EPI Issue 15 by Logan Plaster

Cameron: Opportunities, threats for Indian EM How to design new EDs for infection control The telemedicine revolution has arrived Wilderness medicine tips for everyday care EMERGENCY PHYSICIANS INTERNATIONAL

ISSUE 15

. WINTER 2014 . WWW.EPIJOURNAL.COM

MAPPING EBOLA Harvard researchers explore how cell phone data could be the key to tracking the next pandemic

This map uses mobile phone data to visualize personal connectedness. Color coding has been based on strength of social ties. page 24

dispatches: Readers from 21 countries explain how their EDs prepared for Ebola suit up: A physician teams up with a clothing designer to imagine better PPE

the GLOBAL HEALTH EMERGENCIES COURSE

GHEC 2015 FEB 14–22

This timely annual intensive course at Weill Cornell Medical College, New York, is aimed at providing healthcare practitioners cutting-edge tools necessary to face today’s most pressing public health emergencies around the world photo courtesy of morgana wingard

who should take this course? Students, clinicians (physicians, nurses, midlevel providers), public health practitioners and researchers engaged in international work

course highlights Taught by over 30 world experts from top universities, aid organizations, UN gencies, and governments Special sessions on pandemics and outbreaks taught by field practitioners

photo courtesy of unrwa

what skill sets will the participants acquire? Acquire a nuanced understanding of the key policy, programming and financial challenges in addressing the global burden of diseases, including disease outbreaks, Malaria, TB, HIV, cardiovascular and obesity epidemics; maternal and child health; and access

to care Apply legal, ethical and operational frameworks that guide contemporary complex humanitarian emergencies Demonstrate knowledge of key stakeholders in global health: governments, aid-organizations, and multilateral agencies

– Submit your CV and a 200 word essay on your global health interests and experience to ghecourse@gmail.com to apply

Lectures, workshops, casestudies and group exercises Course certificate and inclusion in global registries Over 70 cme credits offered in previous years full schedule at:

globalemergencymedicine .org/GHEcourse.html

– Licensed healthcare providers: $1500 Residents: $1200 Medical students: $500 fees

EDITOR’S DESK

A Spirit of Collaboration

n this space and elsewhere I’ve described the exciting new growth taking place in international emergency medicine as the specialty matures and develops around the globe. But any major growth comes with its pains. In global EM, I’ve seen this recently in the form of inter-organizational conflict and I’d like to take a moment to address our specialty’s need for a spirit of collaboration. While the practical issues at hand in these conflicts have to do with the scheduling of conferences – and often involve a fair amount of politicking – I want to address two main principles. The first is this: When it comes to global emergency medicine conferences and events, the more the merrier. There is plenty of work to be done! The International Federation for Emergency Medicine (IFEM) will be moving its conference (ICEM) to an annual rotation starting in 2018. The European Society of Emergency Medicine (EuSEM) has just moved to an annual meeting as well, adding even more excellent meetings to the calendar. One look at our event calendar (page 6) and you’ll see that the opportunities for getting involved at a local meeting have never been greater. The issue is not where confererences meet, or who they attract, but the spirit in which they are conducted. Which brings me to point number two. There is so much work yet to do in establishing and operating EM clinical delivery and training systems around the world that all projects and meetings need to be conducted with a spirit of collaboration rather than a spririt of competition. IFEM hopes to lead the way in this effort by reaching out to organizations to get recommendations for ICEM speakers and topics. IFEM also has a new initiative to develop and conduct collaborative topic-focused symposia and clinical workshops with other organizations and host countries. This spirit of collaboration needs to go beyond conference organizing all the way to on-the-ground projects. If you are working in a particular country, it is very important and helpful to find out who else is working in that country, and communicate with them directly. That will allow you to learn about their project, find efficiencies and avoid redundancies. It will also allow you to understand their vision for the future, so that your visions can be discussed and aligned. Avoiding duplication of efforts, and especially efforts that may conflict, is critical to effective national EM development. Given the fragile nature of emergency medicine within many medical systems, it’s also essential that disparate projects present a consistent message to project recipients and other offiicals. When two “dueling” projects present conflicting messages about emergency medicine, it confuses those outside the specialty and delays specialty development. To dig deeper into this issue check out the (outdated but still useful) paper I co-authored in the Annals in 1997 titled “Guidelines for Evaluation of International Emergency Medicine Assistance and Development Projects”. Also, look for an update to this article to be put out by IFEM in the near future. To conclude, I’d like to put out a call for greater cooperation and collaboration among all of us involved in international EM. I encourage you to use the tools available for improving communication – such as the EPI network – and utilize the IFEM leadership to mediate any disputes or conflicts that may arise in your international work.

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

The issue is not where confererences meet, or who they attract, but the spirit in which they are conducted. Which brings me to point number two. There is so much work yet to do in establishing and operating EM clinical delivery and training systems around the world that all projects and meetings need to be conducted with a spirit of collaboration rather than a spririt of competition.

ISSUE 15

. WINTER 2014 . WWW.EPIJOURNAL.COM

MAPPING EBOLA Harvard researchers explore how cell phone data could be the key to tracking the next pandemic

This map uses mobile phone data to visualize personal connectedness. Color coding has been based on strength of social ties. page 24

dispatches: Readers from 19 countries explain how they prepared for Ebola

suit up: A physician teams up with a clothing designer to imagine better PPE

ABOUT EPI With a quarterly print and digital distribution and an online network of more than 2,000 members, EPI is the essential hub connecting global emergency care, sparking dialogue and creating a space for new collaborations. Find copies of the print magazine at international EM conferences around the world, or read it online at www.epijournal.com. Print subscriptions now available for $60, global shipping included. Go to epijournal.bigcartel.com For bulk subscriptions, email logan@epijournal.com

www.epijournal.com

LETTER FROM THE PUBLISHER

Tomorrow’s Toolbox

msterdam feels wonderfully analog. Between its rickety single-speed bicycles and its low-rise canal boats, the city glides along in a way that hasn’t changed much in a hundred years. Not that the Dutch move slowly, mind you. While attending EuSEM in Amsterdam this Fall I had the pleasure of renting a bicycle and joining the morning commute. This can best be described as darting in and out of a swiftly moving current of fish. Tall, smartly-dressed fish each with multiple baby fish in tow. My strategy for staying alive was simply to go with the flow and follow the lead of the hundred blond men, women and children (and babies) swarming the streets around me. This unique contrast – old world meets fast pace – offered an ideal backdrop for EuSEM, a conference committed to bringing the best of technology to bear on age-old medicine. This emphasis on future tech was evident in the exhibit hall – where there were multiple new entrants into the portable ultrasound field – as well as during the lectures, where tweets carried more weight than questions from the audience. And the same emphasis has found its way into these pages. We didn’t set out to make this issue of EPI about technology. But as we reached out to experts and questioned the EPI Network, a clear theme emerged. Whether the issue was Ebola, ED design or education, the future of emergency medicine appears to be wearable, digital, wifi-enabled and mobile-friendly. It’s open source, data-driven and probably available on the app store. Tech innovations can make us safer (read our review of new PPE gear on page 16). They can help us design infection-fighting emergency departments (Manny Hernandez reports on page 26) and allow us to treat patients from a smartphone (read Haywood Hall’s telemedicine update on page 22). New tech platforms can even open up worlds of free online tools for resource-limited settings (read how one Mexican residency had success with the Moodle platform on page 13). Technology isn’t the answer to emergency medicine’s problems. Gadgets and software are merely tools. The essence of emergency care will always come back to patient care and human-to-human interaction. But behind the love of new tech is the spirit of innovation, and that piece is the critical bit. Will we face the challenges of tomorrow with yesterday’s tools, or will we challenge ourselves to do better, creating new brand solutions of our own devising? A final word: create mental margin for innovation. Take a bike ride . . . or float down a canal if you’re so lucky. In our breakneck, put-out-the-fire world it can seem completely impossible to slow down long enough to think outside the box. But that is the only way that we’ll face tomorrow’s problems with innovative answers.

publisher LOGAN PLASTER logan@epijournal.com On Twitter @EPIJournal executive editors PETER CAMERON, MD TERRY MULLIGAN, DO, MPH LEE WALLIS, MD PROF. V. ANANTHARAMAN editors TAYLOR LINDSAY LONNIE STOLTZFOOS 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 ANITA BHAVNANI, 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 advertising RHONDA TRUITT

Logan Plaster Publisher

editorial director C. JAMES HOLLIMAN, MD

on the web

The Walchli Tauber Group, Inc. rhonda.truitt@wt-group.com 001-443-512-8899 ext. 106

LOG ON TO EPIJOURNAL.COM, THE FIRST GLOBAL EMERGENCY MEDICINE NETWORK

Winter 2014 // Emergency Physicians International

You read it at ESEM... Now get it at home EMERGENCY PHYSICIANS INTERNATIONAL

Simple ED design tweaks on a budget

Dr. Saleh Fares on the rise of EM in the UAE

Design: The Value of In-House Imaging

The eight building blocks of austere medicine

Pan-Asian Council Promotes New Research

Why EDs in Hong Kong Are So Understaffed

Karachi: Prepping the ED for the next blast

Design: The Future of Psych EDs

How Important is Training Standardization?

Surfing doctors put new spin on training

Cameron: Less Turf War, More Collaboration

ISSUE 13

. SUMMER 2014 . WWW.EPIJOURNAL.COM

Camels may have helped spread the deadly coronavirus, but its impact has been felt far beyond the desert. page 34

EMERGENCY PHYSICIANS INTERNATIONAL

Typhoon Haiyan Special Report Empowered community health workers form the backbone of disaster relief efforts. Two Filipino physicians share lessons learned following the typhoon disaster response

ISSUE 12

SPRING 2014

. WWW.EPIJOURNAL.COM

India’s MVA Problem: Bystander Apathy EMERGENCY PHYSICIANS INTERNATIONAL

ISSUE 11

FALL 2013

. WWW.EPIJOURNAL.COM

The GET REAL Changing Polish EMS crews compete in a national “Road Rally” that takes them from Face of rail tunnels to Emergency abandoned mountainside ravines. Medicine

Once the beds in Santa Maria were full, it took 92 trips by military aircraft to transport victims of the fire to Porto Alegre.

As the world’s elderly population continues to grow, the emergency department stands poised to become the hub of geriatric care. page 23

the MERS Effect: Dr. Peter Cameron on how to catalyze your ED in response to the Middle East Respiratory Syndrome

global snapshot – Readers share how their EDs handle acute ischemic stroke.

Haywood Hall: How emergency obstetric programs are pivotal in meeting the WHO’s maternal mortality millennium goals

Dr. Barbara Hogan on how EuSEM will help Europe face its next medical crisis.

