2008 study identifying barrier to timely evaluation of chest pain patients in the ED noted that design considerations such as presence of solid doors on exam rooms and proximity of patients to the physician work area can impact time to patient evaluation (4). Anecdotally, even the location of diagnostic imaging modalities within the ED can have appreciable impacts on efficiency and length of stay. One U.S. ED

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reported significant reductions in overall length of stay and walk-out rates tied to the relocation of a fixed plain radiograph room immediately adjacent to the triage stations (7). Similarly, reductions in overall intradepartmental transports can yield positive impacts on cost and efficiency (6). Choosing the Right Architect Choosing the right architect to support an ED project is not always an easy undertaking. Healthcare architecture is one of the most complicated subspecialties and, while many architectural firms claim experience in healthcare design, experience does not always translate into proficiency. When choosing an architectural partner, this author recommends considering the following as a part of the selection process: ++ Experience in healthcare planning and design ++ Approach to including staff in planning and design process ++ Ability to translate future care delivery models into built environment ++ Demonstration of proven outcomes in previous projects ++ Diversity of design solutions ++ Previous client references ++ Global expertise to facilitate innovative solutions Regardless of the stage of evolutionary development, EDs globally and their patients will benefit

REFERENCES 1. Agency for Healthcare Research and Quality. Acuity-adaptable inpatient rooms eliminate most patient transfers, leading to enhanced safety, satisfaction, and efficiency. May 2008. Accessed at www.innovations. ahrq.gov/content.aspx?id=1701 on 5/10/2012. 2. Bozic KJ, et al. The influence of procedure volume and standardization of care on quality and efficiency in total joint replacement surgery. J Bone Joint Surg Am. 2010; 92(16):2643-2652. 3. Carter PM, et al. Optimizing clinical operations as part of a global emergency medicine initiative in Kumasi, Ghana: application of lean manufacturing principals to low-resource health systems. Acad Emerg Med. 2012 Mar;19(3):338-47. 4. Hall K, et al. Impact of emergency

from ED planning and design projects that are focused on careful evaluation of the countless factors impacting the development of a successful design solution informed by global best practices, active engagement of key stakeholders and selection of an experienced architectural partner.

department built environment on timeliness of physician assessment of patients with chest pain. Environment and Behavior. 2008;40: 233-248. 5. Hendrich A. Case study: The impact of acuity adaptable rooms on future designs, bottlenecks, and hospital capacity. Paper presented at the Impact Conference on optimizing the physical space for improved outcomes, satisfaction, and the bottom line, Atlanta, GA. 2003. 6. Hendrich A, et al. Intra-unit patient transports: Time, motion, and cost impact on hospital efficiency. Nursing Economics 2005;23(4): 157–164. 7. Horton E. Personal interview. Apr. 2012. 8. Institute of Medicine. Work and workspace design to prevent and mitigate errors. In Keeping patients safe: Transforming the work environment of nurses. p226–285. Washington, DC: National Academies Press. 2004.

July 2012 // Emergency Physicians International

5 Ample work stations and electronic patient tracking technologies, all with direct line-of-sight to patient treatment stations increase patient monitoring and enhance the overall patient experience.

9. Longhurst CA, et al. Decrease in hospital-wide mortality rate after implementation of a commercially sold computerized physician order entry system. Pediatrics. 2010 Jul;126(1):14-21. 10. Lowthian JA, et al. Demand at the emergency department front door: 10-year trends in presentations. Med J Aust. 2012 Feb;196:128-32. 11. Mazzocato p, et al. How does lean work in emergency care? A case study of a lean-inspired intervention at the Astrid Lindgren Children’s hospital, Stockholm, Sweden. BMC Health Serv Res. 2012 Feb 1;12:28. 12. Niska R, et al. National Hospital Ambulatory Medical Care Survey: 2007 emergency department summary. Natl Health Stat Report. 2010 Aug 6;(26):1-31. 13. Olsen JC, et al. Emergency department design and patient perceptions of privacy and confidentiality. J

