Residency training underway in Khartoum Baby steps for The Medical Council of India Forming a global consensus on quality care
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ISSUE 7
JANUARY 2012
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WWW.EPIJOURNAL.COM
EMERGENCY PHYSICIANS INTERNATIONAL
COMMON GROUND Jim Holliman on how emergency medicine diplomacy could help bring stability to the Middle East.
SAUDI ARABIA
Dr. Judith Tintinalli on being a female physician in a Saudi ED
YEMEN
Bullet-riddled EDs underscore desperate need for emergency care development
QATAR
Can this resource-rich nation become an EM leader in the Arab world?
plus A day in the life of Beijing’s Peking Union Medical College {a photo essay}
IRAQ
War weary but battle-wise, Iraq sets ambitious emergency care goals for 2013
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• REMOTE SITE DOCTORS • CLINIC DOCTORS • COORDINATING DOCTORS • CLINIC MANAGERS • PARAMEDICS These positions offer both permanent residential and rotational roles. Rotational positions include the benefit of paid on and off rotation which allows you to continue to keep your home residence whilst working a fixed rotation, flying in and out of your site of assignment. International SOS coordinates the flights and travel to and from site for each rotation and provides onsite accommodation and facilities. If you believe you have the relevant experience, knowledge and flexibility and welcome the chance to work for a truly global organisation, send your CV and a covering letter, indicating the position of interest, to: medicalcareers@internationalsos.com To find out more about us, visit www.internationalsos.com
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EDITOR’S DESK
Emergency Medicine Diplomacy
I
have been involved in emergency medicine (EM) development efforts in the Middle East since the early 1990s, and the road has been less than smooth. One of my first efforts was to try to organize a multi-national EM conference for the region that would rotate from country to country every two years. But each time we would get the conference planning to the point of implementation, a political crisis or terrorist event would force us to cancel. Finally, with the organizational efforts of the Emergency Medicine Association of Turkey (EMAT), we were able to set up the First Multinational Middle Eastern Conference on EM in Istanbul, Turkey. Unfortunately, the meeting was set for early October, 2001, which turned out to be just a few short weeks after the terrorist attacks of September 11. Not surprisingly, there were huge logistical issues in proceeding with the conference. With the cancellations of international flights and changes in travel regulations, it was uncertain for a time if anyone from outside Turkey would be able to attend the conference. By force of will, a few of us were able to push through and run the conference anyway . . . terrorists be damned. In the end, it turned out to be quite a successful meeting, with about 350 participants. I had hoped that this conference could be put on every other year in a different Middle Eastern country, but the subsequent uptick in violent conflict in the region prevented this from happening. Ten years later and the Middle East is quite a different place, though plenty of the same problems persist. Importantly, with the recent radical governmental changes and the draw down in the war in Iraq, there seems to be new opportunity for the region to redefine its world view image and international aspirations and collaborations. Emergency medicine can play a key role in the region’s development and act as a model for peace and stabilization. These issues will be on display at the First Global Network Conference on Emergency Medicine in Dubai, a conference which has the opportunity to jump start the establishment of a regional identity for the practice of emergency medicine. This meeting could begin to bring about long term collaborative programs and training in emergency medicine. It’s time for EM to champion normalization of relations and medical system interactions between countries in the region. It is time to move away from the inappropriate – even childish – practices of visa denials to attend conferences, derogatory racist language in instructional materials, and “blacklisting” of physicians who participate in international meetings. My involvement in Israeli-Palestinian, Israeli-Jordanian, U.S.-Iran, U.S.-Iraq, and U.S.U.K.-Afghanistan EM collaboration efforts has convinced me of the important role that emergency medicine can play in promoting professional and patient care collaboration which can contribute to the peace process. I have seen directly the cordial interactions that typically occur between emergency physicians who come from countries which happen to be in active conflict with each other. Emergency physicians have a clinical focus on providing the same medical care and respect for everyone who presents to them regardless of the patient’s ethnic origin, religion, or country of residence. This philosophy and focus on EM – treating everyone the same and with respect – serves as a model for the rest of society to emulate when interacting with people from different countries. One suggestion for future regional conferences would be to have interactive sessions on specific recommendations on how EM physicians can improve relations between physicians in different countries, and on how EM physicians can interact with government agencies and medical organizations to promote better behavior by these organizations in relation to international interactions. Let’s look forward to the Dubai conference starting a new interactive initiative for the Middle East!