– now available – PRINT SUBSCRIPTIONS $60/YEAR–GLOBAL SHIPPING INCLUDED EXECUTIVE EDITORS: JIM HOLLIMAN, PETER CAMERON, LEE WALLIS, TERRY MULLIGAN & V. ANANTHARAMAN

EVENT CALENDAR 1/15–11/15 THE COMPREHENSIVE GUIDE TO GLOBAL EM CONFERENCES

JANUARY 2015 Emergency Medicine 2015 // London, United Kingdom

International Symposium on Intensive Care and Emergency Medicine // Brussels, Belgium

International Congress of Central European Emergency Medicine // Gdansk, Poland

March 17-20, 2015 www.intensive.org Contact: ina.lalo@intensive.org

June 17-20, 2015 www.medycynaratunkowa.wroc.pl/ Contact: ptmr@am.wroc.pl

Global Annual Meet on Emergency Medicine and Trauma // Chennai, India March 26-29, 2015 http://www.gamet2015.com Contact: support@gamet2015.com

International Emergency Care Symposium // Melbourne, Australia

APRIL

August 25-28, 2015 www.acem.org.au

9th Annual Update in Paediatric Emergencies // Noosa, Australia

January 22-23, 2015 www.mahealthcareevents.co.uk/emed2015 Contact: conferences@markallengroup.com

April 10-12, 2015 www.colloquium.com.au/noosa Contact: info@colloquium.com.au

Society for Emergency Medicine in Singapore Annual Scientific Conference // Singapore

World Congress on Disaster and Emergency Medicine (WCADEM) // Cape Town, South Africa

January 24-25, 2015 http://semsonline.org Contact: info@sems2015.com

FEBRUARY The Global Health Emergencies Course (GHEC 15) // New York, United States

April 21-24, 2015 www.wcadem2015.org Contact: wcdem2015@icsevents.com

MAY Australian & New Zealand Disaster and Emergency Management Conference // Broadbeach Island, Australia

February 14-22, 2015 www.globalemergencymedicine.org Contact: ghecourse@gmail.com

May 4-5, 2015 http://anzdmc.com.au contact: admin@anzdmc.com.au

Winter Symposium of Emergency Medicine and Intensive Care // Karpacz, Poland

SAEM Annual Meeting // San Diego, California, USA

February 25-28, 2015 www.medycynaratunkowa.wroc.pl/ Contact: ptmr@am.wroc.pl

AAEM Scientific Assembly // Austin, USA

May 12-15, 2015 www.saem.org

11th Annual Conference On Rapid Response Systems And Medical Emergency Teams // Amsterdam, Netherlands

February 28-March 4, 2015 www.aaem.org/education/scientific-assembly Contact: info@aaem.org

May 18-19, 2015 metconference2015.com contact: info@interactiegroep.nl

MARCH

JUNE

Emergency Medicine Symposium // Ha Long Bay, Vietnam

French Society of Emergency Medicine 9th Congress // Paris, France

March 9-13, 2015 www.vietnamem.org

AUGUST

June 10-12, 2015 www.urgences-lecongres.org/fr Contact: infos@urgences-lecongres.org

SEPTEMBER Mediterranean Emergency Medicine Congress // Rome, Italy September 4-9, 2015 www.aaem.org/education/memc Contact: info@aaem.org

OCTOBER EuSEM Congress on Emergency Medicine // Torino, Italy October 11-14, 2015 www.eusem.org

ACEP Scientific Assembly // Boston, USA October 26-29, 2015 www.acep.org

NOVEMBER Asian Conference for Emergency Medicine // Taipei, Taiwan November 7-10, 2015 www.acem2015.org

Australian College for Emergency Medicine Annual Scientific Meeting // Brisbane QLD, Australia November 23-26, 2015 www.acem.org.au Contact: zoe.sum@acem.org.au

LIST YOUR NEXT INTERNATIONAL EVENT FOR FREE ON THE EPI NETWORK – WWW. EPIJOURNAL.COM/ EVENTS

For all information about the congress (registration, abstract submission, accommodation, etc) please contact Organising Secretariat: MCO CongrĂ¨s SAS - 27, rue du Four Ă Chaux - 13007 Marseille T.: +33 (0)4 95 09 38 00 - F.: +33 (0)4 95 09 38 01 - eMail: contact@eusemcongress.org

www.eusemcongress.org

www.epijournal.com

DISPATCHES READER-SUBMITTED UPDATES FROM THE FOUR CORNERS

My hospital’s reaction to Ebola has been... an overreaction to media hype

completely appropriate

Q2: If your ED received an Ebola patient today, would your staff be at significant risk?

YES 44%

Ebola’s Reality in Liberia is Far from the Media Hype Earlier this fall EPI interviewed Dr. Michelle Niescierenko, a pediatric EP who works for Boston Childrens Hospital and spends about four months a year in Liberia, and Dr. Pranav Shetty, the Emergency Health Coordinator for International Medical Corps

EPI: Can you tell us about the practical day-to-day for physicians working in Ebola hotspots? DR. PRANAV SHETTY: There is a lot of concern about this disease, this is the biggest Ebola outbreak ever recorded by two- or three-fold, at least at this time, and people anticipate it to spread, to get even more broad and to cover more geographical area and with more patients. It’s hard to get a full picture of what’s going on because we are dependent

on the surveillance systems that exist within these countries. These are low-income countries with health systems that are stretched at the baseline. With this type of stress to the system, it’s very difficult to adapt and to respond in a coordinated, consolidated manner with such few resources. It’s very challenging for the doctors who are treating these patients in these areas. These health systems typically experience chronic resource deficiencies and the kind of the supplies and the equipment that are needed for caring for Ebola patients multiplies that deficiency significantly. There’s

Winter 2014 // Emergency Physicians International

NO 56%

also a lot of fear around this disease. For every physician, every nurse, every laboratory technician working both in the community and within isolation facilities it’s very challenging because they face a whole host of issues from the personal protective equipment that needs to be worn to the clinical care of patient who are very ill in a low-resource setting. Furthermore, they deal with fear from the violence that sometimes occurs against health workers.

Is it frightening for these doctors to work in an environment where they risk infection? DR. MICHELLE NIESCIERENKO: My colleagues at one of the other main hospitals… would express fear, but also say, you know, they’re worried about our regular patients, our everyday, you know, kids with maCONTINUED ON PAGE 33

Q3. What steps has your hospital taken, if any, in preparation for potential Ebola patients? ______________________

01 BELGIUM We’ve made plans and formed a crisis team. --------------We’ve developed a protocol for handling suspected Ebola patients. --------------We bought special suits, created a special protocol for lock down of the ED ______________________

02 BOTSWANA Public health response is a mixture of panic – refusing visas for affected West African countries (even Nigeria still despite the WHO declaration of no ebola) – and a good public awareness campaign. Apparently community and some hospital health workers have been taught but the practical implications of a high risk presentation to our A&E has not been planned. There is no isolation facility or area for donning and doffing of PPE for staff. The hospital laboratory staff response has not seemed supportive either. There are no in-country facilities to test for ebola and a refusal to discuss how the laboratory staff will assist us in this process. ______________________

03 CANADA We reviewed isolation procedures, refreshed training on protective equipment, assigned regional center for suspected patients, and established an expedited procedure for rapid isolation and transfers to minimize exposures. ______________________

04 COSTA RICA Designed a strategy on where and how to take care of them and instructed the staff in how to use the necessary equipment

______________________

05 FRANCE Established specific supply and people chain reaction process from ER to ICU/ ID wards --------------Developed appropriate telephone triage in the dispatch center; trained physicians & paramedics in donning and doffing PPE; prepared orientation and reception of a suspected ebola patient. Developed adequate measures in transferring patient to referral centers and many other guidelines & protocols ______________________

06 GHANA Training of staff through; power point presentations, simulations and learning to don and doff PPE. ______________________

07 INDIA Developed steps to isolate and quarantine. --------------No steps taken, but barrier nursing and doctor care are regularly followed ______________________

08 IRAQ Established isolation room for Ebola patients; provided Personal Protective Equipment; raised awareness about the disease to all medical staff --------------To be honest, neither my hospital, which is a tertiary center, nor the ministry and the government are taking any preparation. It’s sad to say that there is even little information about this disaster among health professionals. ______________________

09 ISRAEL We’ve had a structured planning process: purchase of PPE, fitting out of the negative pressure room, extensive training of staff, promulgation of protocols.

______________________

10 LEBANON Training in protective clothing robing and disrobing. Meetings with health minister re: direction of possible cases to governmental hospital ______________________

11 MEXICO There have been several conferences for the whole staff, aside from training in how to detect and attend EV patients and also the way they have to use the protective equipment and when to. ______________________

12 THE NETHERLANDS We have Ebola proof suits and one room for use when ebola suspected patient would arrive ______________________

13 NEW ZEALAND The response has been “reassurance” as well as many meetings --------------Guidance for staff has been drawn up but not disseminated --------------Personnel trained in PPE. Plan to identify, isolate, then transfer. Some structural changes still pending. ______________________

14 NIGERIA Massive awareness creation. Every patient or visitor washes hands frequently, temperature checks. Creation of isolation room, complete PPE available ______________________

15 QATAR An algorithm has been developed, there has been training, and an isolation ward is available. ______________________

16 SINGAPORE We’ve initiated PPE training for staff who would possibly have to manage Ebola patients; we issue regular updates on countries that are currently on the WHO active Ebola list; we send regular reminders on criteria for possible Ebola; we have isolation areas in the emergency department and in the inpatient areas

______________________

17 SWEDEN Weekly email updates to all hospital staff on national and local guidelines; preparation for activation of the special unit for highly contagious disease. There are signs with information at the door to the ED for patients seeking the ED, that if they suspect they might be at risk for Ebola, or any other disease that could be highly contagious or airborne, they should press the doorbell and wait outside for staff to transport them to a safe room. Appropiate PPE readily available for ED staff ______________________

18 TURKEY We have a room where we can isolate patients, but adequate personal protection equipment is missing. Room is in the center of the ED. And no front room to change clothes. --------------There has been staff training, the buying of personel protective equipment and we’ve designated areas for potential patient flow ______________________

19 UNITED KINGDOM Protocols are in place, but I’m not really sure if we could immediately consider Ebola at the first instance. --------------Protective equipment and planning in place. However staff training has only just started. ______________________

20 USA Massive preparation–comprehensive protocol in place. Anyone who has been to any country in West Africa in the prior 3 weeks gets placed in a dedicated, closed room. Attending physician completely gowns up and then questions the patient. If there is a suspected case, a “code Ebola” page goes out alerting about 30 people! We have a dedicated neg pressure room, and an entire pod of the ED can be converted to negative pressure for epidemic conditions. We also have developed a 4-hour simulation course for healthcare practitioners. ______________________

21 YEMEN We haven’t made any specific preparations. www.epijournal.com

FIELD REPORT DECEMBER 2014

t An Iraqi man talks with U.S. Soldiers during a Cooperative Medical Engagement in eastern Baghdad. During the CME Iraqi doctors provide free medical care to local Iraqi residents.

IRAQ Emergency medicine gains traction in Kurdish region thanks to visionary leaders like Dr. Shakawan M. Esmaeel. by karwan yasin mohammed nanakali, pgy2

fter five years of studying, I graduated from the College of Medicine. Three months later, I joined the Kurdistan Doctors Syndicate and started my work as a junior doctor in the ED. But I did this without training on how to deal with the critical cases (ie: without ALS or ATLS courses). Our ED was managed by junior doctors with little supervision by SHO or consultants of various departments of medicine and surgery. Unfortunately the poor state of our ED system is just part of a poor general health system, overcrowded with emergency and cold cases. Sometimes a critical case may pass away due to overcrowding alone, and delay in presenta10

tion of some simple procedures (like chest drain insertion). Still, I had been fascinated by emergency medicine and wanted to continue my post-graduate study with EM. But it was available neither in Kurdistan nor in Iraq. Our government – and our people – wanted to improve emergency medicine, but they didn’t know how to do it. And then, in 2011, Dr. Shakawan M. Esmaeel returned. Esmaeel (consultant physician in acute medicine) returned back to Kurdistan from the UK, in cooperation with the Kurdistan Board for Medical Specialties (KBMS) which is supported by Ministry of Higher Education. His goal was to open a board specialty in emergency medicine. In 2013, this dream became a reality. The EM board was born, and we (two colleagues and myself ) were accepted by KBMS-EM, a four-year residency program that grants its graduates board certification in emergency medicine. Now, the KBMS-EM center is located in Erbil, the capital of Kurdistan and Dr. Shakawan M. Esmaeel is program director of KBMS-EM. Among the many things Dr. Esmaeel did for the development and improvement of