Emerg Med. 2008:35(3); 317–320. 14. Rehmani R, Norain A. Trends in emergency department utilization in a hospital in the Eastern region of Saudi Arabia. Saudi Med J. 2007 Feb;28(2):236-40. 15. Retezar R, et al. The effect of triage diagnostic standing orders on emergency department treatment time. Ann Emerg Med. 2011 Feb;57(2):101-3. 16. Sheehan D. Personal interview. May 2012. 17. Singer AJ, et al. Point-of-care testing reduces length of stay in emergency department chest pain patients. Ann Emerg Med. 2005 Jun;45(6):587-91. 18. Spalding SC, et al. Impact of computerized physician order entry on ED patient length of stay. Am J Emerg Med. 2011 Feb;29(2):207-11.

// united arab emirates

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Breaking Ground in Dubai On the heals of the first Global Network Conference on Emergency Medicine [photos], Dr. Saleh Fares, founding president of the Emirate Society of Emergency Medicine, explains whatâ&#x20AC;&#x2122;s next for EM in the UAE.

photos & interview by logan plaster

EPI: Tell us a little bit about your path to emergency medicine. Why did you become an emergency physician? DR. SALEH FARES: During medical school, I was bothered by several devastating stories of people losing their lives in the United Arab Emirates (UAE) due to the lack of adequate emergency services. This 03

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// united arab emirates

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made me seriously consider EM as a career, especially since it was a new specialty in the region. One of my teachers, Dr. Nabil Al Ansari, a Bahraini Board certified emergency physician, highly encouraged me to apply for residency program in Canada. I was lucky to be accepted at McGill University, the first EM program in Canada. Following my EM Board, and being the first Emirati EP, I realized the huge deficit in prehospital care, not only in UAE, but in the region as a whole. I decided to do an EMS fellowship in Toronto, Canada’s largest EMS system, and then did a second fellowship in Disaster Medicine. I was honored to be Harvard’s first Disaster Medicine Fellow in 2009. Currently I am enrolled in a part-time MPH-DrPH program at Johns Hopkins Bloomberg School of Public Health focusing on Health Care Management and Policy, with an aim to be able to move emergency medicine forward in the UAE and the region.

EPI: What is the current state of emergency medicine in the UAE? SF: Healthcare in the UAE has undergone rapid development since its formation in early 1970s. The transition from ‘Accident and Emergency’ (A&E) staffed by non-EPs to emergency departments (EDs) occurred as recently as the 2000s, with western board certified emergency physicians establishing emergency medicine in their respective departments. Sheikh Khalifa Hospital in Abu Dhabi and Rashid Hospital Trauma Center in Dubai were two EDs that had significantly benefited emergency medicine as a specialty by providing state-of the art care, which was not available at other facilities then. Training programs started then, coinciding with the growth of Arab Board Certification in EM. Currently three residency programs in EM are being offered. Emergency medical services (EMS) in UAE is largely organized

July 2012 // Emergency Physicians International

01 Conference attendees from

Pakistan 02 Conference coordinator Hilda

Haghighi with conference chairman Dr. Abdelouahab Bellou 03 (L to R) Drs. Terrence Mulligan, Peter Cameron and Nagi Souaiby 04 Qadhi Saeed Al Murooshid, Director-General of the Dubai Health Authority 05 The growing Dubai skyline 06 Dr. Saleh Fares, founding

president of the Emirate Society of EM, and Dr. Bob Corder, ED Chair at Tawam Hospital 07 Dr. Abdel Noureldin, EM program director at Tawam Hospital in Al Ain, UAE 08 Sheikh Mansour Bin Mohammed (2nd from Left) inaugurates the 1st Global Network Conference on Emergency Medicine

and run by the police departments of the respective Emirates (states), with increasing participation from health authorities.

aspect of it being led by EPs. EPI: How did the Emirate society come about? What was it like forming a brand new EM society?

EPI: What is on the horizon for emergency medicine in the UAE?

SF: With several projects going on, it was necessary to establish a “formal” EM body, under which several projects, initiatives and activities can be launched. We felt that it will put EM on the map, and so a group of emergency physicians have taken major steps in establishing the Emirates Society for Emergency Medicine (ESEM), which will be officially launched in late 2012. We started collaborating with international partners and look forward to having an active EM society in UAE.