C. James Holliman, MD, FACEP, FIFEM editorial director
It’s time for EM to champion normalization of relations and medical system interactions between countries in the [Middle East] region. It is time to move away from the inappropriate – even childish – practices of visa denials to attend conferences, derogatory racist language in instructional materials, and “blacklisting” of physicians who participate in international meetings.
Residency training underway in Khartoum Baby steps for The Medical Council of India Forming a global consensus on quality care
.
ISSUE 7
JANUARY 2012
.
WWW.EPIJOURNAL.COM
EMERGENCY PHYSICIANS INTERNATIONAL
COMMON GROUND
Jim Holliman on how emergency medicine development could help bring stability to the Middle East. SAUDI ARABIA
Dr. Judith Tintinalli on being a female physician in a Saudi ED
YEMEN
Bullet-riddled EDs underscore desperate need for emergency care development
QATAR
Can this resource-rich nation become an EM leader in the Arab world?
IRAQ
War weary but battle-wise, Iraq sets ambitious emergency care goals for 2013
plus A day in the life of Beijing’s Peking Union Medical College {a photo essay}
cover design by tracey jolliffe
ABOUT EPI With a quarterly print and digital distribution and an online network of more than 1,350 members, EPI is the new hub connecting global emergency care, sparking dialogue and creating a space for new collaborations. Find copies of the print magazine at international EM conferences around the world, or read it online at www.epijournal.com
www.epijournal.com
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LETTER FROM THE PUBLISHER
New Year, New Potential
H
ello 2012! The upcoming year promises to be an exciting one for Emergency Physicians International. The print magazine will be distributed at regional EM meetings from Dubai to Dublin to Antalya. The EPI Network (www.epijournal. com) has grown to more than 1,300 members, and the weekly Global Briefing is emailed to about 6,000 physicians from more than 100 countries. Between deadlines we added a new executive editor to the line-up – Lee Wallis, the president of the African Federation of Emergency Medicine. And we just launched our new web site, EM Global Link (www.emgloballink.com), a global hub for emergency medicine opportunities. If you’re wanting to study abroad, lend a hand, or just scratch your itch to travel, hop online and see what’s possible. From Buenos Aires to Barcelona, Helsinki to Hong Kong, emergency medicine is gathering momentum and there’s never been a better time to get involved. 2012 also promises to be an exciting year for EM development. On the cover of this issue, we state that emergency medicine development could assist in stabilizing the Middle East. This might seem like a bold claim given the history of conflict in the region and the fact that emergency medicine is still in its infancy. It might even fly in the face of current events. In September, a security court in Bahrain sentenced more than a dozen doctors to 15 years in prison for treating the wounds of anti-government protesters during the political unrest earlier in the year. Thankfully this was overturned, but in our report on Yemen (page 10), Dr. Brendan Webb describes how, as recently as December, emergency departments were being used as pawns in armed conflict. But these events only act to bring into focus the apolitical, stabilizing role that emergency medicine ought to play. There is a common denominator in EM that doesn’t exist in other specialties, at least not to the same degree. It is the idea of caring for an acute patient when every second counts – when there’s not a moment to worry about a patient’s race, ethnicity, or their voting record. When patients enter the emergency department in extremis, they are simply human beings in need of immediate medical care. Caring for the sick in their hour of need – no matter who they are and no matter the cost – is an act that honors humanity, and it’s the soul of emergency medicine. And maybe, just maybe, that can change the world a little bit this year.