Winter 2014 // Emergency Physicians International

66 74 Life expectancy (M/F) in Iraq

96% Percent of families in Iraq without health insurance

emergency medicine, he established a teaching team (composed of an acute medicine consultant, anesthesitis, internist, orthopedic surgeon and general surgeon), opened a specialized advanced training center for training BLS, ALS and ATLS courses, and created live video links with the Royal College of Edinburgh for participating in related symposiums and conferences. Under the KBMS training program, he is currently trying to organize (for us) a 6-12 month fellowship training program in the United Kingdom. On December 1, 2013, we started our emergency medicine board program with one month of concentrated induction on ALS, ATLS Disaster Management, before entering into the ordinary program. In our one year of training (from December 2013 to the expected December 2014), here’s what we’ve achieved: 1. Weekly lectures, clinical meetings, journal clubs and case presentation were implemented 2. Members were designated with one to two duties at ER 3. We completed an audit on management of STEMI and NSTEMI in Erbil city 4. We are starting to train new junior doctors and medial staff with BLS, ALS AND ATLS courses 5. We offered first aid course for general population 6. We started publishing emergency medical information for the community through newspapers, magazines and social media Finally, another three young trainees have just been accepted in KBMS-EM for the coming year. My hope is that KBMS-EM will be able to open the emergency medicine training center to the rest of Kurdistan cities and a greater number of doctors will enter the program. Together, we can grow. PHOTO BY STAFF SGT. JAMES SELESNICK

SUDAN Despite towering economic challenges, new EM leaders in Sudan chart an aggressive, globallyminded course for training and improved patient care. by dr. abderrhman a. alimam

udan is a country rich in natural and human resources but low in income, ranking 139 out of 177 countries in 2005 in terms of human development indicators (with a Human Development Index of 0.505). The already-limited resources available to the health sector have been steadily reducing during the last few years. Poverty is widespread with substantial variation between and within states. The Human Development Report 2007/2008 ranked Sudan as 69th out of 108 developing countries in terms of the human poverty index. Health care in Sudan is provided at three levels. Basic unit is the primary health care, covered mostly by medical assistance. The second level is the rural hospitals that provide secondary care and diagnostic facilities. At the top is Teaching (general and specialist hospital) with a varying number of specialties and beds providing secondary and tertiary care. Khartoum state (which hosts most of the specialized hospitals) was the first state that replaced the old emergency system – which was based on nontrained house officers – with a new system run by medical officers (residents) with ongoing training for them and 24 hour specialist coverage. Other states are still lagging behind. The system is structured with a primary triage area for sorting patients

into emergent and non-emergent cases. The first group is then triaged into one of three sectors: resuscitation area, critical care area, and an area for less severe cases. All traumatic patients are triaged immediately to the trauma room. But the non-emergent cases are assessed in a separate area as ‘cold cases.’ There is no formal triaging system or time based triaging so far. Sudan’s Emergency Medical Service system (EMS) was established in 2005 and expanded successfully with Red Crescent and other private ambulance services. EMS providers are not formally trained in basic or advanced life support – at this point, the system is lacking organization, trained personnel, and essential equipment. Currently Sudanese EMS provides transportation to the hospital, but patients often prefer private vehicles instead; they’re much cheaper and more readily available. Looking to the Future Despite some milestones in developing the necessary components of emergency medicine, we are still on the first steps on a long path full of challenges. After all, emergency medicine is the

p Two nursing students and a nurse officer in the Emergency Area in El Fasher Hospital, North Darfur. More than 500 patients visit the hospital everyday and they are assisted first by 4 emergency doctors during the day. At night time, only one is on duty. (Photo by Albert González Farran, UNAMID)

youngest specialty in the Sudan Medical Specialization Board (SMSB), which is responsible for almost all postgraduate trainings in Sudan. The current challenges that we are facing, such as lack of trained personnel and resources to care for injured and acutely ill patients, must be met with patience, persistence and good will – and the implementations of new solutions. Appropriately educated and adequately trained personnel are one of the essential pillars of any healthcare system. To reach this goal, there must be coordination at the highest authority level to ensure that educational standards and scope of practice of any specialty is at an acceptable and locally applicable level. A step in the right direction was made when the first EM postgraduate training program was established at the SMSB. This batch of 17 trainees emerged with excellent knowledge and a desire to carry on providing emergency medicine service. They expected to get a lot of training and experience sharing with the arrival of the emergency medicine pioneers, who have the chance and opportunity to go through www.epijournal.com

FIELD REPORT DECEMBER 2014 Sudan currently has one physician for every 3,333 population (World Bank)

sudan cont’d standardized and up to date structural program overseas in emergency medicine. This ‘‘test tube’’ batch should be providing the core faculty for expanding EM training programs in the future and establishing a well-formed EM system. Meanwhile with shorter training sessions, we are carrying on training courses like BLS, ALS, ALSO, PALS and more. Most of it runs at the continuous professional development center (FMOH) and University of Khartoum. We are also working with FMOH to make these courses fundamental for all interns and residents. Under the graduate emergency medicine curriculum recently introduced at three universities, although still taught by non-emergency based physicians, we expect to broaden the concepts of emergency medicine and attract young generations to this field. There are many ways that the emergency medicine community can – and should – work to gain greater momentum. One way would be to conduct regional workshops and community training such as mass CPR training targeting university students. This will create greater awareness of emergency medicine. We also need to use the media to teach the community life saving principles. Workshops targeting health professionals, hospital administrative staff, first responders (EMS) and policy makers also play a key role in understanding and getting support from potential partners and decision makers to develop EM. We aim for the training of physicians as well as the non-physicians. This will require coordination among the SMSB, FMOH, educational institutions and Nongovernmental organizations (NGOs). Long-term sustainability of the emergency medicine training system 12

will depend on funding and collaboration from all stakeholders, including government, non-governmental organizations, teaching institutions, donors and private organizations. But these development efforts should be conducted and organized with close coordination by the FMOH leadership. Besides that, general agreements must be made among relevant institutions as to the definition and scope of EM. We need to determine key strategies that help guide EM development and maturation. These strategies must be practical, take into consideration the existing health care systems with continuous efforts to initiate, and develop and sustain up-to-date emergency medical services. To build a model that has the same EM principles used worldwide – or at least regionally – there must be some remodeling in local culture, geography, and use of resources. There is no model that can simply be implemented and expected to work if they do not have local applicability and stakeholder buy-in. This work needs formalization of a coordinating body from SMSB, FMOH, emergency physicians and community figureheads to develop EM in Sudan, complete with the driving force of short and long-term goals and a clear plan on how to integrate and standardize EMS, the second pillar of EM, and address the issues of leadership, training, funding, infrastructure development, and sustainability of the EM program. And critically, funding for short and long-term EM programs should be secured. This might be the real challenge, given Sudan’s economic difficulties and competing priorities. Regardless of the confounding circumstances, this ‘‘coordinating body’’ should look for funds locally and internationally. In the capital, approaching

Winter 2014 // Emergency Physicians International

local sources, such as the national disaster preparedness fund, the country’s mandatory car insurance and insurance companies might help fund projects for training or for building local capacities for emergency and disaster response. Cooperating with foreign associations such as the African Federation of Emergency Medicine and the International Federation for Emergency Medicine, and with other institutes, such as universities and the community, may secure additional funds until the system can be fully funded by the government or become independent. We encourage all stakeholders to work together to ensure local applicability and long term sustainability to build on the current efforts to provide emergency medicine education, training and clinical care in Khartoum, Sudan, and expand this all over the country Most assuredly, there can be long periods of immobility. But when sudden changes or transformation happen, we need to be ready to take advantage. As progress is made with incremental steps, we need to be prepared for a long campaign. All noblest journeys are made one step at a time, and we are on this path; we know the emergency medicine journey is worthy.

MEXICO Mexican EM training program “flips” the classroom on a limited budget. by dr. jorge loria-castellanos

ew technologies have permeated all levels of society (work, education, home, health); and medical education has not been immune. More and more, institutions are implementing programs using several different educational strategies with students in mind. The goal? Educational tools that make learning more dynamic, easy to follow and intuitive. Take Mexico. The specialty of medical-surgical emergencies (UMQ) arrived in Mexico in 1986 – by 1991, the Mexican Social Security Institute (IMSS) had acquired 40 hospital sites, from which about 4000 specialists PHOTO BY GABRIEL FLORES ROMERO

have graduated. Their education was underway in the same hospital units where they provided care. But in the classroom, it’d been reported that this process is a passive-receptive approach to education, issues are addressed in a repetitive and un-engaging manner – it’s still far from the kind of environment that shapes comprehensive health professionals. Yes, residents are overwhelmed by developing endless emergency assistance activities. Meanwhile, students’ participation in academic activities is limited almost exclusively to “attend” the classroom; this is a concern among educational authorities, who expect that residents develop complex cognitive skills. Trying to promote different ways of generating knowledge, a new approach aimed to eliminate the traditional education style and encourage the use of innovative methods that promote a greater role for students. Enter Moodle. For the last three years, one of the

p TOTAL HEALTH SPENDING accounted for 6.2% of GDP in Mexico (2012)

offices of the City of Mexico has been supported by a Moodle platform, which is a “virtual learning environment” course management (free distribution). Primarily, it helps educators to create online learning communities. But the real value lies in its ability to create a concept of collaborative learning, based on the concepts of pedagogical constructivism, (knowledge is constructed in the mind of the student, rather than handed off unchanged from books or teachings). Studies reported that students using the resources of the Moodle platform (forums, chats, wikis, uploading, etc.) learned more compared to those who followed traditional activities (master classes, guided discussion). In sum, this approach to online education flips the traditional classroom. It requires an ongoing relationship, and online, attending classes is not restricted to a specific site. While it only works with the cooperation and self-direction of the student, it is simultaneously supported and led by a teacher who acts as guardian and adviser. Online education facilitates achieving learning under three main characteristics: it is mediated by the computer, the communication is not in real time and has a range of support available online, and its main objective is to improve the quality, timeliness and coverage of training processes, job training and updating of staff health care through the development of educational strategies with the increasing use of information technology and communication technologies (TIC). Not only are these educational methods cost-effective (for both the institution offering training and student), they remove physical barriers and make course-implementation, on the whole, smoother. Given the success in Mexico, there’s the growing possibility that online education services like Moodle will increasingly couple with EM across the globe.

www.epijournal.com

Education

Apple Collaborates With UAE University On New EM Textbook First-of-its-kind digital textbook is currently soliciting submissions from the international emergency medicine community. by arif alper cevik, md

he United Arab Emirates has seen exciting recent developments in emergency medicine. We recently created the first Emergency Medicine Clerkship/ Education program for students at United Arab Emirates University (UAEU), College of Medicine and Health Sciences. Our curriculum includes a mixture of SAEM and IFEM undergraduate education curriculum. In 2013-2014, the program was a big success and 42% of students mentioned that they would choose emergency medicine as a career choice. In addition, 82% of the students requested additional electives in emergency medicine. We believe that the emergency medicine clerkship played a positive role for improving the reputation of emergency medicine in the medical school and in the UAE. This year we leveraged mobile learning technologies and applying flipped teaching models, following the 14

SAEM and IFEM guidelines. The student’s satisfaction levels improved 20% compared to last year. Using mobile technologies in teaching is one of the main interests of the education leaders of UAEU. This interest has spurred an exciting new collaboration with Apple Inc., which we hope to turn into a truly global project. As emergency medicine is new in UAEU, we have decided to start a project called ‘iEmergency Medicine for Medical Students and Interns’. This project – a digital textbook sourced globally and available for free on iTunesU – will help to create awareness of the emergency medicine specialty among the medical students and interns in UAE and in the region. This project has already been an exciting collaboration between Apple Education, UAEU and multiple emergency medicine societies, but now we have the privilege of extending it to the

Winter 2014 // Emergency Physicians International

global emergency medicine community at large.    The idea behind this iBook is to make learning emergency medicine fun, promote EM as an attractive specialty and encourage students and interns to choose emergency medicine as their future career. We are planning to publish the book in September 2015 in time for the 2015-2016 academic year. The book will include all relevant links to free educational resources and social media, in the spirit of spreading free, open-access medical education. The technical aspects of this book will be completed under the guidance and help of expert from Apple. Language/ grammar will be controlled by professional grammar editors. If you’d like to be considered for this project, review the following options for contribution.