SF: As expected in a rapidly growing country, there are lots of things going on. Emergency departments and trauma centers are being established and expanded in public hospitals throughout UAE. EM trained physicians are increasing in UAE; a fourth EM training program is anticipated to start in 2013 and there are plans to start a critical care fellowship. A trauma care system for Abu Dhabi with plans to extend it to the whole of UAE over the next decade is currently being established and lead by our group. UAE has taken the lead in disaster and emergency management in the region, with the 3rd Crisis and Emergency Management Conference hosted by National Crisis and Emergency Disaster Management Authority (NCEMA) in Abu Dhabi earlier this year. One of the world’s largest disaster management facilities called “Tawazun Disaster Management City,” is being built in Abu Dhabi and is envisioned to be a unique city, with multi-agency training for emergency, crisis and disaster management for all types of natural or man-made disasters, with the medical

EPI: What are the key challenges faced by the Emirate Society of EM, as it gets off the ground? SF: Like any new society, getting the buy-in from busy EPs locally is a major challenge. Funding is another expected challenge but we are optimistic that with time, we will be able to sustain ESEM through memberships and sponsorships.

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// united arab emirates

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01 Eric Revue, an emergency physician

from Paris, France 02 Emirate media prepare for the arrival of Sheikh Mansour Bin Mohammed 03 Emirate emergency medicine residents at Tawam Hospital 04 Dr. Maaret Castren, professor of emergency medicine at Karolinska Instituut

EPI: Are there any unique clinical challenges faced by emergency physicians in the UAE, or in the Middle East?

EPI: What are the unique social challengesÂ faced by emergency physicians in the UAE, or in the Middle East?

SF: Until recently, most EDs in the UAE were staffed with expatriate medically or surgically trained physicians, with EM trained physicians serving as supervisors or consultants in larger well established EDs and trauma centers. There is a shortage of EM trained physicians, and changing the mindset of nonEM trained practitioners in EDs to diagnose, stabilize and treat the complicated cases will require time. This might be aggravated further in the future by EM trained residents who may decide to leave the UAE to finish their training and live outside the country. The need to sustain ED capabilities and mission in the face of a rapidly growing population, declining resources, and financial restraints poses challenges.

SF: UAE is a very multi-ethnic country, due to its large expatriate population; it is a melting pot of different cultures and races. Dealing with patients from different backgrounds can be challenging at times (eg. language barrier and sociocultural norms) but it is interesting and exciting to serve in such a system. UAE has the second largest economy in the region, and is a major financial and tourism destination. It is a modern cosmopolitan country which still has its own unique culture and old world charm.

July 2012 // Emergency Physicians International

INTERVIEW

RESEARCH 3 continued

3 continued

from page 8

There seems to be a large value placed in feeling part of the cutting edge of development in our speciality, especially from those practicing in less than ideal circumstances. This feeling was so strong that some emergency physicians were taking significant personal risks – one even drove through a war zone to collect trial drugs – in order to participate in our study. The CRASH2 trial showed that all injured patients who have significant bleeding or are at risk if bleeding should be treated with tranexamic acid within three hours of injury. There is often a long lag phase between the publication of a research result and its implementation into clinical practice, but having developed an international collaborative research team offers the added benefit of giving a ready made structure for the implementation of the research results. The CRASH2 collaborators have been leading dissemination and implementation within their own countries – who better to write new guidelines in each country than those who did the research? To make this process easy, a series of resources need to be provided from the centre: slide sets, information leaflets and ‘Frequently Asked Question’. One issue that we hadn’t anticipated was finding the funding for this central support for implementation, as it is not covered by the research grant and there are no other sources, so it has had to

come from our own time and resources. International emergency medicine research has a huge potential to answer important questions for our speciality. There are a specific set of structures, skills and experience that is required, which we are just beginning to map out. If we are to realise the potential of international research in emergency medicine we need to look at how our future academics are trained in order to acquire the skills to build on our initial experiences.