Ways to Contribute   1. Be an author/co-author for a chapter  2. Submit high yield clinical pictures for inclusion  3. Submit your high yield clinical cases, physical exams, procedure videos or their links  4. Prepare and submit NBME type MCQ questions  5. Share your experience in a short video about a topic (expert opinion videos)  6. Share your top EM learning website link list for medical students  7. If you are a digital medical artist or if it is your hobby, you can help us create figures and pictures  8. Be a section editor to review the medical contents in the chapters. We are expecting participation from all continents to create this book which will combine almost every possible way of learning for our students and interns.

If you are interested in contributing to this project, email Dr. Alper Cevic: aacevik@ uaeu.ac.ae

Next Gen

Twenty-Eight and Struggling to Keep Up One new doc’s imperfect attempts to dive into smartphone eLearning by stefanie vandervelden, md

t’s the 1st of October, 2014. I’m heading home on the train from the Eusem Congress in Amsterdam. After numerous hours of lectures, several social events, and surviving a big SIMwar, I have just now realized one strange thing: how could it be that a 28-year-old, a “young” emergency doctor, is outdated when it comes to e-learning and apps? Looking at my smartphone (that I now understand is not used to its full potential), I decided to live one day in ‘ER smartphoneland.’

20th of October: D-day My breakfast routine will get pimped today! Instead of squeezing fresh oranges while Facebooking, I make my first podcast attempt. After only 10 seconds on the App Store, I’m already having issues. “In order to install the podcast app, you must upgrade your software to iOS 8 or higher,” says the message on the screen. Despite my boyfriend’s

warnings that the upgrade would make my 1st generation iPhone as slow as a turtle, I charge forth him in the name of progress.

21st of October: D-Day, Part II One major smartphone crash and repair later I’m happily listening to the ERcast on my way to work. And I must say, it was worth the effort. I think I just added a new dimension to multitasking! Once arrived at the ED I say goodbye to the traditional notebook (which, after five years is stuffed to the brim) as well as a couple of hand cards. Today I’ll be traveling light, equipped with only one smartphone. As the day passes by I find my way through the app landscape. During the first prehospital intervention, I easily calculate the doses for a two year old child using PEDIsafe. Not one ECG has secrets anymore,

Dr. Vandervelden practices emergency medicine in Belgium and is the co-chair of the Young Emergency Medicine Doctors section of EuSEM.

thanks to my ECGguide. And Qxcalculate makes it all even easier, from Parkland to FeNa, only one swipe away. During my lunch break I test my diagnostic ability with simulated clinical cases on the Prognosis app. This leads me to my biggest discovery of the day. On the advice of a senior colleague who worked abroad in Australia, I installed the SmartFOAM app. This needs a little explanation. FOAM stands for Free Open Access Meducation. The underlying ethos is to provide medical education for anyone, anywhere, anytime. It is independent of platform or media. It includes blogs, podcasts, tweets, Google hangouts, online videos, text documents, photographs, Facebook groups, and a whole lot more. FOAM is the concept, #FOAMed is the Twitter hashtag and Smart FOAM is a mobile app which collects all your #FOAMed resources in one place. The idea is to make it easier to access FOAM, given that the volume of content is increasing by the minute. When I scanned SmartFOAM I realized that I’d only discovered the tip of a huge iceberg. This concept is already big in the USA and Australia. I think It won’t take long before Europe is conquered. Want to take your love of apps and the FOAM world to another level? Consider attending the SMACC (social media and critical care) conference. This is a collaboration between a group of critical care websites from around the world. During its annual congress (this year in Chicago) they provide academic content in an innovative and engaging format. One thing is certainly clear: there is much more to explore in the changing world of eLearning. But as I look at the 5% battery left on my smartphone – even before my shift ends – I realize that it’ll have to wait for another day. Thank goodness we don’t work 24 hour shifts anymore! The “Next Gen” column is a collaboration between EPI and the ‘Young Doctors’ section of the European Society of Emergency Medicine (EuSEM)

www.epijournal.com

Gear

For Better PPE, Go Back to the Drawing Board

02 01

An EP teams up with a fashion designer to imagine the next phase in personal protective equipment (PPE). by taylor lindsay with keith raymond, md

he current state of Personal Protective Equipment (PPE) has been in need of help for a while now. The parts are complex, time consuming, and not user-friendly, which often results in reduced patient interaction while increasing exposure risk. An alternative may be on its way. The prototypes have yet to be produced, but emergency physician Keith Raymond and designer Victor Stapelberg are in the process of proposing a Biosafety IV suit that will address the many weaknesses they seen in current PPE. The design – dubbed Total Personal Protective Equipment (or TPPE) – is reusable, can be donned and doffed by the individual without assistance, and minimizes exposure and time to care. It’s also designed with comfort in mind. The use and care of the TPPE suit are designed to be self explanatory – and essentially idiot proof. Taking cues from current scuba dry suit technology, military grade materials, and existing decontamination anterooms, 16

it’s a single garment suit. Two distinct designs are in the works. The first is full body coverage with integrated mask, gloves and boots. The user enters the suit through a pleated zipper that runs from the left shoulder to the right hip. The pleat fully covers the zipper so that splash protection is assured. Standard rubber boots with steel sheath and toe protect from glass and needle puncture are integrated into the suit. The suit material may be an impregnated kevlar and polyvinyl blend in a rip stop matrix

Winter 2014 // Emergency Physicians International

that is bacteria and viral resistant as well as impenetrable to foreign bodies, while allowing maximum protection. Arm material extends into gloves that come in various sizes to maximize dexterity. The second design features neoprene wrist cuffs so that standard surgical double gloves could be used instead. The integrated hood is transparent polycarbonate with UV protection with 360 degree view capability and a crown design for fall impact protection using a bubble lattice. The hood has an in-

The proposed “Total PPE” combines scuba dry suit technology with military grade materials.

HOOD Integrated hood is transparent polycarbonate with UV protection with 360 degree view capability and a crown design for fall impact protection using a bubble lattice. The hood has an internal neck dam that prevents air from leaking into the suit below. A self-retracting wiper, activated with an easy-access handle, removes condensation on the inside front of the hood. CUFFS Neoprene wrist cuffs so that standard surgical double gloves could be used BODY Full body coverage with integrated mask, gloves and boots. The suit material may be an impregnated kevlar and polyvinyl blend in a rip stop matrix that is bacteria and viral resistant as well as impenetrable to foreign bodies, while allowing maximum protection.

BACK The user enters the suit through a pleated zipper that runs from the left shoulder to the right hip. The pleat fully covers the zipper so that splash protection is assured. A Lumbar pad is integrated into self sealing intake output flaps where a filter and air scrubber canister can be attached and detached from the suit from behind.

ARMS Arm material extends into gloves that come in various sizes to maximize dexterity.

BOOTS Standard rubber boots with steel sheath and toe protect from glass and needle puncture are integrated into the suit.

The current CDC process for PPE includes a collection of individual gear items that might not always be available ternal neck dam that prevents air from leaking into the suit below. A Lumbar pad is integrated into self sealing intake output flaps where a filter and air scrubber canister can be attached and detached from the suit from behind. The canisters are affixed to the decontamination anteroom wall with height adjustable plastic flexible C clamps so the user merely backs into the canister attached to the wall to engage and disengage the unit. On either side of the height adjustable C clamp system are sliding shoulder harness crooks. The practitioner pulls the adjustable crooks over their shoulders once the canister is affixed to the suit. They then pull down on self rewinding cords that allows the excess suit material to be rolled around the lumbar support tunnel to shrink wrap the torso of the suit to fit, thus reducing the risk of snagging and tearing the suit on equipment. In outdoor environments the canister and shoulder clamps system can be affixed to a vehicle or be free standing. Following use in a contaminated patient care environment the user steps under a dilute chlorine solution shower, then detaches the canister, unzips and steps out of the suit into a clean room. The shrink wrap suit is loosened by bending the elbows and pulling them toward the midline to unroll the excess suit material around the lumbar tunnel. This eliminates the need for an attendant or assistant, and time to activity. The reusable suit is hung on a hook from the collar on the wall to dry available within minutes

for reuse as necessary. Being reusable, it significantly decreases waste.

Adaptations The change is needed, but there are some limitations to be dealt with. Flexibility and movement while wearing the PPE 2.0 needs to be determined. If adopted for field wear in battle or under circumstances of biowarfare, the price would be significantly reduced (meaning less expensive materials would be utilized). The adjustable wall mount C clamp and shoulder harness system has been designed, but not executed due to material and cost constraints. And while the air scrubber canisters can be based on current designs, it might be that an entirely new system must be devised for this biosafety suit. Raymond and Stapelberg are determined to bring PPE 2.0 to the world. “We would welcome bids from manufacturers so that this more efficient and user friendly design could be put into Hospital and field use as soon as possible,” says Raymond. “We believe that presenting the design to physicians for consideration and revision is prudent as equipment is often not reviewed by healthcare providers first before they are put into production; this results in supplies that are awkward to use at best and dangerous to the provider in practice at worst.” Given the strength of their case, and the current needs in the market, we may not have to wait long for the PPE 2.0.

www.epijournal.com

Profile

Meet Gamal Khalifa, Champion of North African EM A founding father of Egyptian emergency medicine, Dr. Khalifa countinues to provide vision for the specialty in North Africa and the Middle East by crystal bae

he practice of emergency medicine is such an integral part to all health care systems that it is easy to forget that it is still a relatively newly recognized specialty. The first emergency medicine training programs were formed in the 1970s in the United States, and soon more countries followed. The University of Alexandria in Egypt was one of the first institutions to establish an emergency medicine program outside the United States. Dr. Gamal Eldin Khalifa was one of the first emergency medicine graduates from the University of Alexandria and can therefore boast the title of one of the first physicians ever to specialize in emergency medicine, apart from those in the United States. Born in a small town in Northern Egypt, Khalifa never wanted to become a physician. With a photographic memory and the ability to do complicated mathematics in his head, he originally pursued a career in engineering. But after one month in a military engineering school, he decided that he did not want a life in the military. At his father’s urging, he went to medical school, graduating with honors from the University of Alexandria in 1977. He then spent one year in general surgery residency but soon felt dissatisfied with the monotony of the same surgical procedures he was performing. In 1978 Professor Abdel Megid Sadek, a Cambridge University graduate professor of surgery, brought emergency medicine to Egypt, recruiting 18

doctors to join the program. Ready for a new challenge, Khalifa was interviewed and accepted into the emergency medicine program. After a thirty-five year career in emergency medicine, Khalifa still feels the challenge and excitement of every patient and the unpredictability of this specialty. As one of the first emergency medicine physicians, Khalifa became a pioneer in the advancement of emergency medicine internationally. He has personally served and helped develop the specialty of emergency medicine in Saudi Arabia, Kuwait, the United Arab Emirates, Sudan and Syria. He has also received training in hospital management and obtained a twoyear diploma in Hospital Management. In 2005, Khalifa expanded his interests into disaster medicine and became certified by the European Master in Disaster Medicine, EMDM, in Italy. He continued his work with the EMDM as a tutor and lecturer and facilitator for full scale exercises, training medical staff on

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different medical disaster courses. By 2010, he co-authored the International Disaster Nursing Manual, printed by the Cambridge University Press. He has actively participated in JCI hospital accreditation and re-accreditation of 2 healthcare facilities in Abu Dhabi for 10 years and ultimately became certified as a Certified Professional in Healthcare Quality (CPHQ). He is also certified through the College of Emergency Medicine. Another one of Khalifa’s major accomplishments was the establishment of the Egyptian Resuscitation Council (EgRC) in 2001. The EgRC originally started out as a group of friends, comprised of two emergency medicine doctors, including Khalifa, and four professors of anesthesia, solely as emergency medical consultants. EgRC, with the leadership of Khalifa, disseminated training on Resuscitation, Trauma , Disaster and Emergency Medicine all over Egypt, the Middle East, and North Africa. The EgRC now runs courses in most universities in Egypt, as well as in 15 other countries including the Tunisia, Libya, Lebanon, KSA, Sudan, Qatar, Tunisia, and UAE and Syria. The EgRC members have also helped many countries form their own resuscitation councils, including Hungary, Cyprus, and Turkey. Khalifa was then granted the Fellowship of the European Resuscitation Council, after which he became and continues to serve as an executive member of the European Resuscitation Council (ERC). He is the co-author for the guidelines of the ERC and the ERC Advanced Life Support Manual as well as a reviewer for the journal, “Resuscitation.” Emergency medicine in Egypt has also transformed during the years of Khalifa’s medical career. In the early 1980’s, the University of Alexandria was the only institution with an established program, graduating 3-4 graduates per year. After a few year hiatus where the dean of the university stopped the program, emergency medicine can now be found in three Egyptian universities.

In 1978 Professor Abdel Megid Sadek, a Cambridge University graduate professor of surgery, brought emergency medicine to Egypt, recruiting doctors to join the program. Ready for a new challenge, Khalifa was interviewed and accepted into the emergency medicine program.

The ministry of health has developed a four year training program which now graduates 20-25 graduates per year. The major challenge in emergency medicine that Egypt now faces is keeping their trained doctors in-country. There is a huge drain of trained Egyptian emergency medicine physicians going to Europe, Australia, and the United States for higher pay. However, small hospitals in rural communities in Egypt need these highly trained doctors! Khalifa has a vision for emergency care in Egypt where all communities, rich and poor, have access to good quality of care. He believes that high quality, not necessarily high technology, should be the mandate of emergency care training. Adequately trained emergency medicine doctors should be able to practice medicine at all resource levels, not just at high-resource levels. Education and the will and motivation of doctors, nurses, and paramedics are the key to reaching this goal. After a fulfilling career in emergency medicine and a resume long enough to fill a book, Khalifa is now a retired clinician. He spends four months a year as a visiting senior consultant for the Hamad Medical Corporation in Doha, Qatar as well as the senior training consultant at the Compass Training Center in Cairo, Egypt. The rest of his year is dedicated to research, teaching, and training in the Middle East, North Africa, and many European countries through his expertise on resuscitation, trauma, disaster, and emergency medicine. He is currently serving his fourth term as the President for the Egyptian Resuscitation Council and sits on the Board of Directors for the World Association for Disaster and Emergency Medicine. Now that he is retired, Khalifa enjoys spending some time with his family, playing chess, swimming, and deep water fishing. At age 61, he hopes to publish his second book about his long journey in emergency medicine and his vision for its future.

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The top three ways to reach the growing market of global emergency physicians

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Austere Medicine

Building Situational Awareness Through Wilderness Medicine Outdoor medicine training can give emergency physicians the tools they need to handle everyday emergencies outside the hospital. by michiel van veelen, md

hen people think about wilderness medicine, most people think of Everest basecamp, an arctic expedition or deep sea diving. But “the wilderness” is much closer to 20

home and wilderness medicine skills are useful to every emergency physician. I’ll explain why by first telling a story. Often at the beginning of a course we will run a drill that surprises our trainees with an emergency before formal

Winter 2014 // Emergency Physicians International

s Ascent of Pfannknecht during a mountain medicine course in Austria

training has begun. In one recent drill, the trainees were unexpectedly confronted with a victim lying face down and not reacting to stimuli after a long day of alpine climbing. One doctor considered intubation; others wanted to call an ambulance. We were shocked, however, to see that for several minutes as they discussed options, no one dared to touch or move the patient, even though that is the only way to adequately asses the airway. After working with the doctors on our courses I realized that it is not a lack of competency or clinical reasoning that keeps these physicians from acting in an out-of-hospital emergency. Most doctors, even those trained in emergency medicine, are unprepared when confronted by emergencies outside the familiar surroundings of the hospital. For instance it is very uncommon for a doctor to be confronted with a severely sick or hurt victim that is not lying straight on his or her back. A person lying face down or twisted around a tree – or around a piece of furniture for that matter – presents a range of dilemmas that can paralyze any doctor. Do you think your approach to a victim outside the hospital will be as structured as it is in your emergency department, without any of the equipment, staff and logistics?

Moving the Victim A common dilemma concerns the cervical spine in a trauma victim. When should you leave the victim’s neck in the position you encountered it and when can you try to achieve a more anatomical position? There are still many doctors who believe that you should never touch or move a trauma patient even though the vast majority of them arrive straight on their back in the hospital (how did they get that way?). Wilderness Tip: The decision whether or not to immobilize the spine in case of significant mechanism of injury can be aided by using a clinical decision rule such as the NEXUS criteria. But keep in mind that immobilizing, and in particular transporting, victims in a remote setting is often practically nearly impossible! To adequately assess the airway and

possibly immobilize the spine, it is essential to move a victim in an anatomical position on its back and straighten the neck with gentle traction. Unless there is noticeable mechanical resistance to movement, or if it causes an increase in pain or focal neurological deficit.

Exposure to the Elements Another problem physicians often face outside the hospital is underestimation of exposure to the elements. Because most of our patient contact is done indoors we hardly have any hands-on experience with the rate and mechanisms of cooling down such as radiation, conduction and convection. Early recognition and prevention of hypothermia seems simple but lack of training or experience can result in devastating outcomes. Each year, approximately 1500 patients in the United States have hypothermia noted on their death certificate; however, the incidence of primary and secondary hypothermia and the associated morbidity and mortality remain unknown. Wilderness Tip: In Hypothermia stage I, II and III (mild, moderate and severe hypothermia) treatment consists of providing a warm environment and preventing further heat loss. This is achievable by all of us as long as we think about it soon enough by carrying a multi-layered compact survival bag, such as the blizzard bag. It can be an actual lifesaver as opposed to traditional â&#x20AC;&#x2DC;space blanketsâ&#x20AC;&#x2122;.

It is important to note that in stage II or III movement should be minimized to prevent arrhythmias.

Taking Charge Last but not least is the problem of leadership and responsibility. Who dares to take the lead and consequently take responsibility in such a situation? It is also realistic to think about possible legal consequences of your (lack of ) treatment. Add this consideration to the sensory overload, and the paralysis of our trainees is explained. Wilderness Tip: The most experienced doctor in acute care medicine should claim leadership. Do not rush to help but survey for scene safety. Keep your hands free by delegating your company members into jobs such as manual cervical immobilization, contacting emergency medical services and noting down (a change in) vitals while you perform a structured CABCD patient assessment. Of course all doctors have a legal duty of care. When approaching a victim, immediately identify yourself as a medical professional and request the victimâ&#x20AC;&#x2122;s permission to treat. If the victim is unconscious their consent is implied. During our courses we see our trainees grow in their abilities to adequately assess and stabilize multiple emergencies in abnormal settings with limited resources, regardless of their specialty background. They develop situational

01 Glacier training 02 Orientation is key to any emergency evacuation 03 Practicing patient assessments in the dark

awareness, a systematic approach and confidence in unorthodox settings, which enables them to fully utilize their medical skills. Special attention is paid to external factors such as hypo- and hyperthermia, altitude, submersion and other potentially dangerous factors to which you can be exposed during outdoor activities. Developing situational awareness and environmental savvy will help you utilize your emergency medicine skills outside the hospital, wherever you find yourself, whether its a traffic accident, a fallen elderly woman at the mall, or on a plane. Dr. Van Veelen is part of the team that runs Outdoor Medicine, a nonprofit society based in The Netherlands that teaches wilderness medicine skills to medical professionals. More at www. outdoormedicine.org www.epijournal.com

R report

// telemedicine

TeleDoc

I have very few expenses related to actually managing patients. You need a phone with good coverage and you need a computer in order to do the documentation. In terms of freeing up my time personally, this has allowed me to start taking my kids to school in the mornings. That’s a real shock for me. -Haywood Hall, MD

Haywood Hall on how telemedicine allowed him to pursue his global health passions in Mexico...while earning U.S. dollars treating patients on his phone. Interview by Logan Plaster

EPI: So you’re officially a telemedicine doc now. Who do you work for?

of problems over the phone. And that works to everyone’s benefit. They don’t have to hang out in the ER all day.

There are a few different providers out there who do telemedicine. I work with MDLIVE, but there’s Healthtap and ECI and others. They seem to be cropping up everywhere. My work is a partnership between MDLIVE and ECI TeleHealth. It’s actually a bit of a complicated landscape, as these things tend to be.

What kinds of complaints are you resolving over the phone that were previously punted to the ED?

Give us some big picture background. Why is telemedicine necessary or useful? The issue nowadays is really that there’s very limited access to primary care docs. We’re obviously trying to place people more in primary care settings and the emergency department continues to be a buffer for everything. So what’s happening is that there’s more and more people showing up to the ERs. And so now, because large groups of people are on prepaid health plans, insurers are incentivized to keep people from overusing the facilities – urgent care or emergency departments in particular. So they’re given an option to talk to a physician. We used to have something like this called a nursing hotline. The big difference was that the old nursing hotlines were pretty consistent about punting patients to the ED. By having a physician involved, we’re actually able to resolve a fair number 22

Winter 2014 // Emergency Physicians International

A sore throat or an earache or urinary tract infection symptoms. In the old system they’d be more inclined to shunt it away and say: “Well, you could wait until tomorrow and go see your doctor,” or something like that. But the problem is that there’s actually fewer and fewer places to go for this episodic care. And so having a doc who can say: “Well, this does sound like a UTI,” and resolve the problem to some extent is really valuable. About how many cases do you refer to a hospital versus resolving on the phone? I’d say probably five percent get told that they have to go to the ER or urgent care to see their doctor first thing in the morning. I can put in my documentation that they don’t need follow-up or they can go to an emergency department or an urgent care or their primary doc. So it’s somewhere around five percent that I actually say: You know, somebody has to look at this.

Are you able to write prescription after a phone consult? Yeah, we send prescriptions electronically. It’s a whole system that’s pretty clean. We cannot write for any narcotics. We can’t write for any psychotropic drugs. And we can’t write for lifestyle drugs such as Viagra. Apparently, the patients know that we can’t do that. So what does telemedicine look like for you specifically, working through MDLIVE? MDLIVE has an online platform through which I get calls to manage patients. These are patients who have been pre-screened to some extent; they might be urgent care patients or they might have considered going to the emergency department for something that is a very basic primary care problem: UTIs or something along those lines. Initially I found the patient encounter awkward because I was not really seeing a patient and I did not have their vital signs. Working in an emergency department, I’m expecting to see a disaster at every turn. So you really have to be pretty disciplined to keep a low threshold for saying: “I know it’s just a little stomach pain, but you called me. And you know, I don’t know, sometimes I have seen an appendicitis like this. It’s just too early.” So I keep a very low threshold. Does the patient know who you are during this encounter? Well, they know I’m a physician. I introduce myself as Dr. Hall from MDLIVE, so they can look me up. In terms of credentials, the MDLIVE contracts are for physicians who are emergency medicine, internal medicine, pediatrics or family medicine. So they select their physicians through the MDLIVE portal based on those kinds of profiles. Some telemedicine systems, like HealthTap, have almost a social network component where you can see a lot more about the physician. Lets talk liability. What happens if you give bad advice?

Basic Life Support Courses in Latin America. Thanks in part to doing telemedicine, I’m hoping to spend even more time in Mexico doing what I’m passionate about. I certainly don’t make nearly as much money as I would in an American emergency department, but I can handle 20 calls a day and I have very few expenses related to actually managing patients. You need a phone with good coverage and you need a computer in order to do the documentation. In terms of freeing up my time personally, this has allowed me to start taking my kids to school in the mornings. That’s a real shock for me. Plus, it’s just a lot less wear and tear on me doing this. So you can take 20 calls a day. Walk us through what that looks like. The calls are typically maybe ten minutes total. And I can get between 10 and 20 calls a day if I block some time aside. I fit these calls in around my other work, woven around a full day’s schedule of meetings. Each call pays $25, but there’s other places that may pay more or less. There’s some days when I’m not really picking up calls and other days when I’m picking up a lot more calls. So it kind of averages out. They pay more when you’re working at night, too. If you wanted to, could you choose to take more calls and make more money? What’s the limiting factor? In terms of demand, I suspect that over time there’s just going to be more and more need for this. And also as the reimbursement mechanisms get into place – like whether Medicare, Medicaid cover telemedicine – will make a difference. Right now there are times when I’m available, but there aren’t any patients, but that’s also a function of how many state licenses you have. More licenses means more potential calls. Plus, influeza season is approaching and there are large contracts that the company is starting to ramp up for. For me, it’s about fitting telemedicine around my other work. If there’s a call and I can reasonably answer it, I answer it. I think if I was just sitting around just doing telemedicine, I’d be managing more calls. What about tax implications?