RESOURCES The CRASH2 Trial www.crash2.lshtm.ac.uk Coats TJ. Future research in emergency medicine: explanation or pragmatism? Large or small? Simple or complex? Emerg Med J. 2011; 28(12):1004-7 Good clinical practice in clinical trials: core knowledge for emergency physicians. Goodacre S, Coats T, Clancy M. Emerg Med J 2008; 25: 789 Leicester Emergency Medicine Academic Group www.le.ac.uk/emag

the 9th Annual NY Symposium on

INTERNATIONAL EMERGENCY MEDICINE

from page 10

they are targeting their own constituency. ICEM is attempting to be a world meeting where everyone will find something of value, and leave a better emergency physician. EPI: Key goals for this conference? FH: I’d like this ICEM to showcase Irish EM. We are a small country, but in Ireland, EM punches above its weight. There will be speakers from all over the world, but I think the Irish speakers will hold their own with the best. Also, a key goal of this ICEM is the recognition by political figures of the importance of EM. That’s an issue that we all struggle with. We’re hopeful that a senior government official – even the President of Ireland – will make an appearance at the conference, which would be a first for an ICEM meeting. This is an important step for EM, so that it gets the recognition it deserves worldwide. Which is so important, because there is a degree of ignorance about what emergency medicine is, and what EDs do. Every political system in the world is wedded to the notion that emergency medicine can be replaced by something else, be it primary care, hospital care, etc... We need to move to a point internationally where the pivotal role of emergency medicine is recognized.

August 22 – 23, 2012 New York Academy of Medicine New York City

A regional symposium in association with:

“IEM Opportunties for Students, Residents & Fellows”

KEYNOTE SPEAKERS: Art Kellerman MD, MPH • Vice President, RAND Corporation • Director, RAND Health Gregg Margolis PhD, NREMT-P (invited) • Director, Division of Health Systems and Health Policy • US Department of Health and Human Services Peter Cameron MD • President of IFEM

TOPICS: EM and Global Health Global Development of EMS and Prehospital Medicine Opportunities for IEM rotations for students and residents EM and Humanitarian and Post-Conflict Resolution IEM Opportunites by region: Africa, Asia, Latin America, India, Middle East plus... The International EM Fellowship Consortium: Funding, Education, Research, Collaborations

PROGRAM DIRECTORS: Kumar Alagappan, MD Terrence Mulligan, DO, MPH John Acerra, MD, MPH Sassan Naderi, MD Mary Frances Ward, RN, ANP, MS RSVP TO Danielle Gurr, BA iemsymposium2012@gmail.com or call (516) 562-1514

FACULTY/ATTENDINGS: $125 | RNs / NPs / PAs: $50 STUDENTS/RESIDENTS: FREE www.epijournal.com 37

Grand Rounds

PETER CAMERON, MD // PRESIDENT OF IFEM

Emergency Care for an Aging Population Examining emergency medicine’s role in caring for our vulnerable, elderly patients