We have malpractice insurance for this, but the fact is that you really need to be handling very low risk patients in the system. So anybody who’s handling chest pain over the phone is getting into deep water. Anybody who’s been seen by another physician in an ER and is continuing to have problems probably shouldn’t be handled over the phone. You know, it’s really designed for very simple episodic things. There is not likely to be much case law. That doesn’t mean that there aren’t any out there for bad advice. Even in a regular physical clinical setting you can always have a bad outcome and have somebody potentially try to sue. I mean, I think that’s part of practice unfortunately. It’s the United States; you can sue. You’ve chosen to work in telemedicine in part for the lifestyle that it allows you to live. Tell us a bit about that. Up until recently I was spending three weeks out of every month in Mexico, where I run PACE MD, a global health organization that offers free

Turns out that if you live in the United States less than 35 days out of the year, you get a $100,000 “foreign income earned abroad” tax credit. Of course people need to talk to their accountants about it, but that’s a real thing. And so if you’re not paying any taxes on the first $100,000 or so of your income, then that’s pretty significant. So if you’ve got like 20 calls a day, you could live very well off of that in a lot of places, probably even in the United States. If you’re retired or anywhere near thinking about retiring, being able to take these calls for a few years might be enough to push you over the edge. You mentioned that these are pretty low acuity calls. Is this mentally stimulating work? In the emergency department we’re used to all kinds of excitement and all kinds of things and so the stimulation level is very, very high all the time. By definition, these telemedicine calls are very, very low complexwww.epijournal.com

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ity. So there’s not a lot of challenge there. You need to make sure that people don’t think you can resolve anything but the simplest, simplest problems. We don’t want to take any chances. On the flip side, I take satisfaction in knowing I’m decompressing the ER for serious cases. But you’re talking to people and if you like talking to people on the phone and stuff, if that’s enough for you then that may be fine. You’re not doing physical exams. You’re not reading x-rays. But that won’t always be the case. As time goes on, the technology is changing. I can see on our platform that there’s ways of ordering lab tests and there’s ways for people to send images of different sorts that I can look at. And I can see where this is going over time. This could get to be quite an interesting practice. Can you speak a little more to the future of telemedicine?

Pifalls of Telemedicine

“...it can be too easy. It’s easy to just call and get prescriptions and refills. And maybe there’s a deeper problem going on. So I think you’d have to be very careful with people who say, “I’m just calling up for a med refill”. They think that they know exactly what the problem is, but it’s been going on for a while. That little something is going to turn into something else if a doctor isn’t paying attention.”

I’m sure this is going to become much more complex, in terms of managing problems over time. There is a lot of medical telemetric stuff showing up. I saw a retinascope that clips on to an iPhone the other day. And we have seen ultrasound transducers that plug into iPhones. A lot of home health devices will start to be integrated. Those smart watches are probably going to be very important one day. Of course, that’s a new kind of practice – not exactly emergency medicine anymore. But it’s going to be a very interesting thing as time goes on, as the technology changes. Let’s say the next phase of telemedicine involves a lot more video contact with the patients, looking at vitals and tests in real time. What kind of pitfalls do you foresee? I think telemedicine can be too easy. It’s easy to just call and get prescriptions and refills. And maybe there’s a deeper problem going on. So I think you’d have to be very careful with people who say, “I’m just calling up for a med refill.” They think that they know exactly what the problem is, but it’s been going on for a while. That little something is going to turn into something else if a doctor isn’t paying attention. A seasoned emergency doc looks at a patient from across the room and says, “That person is sick.” And you don’t have that ability over the phone. Then if it’s a mother talking about their child that’s even further removed. And people do try to call you for their husbands or their almost-adult sons. And then you have to say: “I really would like to talk to them a little bit, just to see what they sound like.” Another problem is that people call in because they want to have something specific. They have a pretty clear idea of what they think they want, so you’re just getting highly filtered information sometimes. So those are things you have to be careful of. We can’t take the place of their primary physician or an urgent care doc if there’s any possibility of it turning into a problem. I think as ER docs, we know that things can turn into a real problem. So you just have to document very well. You’re being the 24

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shortstop, and it would be unwise to overstep that limited role. Has phone-based telemedicine given you a more acute sense of hearing when it comes to clinical gestalt? Well, if the patient’s talking and has any shortness of breath, I can pick that kind of stuff up, but you don’t want to practice medicine that way over the phone. Things have to get pretty bad before you can hear them on the phone . . . and then it gets very silent of course. How hard of a transition was this, clinically, for you as an emergency physician?

In the ER, we typically assume that people are sick. It’s a small subset of the population who has made the effort to come out and wait in the ED to be seen. We see a snake under every rock. In telemedicine, it’s almost like being out in the broad population as a whole. They’ve got a runny nose and they know they have a runny nose. It’s not a big deal for them. So you do have to keep your spidey senses tingling, but you also have to realize that this really is primary care for very basic, simple things. So that’s not the easiest transition for us. But I think that our emergency medicine experience makes us very good at this in a lot of ways. It’s definitely different. And you know, there’s plenty of us that have seen tens of thousands of patients. And it’s kind of neat to do something a little bit different for a while. It’s a way of kind of shifting gears a little bit. I think it’s a perfectly viable thing. Have you gotten any odd or more extreme calls? You mean like heavy breathing? No. Just like in the emergency department or anywhere else, you get people and you wonder exactly what they were thinking. Somebody had a chief complaint of tachycardia. Or chest pain. It’s very hard to say anything to them other than, “You probably need to be seen, like pretty soon!” It’s like there’s a 90 percent chance that it’s nothing. But we can’t see thousands of patients and then let ten percent of them have an actual heart attack. Final question. So the patient (or their insurer) pays about $50 for this service. Is it worth it? Yes. People need that reassurance sometimes, and a quick fix for a simple problem. We have made access to health care so hard, even when they have a primary care doc. I call it delusions of system continuity. And I would like to think that emergency physicians would be uniquely qualified, using good judgment about anything that’s even remotely complicated or dangerous. That’s kind of what we do.

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Simple ED design tweaks on a budget

Dr. Saleh Fares on the rise of EM in the UAE

Design: The Value of In-House Imaging

The eight building blocks of austere medicine

Pan-Asian Council Promotes New Research

Why EDs in Hong Kong Are So Understaffed

Karachi: Prepping the ED for the next blast

Design: The Future of Psych EDs

How Important is Training Standardization?

Surfing doctors put new spin on training

Cameron: Less Turf War, More Collaboration

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Camels may have helped spread the deadly coronavirus, but its impact has been felt far beyond the desert. page 34

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Typhoon Haiyan Special Report Empowered community health workers form the backbone of disaster relief efforts. Two Filipino physicians share lessons learned following the typhoon disaster response

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India’s MVA Problem: Bystander Apathy EMERGENCY PHYSICIANS INTERNATIONAL

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The GET REAL Changing Polish EMS crews compete in a national “Road Rally” that takes them from Face of rail tunnels to Emergency abandoned mountainside ravines. Medicine

Once the beds in Santa Maria were full, it took 92 trips by military aircraft to transport victims of the fire to Porto Alegre.

As the world’s elderly population continues to grow, the emergency department stands poised to become the hub of geriatric care. page 23

the MERS Effect: Dr. Peter Cameron on how to catalyze your ED in response to the Middle East Respiratory Syndrome

global snapshot – Readers share how their EDs handle acute ischemic stroke.

Haywood Hall: How emergency obstetric programs are pivotal in meeting the WHO’s maternal mortality millennium goals

Dr. Barbara Hogan on how EuSEM will help Europe face its next medical crisis.

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Looking Beyond Ebola: Designing Tomorrow’s ED for Infection Control Whenever there is an infectious disease scare, critical eyes turn on the emergency department. The key is to look forward, not back, and design new EDs with infection control principles in mind from the beginning.

by manuel hernandez, md, mba

bola. MERS. H1N1. SARS. Since the turn of the century global public health experts have responded to no less than four large-scale public health crises. While creating a lot of interest – and a fair amount of panic – each has served as a reminder of the importance the ED has as one of the first lines of defense in responding to many infectious threats in our communities.

A few years ago I was working with a large Canadian hospital that was planning a new ED. As the discussions and planning turned to infection control, the topic that dominated the discussion was designing an ED that could handle another SARS-like pandemic. What 26

was nearly lost in the discussion was how EDs should be designed to support infection control processes at both macro and micro levels. It got me thinking about how well many EDs are, or are not, designed to protect our patients and staff from the very real threats that come from just being in the ED environment. A study completed at a large urban ED in the United States showed that during the average 8-hour shift, each patient came within one meter of a median of five other patients, and each staff member was within one meter of just over 13 other staff members and four patients (Lowery-North). This level of close-proximity contact between staff and patients highlights just how

Winter 2014 // Emergency Physicians International

easy and frequent community transmission of infectious pathogens can be in the ED. Hospital-based risks of infectious disease transmission also deserve considerable attention when planning a new or renovated ED. Also known as healthcare-associated infections (HAIs), these include catheter-associated bloodstream infections, catheter-associated urinary tract infections, and ventilator-associated pneumonia. In the landmark 1999 publication entitled ‘To Err is Human,’ the Institute of Medicine estimated that, in the United States alone, as many as 98,000 people die in hospitals annually from medical errors, including HAIs. Morbidity and mortality concerns aside, the cost of HAIs to a health system can be staggering. Multiple studies in the early part of this century have convincingly documented the economic impact of poor infection control methodologies (Dimick, Lansford, Shannon, Tambyah, Warren, Warren) The most recent data on HIAs suggest that up to 70% of these conditions can be avoided using existing evidence-based strategies (Umscheid). Mitigating the transmission of infectious pathogens beyond source patients in the ED does not happen by accident; it occurs by design. The interplay between processes, human behavior, facility/campus design and technology all come together to keep everyone safe from harm.

THE ARRIVAL SEQUENCE – KEEPING EVERYONE ELSE SAFE

01 In the event of large-scale pandemics, external covered spaces proximate to the ED can be used for initial intake and screening. 02 Multiple waiting areas designed into the new ED better enable the facility to separate potentially contagious patients from the general patient population during intake, screening and while awaiting a treatment station. 03 Locating a sink at the entry to a treatment station increases compliance with hand hygiene activities.

Delays in identifying patients with potentially infectious conditions translate into increased transmission exposure. An illustrative example can be seen in 2003 when the SARS virus reached Toronto. A family caregiver of the first index case arrived at a busy ED that was ill-prepared and, quite likely, improperly designed to handle such a highly infectious situation. As a result, 126 nosocomial infections of patients and staff with SARS resulted from this single patient encounter (Varia). Design Tip: Designing the arrival experience to mitigate infectious pathogen exposure begins with placing Personal Protective Equipment (PPE) in easy reach of patients, visitors and staff. Proper signage should direct those entering the facility with a fever and suspected contagious infection to apply appropriate PPE, which happens to be stored in the same location. Hand hygiene stations should be located at every access point to the ED for patients and visitors as well as in high-traffic locations such as the triage rooms and registration areas.

REDUCING PATHOGEN TRANSMISSION IN THE TREATMENT AREA One of the more concerning pathogens in the clinical setting is methicillin-resistant staphylococcus aureus (MRSA). A study of

MRSA contamination in an ICU setting in the UK demonstrated that MRSA contaminations were most commonly documented in spaces under the patient bed (38%), as well as on workstations (17%), monitors (19%) and ledges behind beds (13%) (Hardy). In the same study, 43% of patients who were found to be colonized with MRSA during their hospital stay became colonized while in the hospital setting. Design Tip: One of the most important design considerations to prevent easy transmission of infectious pathogens in the ED including MRSA is the use of single-patient rooms separated by solid walls as opposed to multi-bedded rooms with patient separated by curtains, mobile screens or other soft barrier devices. A study undertaken in a Canadian ICU demonstrated that conversion of the clinical area to single-patient rooms resulted in clinically significant and substantial decreases in Clostridium difficile, vancomycin-resistant enterococcus and MRSA incidence (Teltsch). While the cost of single patient rooms may seem prohibitive in some healthcare systems, the return on investment with respect to lower incidence of HAIs is clear. Recently, attention has turned to so-called “self-disinfecting” surfaces such as copper that are showing early promise with respect to reducing contamination and subsequent HAIs (Niiyama, Weber). While the research into these technologies is promising, there has yet to be reproducible large-scale studies that have reliable reproduced these findings. Further study is warranted in this area.

PROMOTING STAFF AND PATIENT HAND HYGIENE Clinician compliance with hand hygiene has been lackluster on a global scale. A recent study of hand hygiene compliance among clinicians at six major pubic hospitals in Kuwait demonstrated that ED staff was compliant with hand hygiene only 15% of the time after activities described as “dirty contacts” by the Fulkerson scale (Al-Wazzan). Similar results have been documented around the globe, including in Spain, France, Saudi Arabia, the UK, New Zealand and a host of other countries (Novoa, Moret, Basurrah, Al-Damouk). In the case of Kuwait, a number of facility design considerations were listed as reasons for poor compliwww.epijournal.com

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ance. This included not enough disposable paper-based hand towels (23%), sink locations not appropriate (17%) and not enough alcohol-based rub (9%). In a study of hand hygiene compliance at a large hospital in Ethiopia, significant gains were made from the implementation of a multimodal hand hygiene campaign based on World Health Organization (WHO) guidelines (Schmitz). In the case of proper hand hygiene, very simple, and often low-cost, design solutions combined with behavioral modification can be implemented to promote compliance and create queues to promote patients, visitors and staff hand hygiene. Design Tip: Ensuring the ED is designed with adequate hand hygiene stations or antiseptic dispensers is essential. At a minimum, there should be dedicated resources for hand hygiene at every patient treatment station; in staff work and break areas; in patient, staff and visitor toilets; in soiled utility rooms; in medication dispensing and preparation areas; and, anywhere that food for consumption is stored or available. More advanced EDs have begun placing hand sanitizer and antiseptic stations at the entry to every treatment station and some

have considered going as far as to create audible or visible alarms when someone enters a treatment station without first engaging in hand hygiene activities. Hospitals that have explored the use of wearable alcohol gel dispensers have found limited success in these tools in isolation of other hand hygiene initiatives (Haas).

PLANNING FOR THE NEXT PANDEMIC One of the more challenging aspects of designing new EDs surrounds planning for the infrequent, but extremely dangerous, eruption of an epidemic or pandemic. EDs improperly designed and operated can result in exacerbation of the already difficult situations created during explosions of communicable diseases such as ebola, MERS, influenza, RSV and the like. While itâ&#x20AC;&#x2122;s easy to get caught up on planning for ebola, MERS and other new diseases, itâ&#x20AC;&#x2122;s important not to lose perspective. The WHO estimated that every year there are 250,000-500,000 deaths worldwide that can be attributed to influenza (WHO). Many of the process and design elements considered standard for good infection control

Winter 2014 // Emergency Physicians International

practices can be leveraged on a much larger scale for pandemic planning. The key to managing pandemics stemming from contagious pathogens consists of a number of key concepts: social segregation of affected patients; proper barrier precautions to prevent spread to care providers and, subsequently, other patients and staff; appropriate ventilation for airborne pathogens; and, appropriate decontamination of patients, care providers, treatment areas, equipment and supplies. An essential design consideration for pandemics and other surge situations is rapid, easy access, to an adequate supply of PPE to properly protect the ED staff involved in patient care. The ED should be designed with adequate storage space for all PPE necessary to provide patient care for an extended period of time reflective of the time is would be expected to mobilize and deliver the second supply of PPE. Ideally, the in-ED PPE will be located in one place and housed in mobile carts that allow for easy deployment in any part of the ED or in external environments. Once inside the confines of the ED, appropriate spaces must be provided to ensure potentially-infectious patients are segregated from

Covering the Basics: Tips from IFEM’s ‘Pandemic Flu Guidelines’ In addition to institutional protocols, EDs should possess their own policy guidelines, tailored specifically for application in an ED setting. This should cover essential areas, such as: 01 Basic, important information on the clinical characteristics of pandemic flu and its initial management. 02 Definitions of alert levels and their respective responses 03 Criteria for isolation and transfer to designated flu hospitals / health centres. 04 Physical infrastructure for receiving, managing and appropriately transferr0ing potentially infected patients 05 A preparatory model for ED staff with regard to education and training, audits, exercises, surveillance, prophylaxis and stockpiling. 02

01 Proper hand hygiene is essential to proper infection control in the ED. Hand washing stations in common areas and designed for patients of all ages increases hand hygiene compliance. 02 Blueprint shows negative pressure ventilation isolation rooms located in close proximity to intake areas, which reduces the risk of exposure to other patients and visitors.

the general patient population and visitors. Adequately sized segregated waiting area should be provided to limit exposure to the general population. Ideally, these spaces will be physically contained from other areas of the ED and contain an adequate number of hand hygiene resources. In instances where airborne transmission is a concern, appropriate ventilation design including negative pressure ventilation should considered. In the case of the H1N1 pandemic, one academic medical center in the United States developed a drive-thru ED to completely socially segregate suspected H1N1 cased from the general ED population (Weiss). Similarly, a children’s hospital in Houston established a mobile team that screened presenting patients in a covered area outside of the ED (Cruz). Once treatment is ready to commence, care should be provided in segregated areas of the ED separate from the general population. This is best accomplished in EDs where a specific zone or pod can be physically cordoned off from the rest of the department. In some instances, large gathering spaces such as a staff dining room or hospital lobby have been used as an alternative. Regardless of the space used, adequate supplies, equipment, medical gasses,

monitoring tools, and staff are essential in the area to limit travel into and out of this space. Finally, circulation paths for patients, staff and visitors from the exterior of the building into the ED, and from the ED to diagnostic areas and the inpatient platform must be considered, again, with the goal of limiting contact between pandemic patients and those not infected or involved in the care delivery process.

CONCLUSION Community and hospital-associated infections continue to represent a challenge to ED design and planning. Developing a rigorous design process using a multimodal approach that combines process redesign, human behavior modification, proper facility design and leveraging technology properly will better prepare EDs to successfully manage both day-today care of patients with infectious pathologies while ensuring proper preparation for the day the next pandemic arrives. REFERENCES AVAILABLE ON WWW.EPIJOURNAL.COM

www.epijournal.com

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// big data Eric Fischer uses cell phone data to visualize population movement in cities around the world. This series maps populations (London on this page, Taipai on 32) based on where they take photos, and whether they are locals (blue), tourists (red) or unkown (yellow).

MAPPING EBOLA Why cell phone data could be the key to tracking the next pandemic by satchit balsari, md, mph jennifer leaning, md, sma jukka-pekka onnela, phd tarun khanna, phd images by eric fischer

he current Ebola outbreak has brought media attention to the public health practice known as ‘contact tracing.’ This practice – of locating every person who has come in contact with an infected individual – has proved to be valuable in managing contagious diseases, such as STDs and tuberculosis. While tracing sexual contacts in order to manage the spread of sexually-transmitted diseases may be challenging, the job is significantly harder when tracking casual social contacts of patients with tuberculosis. Or Ebola. According to the CDC, contact tracing can stop Ebola in its tracks. What it entails, as recent media attention on the topic has taught us, is finding everyone who comes in direct contact with a symptomatic Ebola patient. The more the patient travels, or the more crowded the locations, the more difficult the tracing process gets. While contacts may be easier to find at certain sites like hospitals, airplanes and cruise ships, it becomes virtually impossible to do so in densely crowded urban environments like buses, subways and restaurants. One missed contact, says the CDC, can keep spreading the epidemic. The likelihood of successful tracing in dense conglomerations, therefore, seems to very low. But

it may not have to be. Over the last decade cell phone penetration has grown exponentially with cell phone to person ratios reaching or exceeding 1 in most urban centers around the world. In other words, almost everyone has a cell phone, especially in cities. And our cellphones almost always know where we are. People often voluntarily share their whereabouts on social media like Facebook and Foursquare, by “checking in” at their destinations, or allow friends to know where they are by activating GPS location apps like “Find My Friends.” Apps like Trip Journal and Pathbook allow users to share their travel routes with friends and family, in real time. MIT Media Lab researchers recently demonstrated that cellphone usage creates fairly unique digital signatures: Knowing roughly where and when a user is four times a day is sufficient to uniquely identify them 95% of the time. Now imagine such digital footprints being made available to public health epidemiologists tasked with the herculean goal of tracing everyone that came in contact with a contagious person. Suddenly, contact tracing can rely on triangulated geospatial data rather than on memory and recall. While many citizens may not be ready to

s Mobile phone communication data can be used to investigate structural properties of large-scale social networks and human mobility patterns. Here is an analysis of mobile phone communication networks. Here the nodes correspond to individuals and ties connect pairs of individuals who communicated with one another during the study period. Ties have been colored based on their strength, aggregate communication time over the study period, such that weak ties appear in yellow and strong ties appear in red. Structure and tie strengths in mobile communication networks by JP Onnela, J Saramäki, J Hyvönen, G Szabó, D Lazer, K Kaski, J Kertész, and AL Barabási. PNAS 104, 7332 (2007).

turn over such private data to the government without substantial protective laws in place, anonymyzied data can still play a meaningful role. Researchers around the world are already using cellphone data to identify populations at risk. Using data from Digicel, Haiti’s www.epijournal.com

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largest mobile carrier, the Stockholm based Flowminder Foundation demonstrated that the majority of the 630,000 Haitians who left Portau-Prince on the day of the earthquake had done so within three weeks, and generally went to the same places where they had spent Christmas or New Year’s Eve. Access to such anonymized data would have huge policy and programming implications for urban epidemiologists. Even if personal route maps are not accessed, predicting association and travel patterns from anonymized data holds tremendous promise for shaping response: Where do most people from a particular neighborhood go to work every morning? Do most travel by bus or train? Do patients discharged from emergency departments tend to go straight home or do they often go to the nearest pharmacy or the market? Introduce a layer of granularity and we can ask even more specific questions: How does the staff who took care of the sick patient usually go home? Who were the persons that were in the vicinity of the index patient? The relatively safe asymptomatic phase when the Ebola patient is not contagious may have prevented the wide spread of disease in the United States – where known returnees from West Africa vigilantly self-monitor for signs of infection for a period of three weeks. But this may not be the case with the next outbreak when another pathogen may be even more contagious and incubation periods even shorter. In dense urban centers of Ebola affected countries with a large number of contagious symptomatic patients, contact tracing has been incredibly important, and remains a resource-intensive enterprise. Underlying the study of anonymized cell phone data are general principles of human behavior. Their adaptation requires some degree of contextual intelligence, but the principles are robust. While Big Data may help predict population trends, small granular data may be invaluable for contact tracing. Were epidemiologists indeed allowed access to everyone’s GPS trackers, they would potentially be able to identify contacts by studying the patient’s timeline, and the digital footprints of all that may have been present at the same locations. The result would be a sub-set that would include those most at risk. Such monitoring would also alert 32

Taipei, visualized by mapping where individuals took photos: Locals (blue), tourists (red) or unkown (yellow).