derly relative. Therefore, the elderly are often left with little option but to call an ambulance for even relatively minor problems. They are also likely to leave problems for longer (resulting in more severe illness) because of inability to access care. The end product of this sequence of events is a presentation to the ED by an elderly person by ambulance, as this is the only way they can access care. The lack of coordination between agencies results in duplication of effort, medication errors and confused aims for treatment. Unfortunately, once in the ED, because the older patient is at “high risk” for every medical complaint (according to the evidence), the patient will be extensively investigated, will not be discharged quickly and has a high likelihood of admissociety seems reluctant to deal with. Put another way, emergency physicians are sion to an inpatient bed. Once in hospital, the risk of deteriorating, becoming facing the full brunt of a major shift in the way society views its older citizens. The confused, disorientated and de-conditioned is increased. Following discharge from number of co-morbidities and chronic illnesses increase with age, and yet with the hospital, the chance of a coordinated program of convalescence back into the modern interventions we can keep the elderly alive – living reasonable lives – for community is low, with increased risk of death and readmission. extended periods of time. This is good news – especially for those of us looking at There has been a lot of discussion regarding informed patient choice about the the possibility of enjoying a long and healthy old age in the extent of medical management and advanced directives, not-too-distant future. The problem begins when patients however the information given to patients and their relatives are managed in order to extend their life span without regard is very much dependent on the individual practitioner. I am Evidence shows the to quality and enjoyment of life in the twilight years. often surprised by the frequency of presentation of elderly fastest growth in ED Evidence from the emergency literature shows the fastpatients with advanced cancer (or other terminal illness), attendances are by est growth in ED attendances are by patients aged 65 years where the coordinating clinician states “full resuscitation” is or older. This group, many of whom have chronic diseases, patients aged 65+. the preferred option of the patient. When I explain to famco-morbidities and polypharmacy, represents almost oneWhat’s more, over the ily members what is involved in “full resuscitation” and the fifth of all presentations to emergency departments in most next 25 years, the very likely outcome from such an approach, somehow the decideveloped countries. And those numbers are only going to elderly proportion sion changes to “please make my loved one comfortable.” I increase with the aging of the global population. The per(85+) is projected to have to do this in the ED corridor in five minutes with 20 centage of people aged 65+ is projected to increase from rise from 1.5% to 5% of patients waiting to be seen. Somehow I feel that the family 13% to 25% in most countries over the next 25 years. More the population. has been misled and the patient’s dignity has been reduced. importantly, the very elderly proportion (85+) is projected to Maybe the intensity of the ED makes these decisions seem rise from 1.5% to 5% of the population. more immediate and powerful? Whatever the case, there It is clear that expectations regarding care of the elderly seems to be a lack of clarity in the management of elderly are changing. There is a greater expectation that the elderly will stay in the compatients; namely, the objectives of treatment and likely outcomes are seldom exmunity, that they will have community supports to enable this and they will have plained in a full and frank way. access to the same level of acute care that younger patients have, including intenWhat are we, as emergency physicians, to do? The first thing is to recognise the sive care admission. This is very different from 30 years ago when patients older extent of the problem and quantify it, locally and internationally. We must trial than 65 years were routinely excluded from expensive therapies such as dialysis. different models of care and work towards better communication and coordination Now, patients over 70 receive heart transplants and some over 90 receive openwith community providers. The concept of after-hours GP care is long gone – we heart surgery! need alternate ways of providing access to urgent care. This may involve outreach Unfortunately, as the number of elderly patients with chronic illness increases, programs from Hospitals with nurse practitioners, allied health and paramedics, it seems the ability of the community to respond to the problem has decreased. linked into specialist groups or integrated community clinics with an outreach In Australia, as in most countries, the concept of a general practitioner providing facility. The major part of the care provided may frequently be psychosocial as op24/7 access has disappeared. There are many community facilities open during ofposed to sophisticated medical care. This means that EDs must have coordinated fice hours but for three quarters of the week there is nothing. Even worse, despite care capability to ensure that expertise is immediately available from allied health the multiple specialties/subspecialties and institutions involved with the care of the – including social work and physiotherapy. Funding paradigms must change from elderly population’s complex medical problems (such as diabetes and cancer) there fees for individual services to coordinated care bundles. The fee–for-service model is little attempt to coordinate management of patients in a holistic way. In addidoes not work when the skills needed are social/coordination with programmatic tion, social and psychological problems are often managed by separate agencies. application over months. Specialties such as surgery regard their role as purely technical, with no regard to More importantly, at a community level we must start discussing the “best treatthe psychosocial context of the patient. ment” versus surrogate markers for optimal treatment such as “survival.” Most Elderly people frequently have mobility problems and many have minor cogniolder citizens want to know that someone cares and that they will be made comtive deficits, making travel difficult. Families often live in distant locations and fortable. They don’t want to die prematurely, but they don’t want life at any cost. even if they live locally, may have responsibilities that preclude support of an el-

Another shift in the ED, another tsunami of old people transported to the acute care area with multiple medical, social, cognitive and psychological issues. Virtually every adult ED in the developed world is being overwhelmed by the increasing demands of elderly patients with a broad spectrum of complex inter-related problems – problems which

July 2012 // Emergency Physicians International

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