authorities to potential contacts boarding buses, trucks, trains, and flights. With unbridled access, we do run the risk of information overload, a distinct characteristic of our times. It is also likely that incremental increases in the level of contact tracing are likely to yield diminishing benefits. To learn to use cellphone effectively, researchers need greater access than they currently have. Anonymized cellphone data, whether retrospective, or in realtime, will allow epidemiologists to learn to sift through hundreds of millions of data points, unmasking unforeseen limitations and unleashing the potential for vast public good. Privacy concerns are legitimate, and in the post-Snowden era, there will be significant resistance to government-initiated monitoring of personal cellphone data. Last month, in the United States, the Florida Supreme Court ruled that ‘stingrays’ – simulated stealth cellphone towers used to track people’s movements – were in violation of the Fourth Amendment, and could not be deployed by law enforcement agencies without a warrant. There is, of course, global precedence for limiting personal liberties for public safety. Quarantine, in the context of epidemic disease, is one example, deployed with varying levels of success over the centuries. Since 1985, the United Nations has laid out the Siracusa principles that provide officials with guidance on how to weigh the health and rights of communities against the health and rights of individuals. In times of high crises citizens could be given

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a choice to allow their movements to be accessed so that public health responders can do their job better. And citizens may demand that granting access be incumbent on stringent laws that prevent data misuse. Our timely ability to strike an appropriate balance between our collective health and individual rights may be one of the critical factors that shape the outcome of this and other epidemics. Until then, depriving epidemiologists of these data renders them unable to harness the full power of today’s technology to protect our health. Satchit Balsari is an assistant professor and chief of the Global Emergency Medicine Division at NewYork-Presbyterian’s Weill Cornell emergency department. He is as visiting scientist at the Harvard School of Public Health. Jennifer Leaning is Francois-Xavier Bagnoud Professor of Health and Human Rights at the Harvard School of Public Health and Director, FXB Center for Health and Human Rights Jukka-Pekka Onnela is assistant professor in the Dept. of Biiostatistics at the Harvard School of Public Health Tarun Khanna is Jorge Paulo Lemann Professor at Harvard Business School and Director, Harvard South Asia Institute The authors have employed mobile technology to study disease surveillance and social homophily at the world’s largest mass gathering, the Kumbh Mela in India, attended by over 100 million people.

dispatches // ebola CONT’D FROM PAGE 8

laria who are seizing and our moms with obstructed labor, and who are going to take care of those patients? And so their worry was actually more for those patients than about Ebola patients or about themselves getting exposed, which is, to be honest, a heroic story, but it’s been completely overlooked. DR. SHETTY: We must imagine so. Our staff that are currently on the ground say that yes people are of course worried. They understand the precautions that need to be taken, but there’s no place of no risk. There are many kinds of procedures in infection control that are in place, but human errors occur. We know that in a lot of facilities staff are not able to attend to their regular work. They don’t want to go to a place of high exposure and then bring the virus back to their family.

What do you think emergency departments, and hospitals in general, could have done differently to prepare for an outbreak like this one? DR. SHETTY: The idea is that if we can identify this outbreak or cases early, then we can do everything we can to prepare for it, but we’re in a place where the surveillance system is already weak; we’re in a place where the resources to deal with such an outbreak are not there. This isn’t the place that we can isolate every suspected case. We have to strengthen our ability to do initial identification, laboratory confirmation, tracing of both direct and indirect contacts, follow up of false rumors about Ebola that exist within rural communities that require a whole logistical effort to get to, etc... Strengthening the public health system in this way needs to happen to help control the spread of the virus. On the clinical side, it’s about the ability of each individual facility to have the personal protective equipment available to its staff and have them trained in the use of that equipment. Even if you have the equipment, if the process is not in place to use it properly, that can render it ineffective. This means the emergency

departments must have the processes and structures in place to allow for early identification of suspected cases and then having the ability to isolate patients and treat them as best they can. DR. NIESCIERENKO: I was there initially in March when the first case was reported in north Liberia, and I have to say the public education as early as March was excellent. I mean, they were out in announcement trucks, flyers, radio, church sermons, I mean, you name it, they did it. I think it gets to the issue of supply and funding in the health system that’s so poor. I don’t think there’s much more they could have done.

What lessons have been learned through having to respond to Ebola? Are there any changes that hospitals and clinics in these countries have made, or will make, as a result? DR. NIESCIERENKO: I think it’s early to see how this is really going to affect the way we practice medicine there. I think certainly people are going to be far more cautious than we were. I mean, even I’m guilty of not wearing gloves when I would always wear gloves for something in the US, when I’m in Liberia. And so I think that people are going to be far more cautious going forward. One of the things that I think the country has already realized and learned is that regionality is really important. Liberia actually was declared Ebola-free May 6 and remained Ebola-free for 5 weeks, but unfortunately it’s neighbors did not, and so the ability to advocate regionally for itself I think is a new lesson learned.

infection control processes to treat patients effectively and safely.

How should the international medical community respond to this outbreak? DR. SHETTY: From the health side, support to organizations who are responding to the crisis is needed now. Help with making contact and coordination on the ground is urgently needed. This is not something that requires scores and scores of medical volunteers to come and treat patients, it’s really about prevention and containment. DR. NIESCIERENKO: I think that we can do several different things. One is steer funding to the organizations that can work in this type of environment. And so there are very few NGOs that have Ebola outbreaks and so I think, you know, Samaritan’s Purse has learned an interesting lesson, with this being their first Ebola outbreak. It’s clinically a tough disease to treat from a sanitation, protection, medical aspect, so I think really funneling donations and money and good intentioned people to the organizations that do the work routinely. This is not the opportunity for well-intentioned people with no experience to go and try to help. We add to the burden if we become casualties. And then I think also it’s an opportunity for us in the medical community to advocate for our colleagues. Healthcare workers are at a primary risk to contract this. This is an opportunity to really push organizations to protect healthcare workers, or to do it ourselves by getting them supplies or getting donations to the right people who can.

What is the greatest challenge facing doctors on the ground in these countries?

Have any particular people or groups stood out to you for their dedication, innovation or leadership?

DR. SHETTY: Doctors are facing many challenges with this outbreak. From a public health standpoint, a big challenge is following up on contact tracing. Another big challenge is convincing traditional healers and local tribe chiefs to tell their communities to go the health facilities at initial signs of illness and teaching them about other public health measures such as not moving or touched infected bodies. On the clinical side, the biggest challenge is employing the proper isolation techniques and

DR. NIESCIERENKO: So I would say as far as international organizations, MSF has been in Guinea since the beginning, since Febrauary, and opened the treatment centers there and didn’t have enough resources to open one in Liberia but still sent their people to do training and oversight. I think their willingness to stick by the situation is really impressive, given their challenges. ;

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Grand Rounds

PETER CAMERON, MD // IMMEDIATE PAST PRESIDENT OF IFEM

Indian EM: A System Overview The recent EMCON conference put on display the ambitious steps being taken to improve Indian emergency medicine. But with over 1 billion potential patients, the challenges are daunting.

In November I had the pleasure of being a guest of the Society for Emergency Medicine India (SEMI) at their annual meeting, EMCON. The event gave me the opportunity to observe emergency medicine in India, and make a few observations as an outsider.

The conference has grown in the number of attendees, as well as topics and workshops, over its 16 years of existence. It’s been great to witness Indian emergency medicine take off, and to celebrate Indian emergency medicine’s accomplishments in Mumbai. The conference attracted approximately 1,200 delegates from all over India as well as from many neighboring states where emergency medicine (EM) is also just starting to be discussed as a possible way to improve the delivery of healthcare services. There was also a large contingent of foreign faculty and guests from the U.S., U.K., Australia, Singapore and other places where EM is better developed and integrated into essential health services. While the excitement for EM is palpable, much needs to be done to support its growth and firm foundation in the Indian healthcare system. In addition to the meeting, there was a lot of discussion about the future of Indian EM. The health system in India is multi-layered and has various sources of funding and training models for providers, often with little agreement on common standards/competencies and accreditation criteria. In 2013 the creation of the Diploma of the National Board (DNB) program for EM was sanctioned by the National Board of Examinations (NBE), one of the two agencies created by the Indian parliament to devise and regulate Indian medical residencies. Dr. Bipin Batra, CEO and Executive Director of the NBE, was one of the honorary guests at EMCON, and he has been the key person responsible for helping develop the DNB in EM, which previously had many false starts in India. While some of the details of the DNB training program are still being worked out, the basic premise is it’s a three year residency training program and qualified applicants must possess a MBBS and clear a common entrance and exit exam to qualify as a DNB. Approximately 20 hospitals throughout India have received a number of DNB EM residents, and typically the NBE allots anywhere from two to four residents to each Indian emergency department. A strategic MOU was signed between Boston University in the U.S. and SEMI to work jointly with the NBE to develop faculty training programming for Indian EM physicians who will now be responsible for teaching the new generation of Indian DNB residents. Most faculty have migrated to the emergency department from another specialty (“grandfathered”) and require some faculty development, to ensure well-rounded competencies in EM, as well as assessment and curriculum development skills.

Winter 2014 // Emergency Physicians International

In response to the popularity of EM, it is expected that there will be a growth of 250 new EM residency positions created very shortly in India, not all of them officially sanctioned by the DNB or another governmentsanctioned accrediting agency. The idea of starting this number of new residencies and educating the proposed army of EM doctors is mind-boggling! However, with 1.2 billion people in India, many without basic emergency services, there is an urgency to accelerate EM training. The scale of this initiative raises many questions. How do you attract high quality teachers? How do you individually mentor so many trainees? Will the course standards be the same across all the programs? Will graduates obtain jobs and be attractive to employers after they finish their training? Is the health system ready for such a large influx of specialty trained doctors in such a short time frame? Will there be a common exam? So many questions that must be answered . . . all the while working to raise standards. While there is already strong collaborations between several private institutions and their American training partners including Upstate Medical Center, George Washington University and others to host and provide teaching for Master of Emergency Medicine programs, the current foreign collaborations will not support 250+ new doctors. The U.K. College of Emergency Medicine provides the MCEM exam as an entrance examination and Australia has just entered into a partnership with the Indian government to help with the development of trauma systems. While the creation of the DNB in EM was a significant milestone in the development of EM, much needs to be done to further support its growth and to strengthen the entire Indian national health system. The WHO recommends that each country spend between eight to 12 percent of its GDP on healthcare, but India has spent a little less than four percent on healthcare as per the latest figures from the WHO published in 2012. Within that four percent, approximately three percent is spent at private healthcare PHOTO BY JOHN ISAAC / WORLD BANK

Most of the Indian population receives healthcare services from the government, which has underspent and misspent on services that are not well matched to the needs of most of the population. While the Indian government typically does a good job with delivering vaccines and some preventative services, the general healthcare infrastructure is weak and unresponsive to the needs of most Indians, and that includes emergency care services.

providers that cater to a middle and upper class elite who are typically urban and have access to some of the latest and most developed therapies available anywhere in the world. Most of the Indian population, however, receives healthcare services from the government, which has underspent and misspent on services that are not well matched to the needs of most of the population. While the Indian government typically does a good job with delivering vaccines and some preventative services, the general healthcare infrastructure is weak and unresponsive to the needs of most Indians, and that includes emergency care services. EM can play a significant role in improving the Indian health system responsiveness and provide services that most Indians will need for themselves or their families at some point in their lives. The Indian government should consider developing EM as a national priority and use it as a central plank to improve health system responsiveness and inclusiveness. There has been tremendous attention on the development of physician training for EM, but anyone who works on the clinical side knows and understands that good emergency care requires a full team of skilled professionals including nurses, pre-hospital care specialists and allied health. While there has been some thought about this at an institutional level, there will need to be an equally large, national response to develop skills if EM is to be able to provide system-wide services. As I relaxed in the faculty lounge in the luxury conference hotel with some of my Indian colleagues and friends in Mumbai and contemplated the opportunities and risks of developing EM in India I thought to myself: Wow! Only in India! Dr. Peter Cameron is the immediate past president of the International Federation for Emergency Medicine (IFEM)

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