Logan Plaster Publisher
publisher LOGAN PLASTER Logan@Plasterpub.com editorial director C. JAMES HOLLIMAN, MD executive editors PETER CAMERON, MD TERRY MULLIGAN, DO, MPH LEE WALLIS, MD MARK PLASTER, MD associate editor LONNIE STOLTZFOOS editorial interns PEREL BERAL DR. RASHMI SHARMA regional corespondents CONRAD BUCKLE, MD MARCIO RODRIGUES, MD CARLOS RISSA, MD KATRIN HRUSKA, MD SUBROTO DAS, MD MOHAMED AL-ASFOOR, MD JIRAPORN SRI-ON, MD editorial advisors ARIF ALPER CEVIK, MD KATE DOUGLASS, MD HAYWOOD HALL, MD CHAK-WAH KAM, MD GREG LARKIN, MD PROF. DONGPILL LEE SAM-BEOM LEE, MD ALBERTO MACHADO, MD JORGE OTERO, MD advertising MICHELLE RUCKS mrucks@epmonthly.com Submissions & Letters LOGAN PLASTER logan@plasterpub.com
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January 2012 // Emergency Physicians International
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EVENT CALENDAR 02/12–01/13
12 MONTHS OF INTERNATIONAL EM CONFERENCES
SEMES 24th National Conference // Oviedo, Spain June 13-15, 2012 www.semes.org
SEPTEMBER
7th Annual Meeting of the German Association for Emergency Medicine // Berlin, Germany September 20-22, 2012 www.dgina.de
MARCH
3rd EurAsian Congress on Emergency Medicine (EACEM 2012) // Antalya, Turkey
The 16th Annual Scientific Assembly of the Israeli Association of EM // Tel Aviv, Israel March 13-14, 2012 www.kldltd.co.il
32nd International Symposium on Intensive Care and Emergency Medicine // Brussels, Belgium
September 19 – 22, 2012 www.eacem2012.org
OCTOBER
EuSEM 2012 // Antalya, Turkey
March 20-23, 2012 www.intensive.org
October 3 – 6, 2012 www.eusem.org
MAY
5th International Conference of SPMED // Lima, Peru
The Inter-American Emergency Medicine Conference // Buenos Aires, Argentina
October 4-6, 2012 www.spmed.org.pe
May 16 – 18, 2012 International-em.org
The American College of Emergency Physicians Scientific Assembly // Colorado, United States
6th Dutch North Sea Emergency Medicine Conference // Egmond aan Zee, Netherlands
October 8 – 1, 2012 www.acep.org/sa
May 30 - June 1, 2012 nvsha.nl
Pan-Pacific Emergency Medicine Congress 2012 (PEMC 2012) // Seoul, Korea
JUNE
October 23 – 26, 2012 www.pemc2012.org
First International Congress of Pediatric Emergency Medicine // Leon Guanajuato, Mexico
African Conference of Emergency Medicine // Ghana, Africa
June 14-16, 2012 www.anmuep.org.mx
The 2012 International Conference on Emergency Medicine (ICEM) // Dublin, Ireland June 27-30, 2012 www.icem2012.org
October 30 - November 1, 2012 www.pemc2012.org
NOVEMBER
CAEP Twelve (Canadian Association of Emergency Physicians) // Niagara Falls, Canada
14th Annual Conference for Society for Emergency Medicine in India // New Delhi, India November 16-18, 2012 www.semi.org.in
June 2-6, 2012 caep.ca
L I S T YO U R N E X T I N T E R N AT I O N A L E V E N T F O R F R E E O N T H E E P I N E T W O R K – W W W. E P I J O U R N A L .C O M 6
January 2012 // Emergency Physicians International
IN THIS ISSUE www.epijournal.com
03 | Editor’s Desk 08 | Policy Mind the Training Gap: The Medical Council of India faces an EP shortage. 09 | Clinical Video or direct laryngoscopy? With the newest tools, you won’t have to choose.
Source 11 | Dispatches Can emergency physicians from other countries practice in your region? 12 | Yemen Heavy armed conflict reveals desperate need for advanced emergency medicine training. 13 | Iraq Armed with lessons learned on the battlefield, Iraq sets ambitious EM training goals for 2013 14 | Qatar Could the resource-rich nation become an EM leader in the Arab world?
Reports 15 | Global Research Review Dr. Adam Levine reviews studies from Iraq and Bangladesh. 17 | In Khartoum, class is in session 18 | EM Development in Saudi Arabia Dr. Judith Tintinalli on being a female physician in a Saudi ED, plus an indepth infrastructure analysis 22 | Beijing Photo Essay A day in the life of the Peking Union Medical College 28 | Grand Rounds Benchmarks without borders: Building a global consensus on quality care
African Conference on Emergency Medicine Accra International Convention Centre, Ghana save the date:
30 October to 1 November 2012
www.afcem2012.com
www.epijournal.com
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POLICY
Mind the Training Gap The Medical Council of India (MCI) is slowly taking positive steps towards educating a new emergency physician workforce. by dr. subroto das
A
decade and a half since the advent of Academic Emergency Medicine in India, the struggle to institutionalize EM in the country has gathered a never seen before momentum. This has been due, in part, to organizations like the Society for Emergency Medicine, India (SEMI), continually emphasizing emergency medicine before the Medical Council of India (MCI), the nation’s nodal agency responsible for accreditation of all Medical Courses in India. It started in 1988 when the MCI instituted a course by the name of Accident & Emergency Medicine as the 24th specialty for post-graduate eduction. The specialty was then abolished in 2000 because, according to MCI, because it overlapped with other branches of medicine. Soon after, private universities began to feel the need for this course of study and added it back into the curriculum. These private programs had the support of foreign institutes, including some partnerships which still continue to this day. In 2009, MCI awoke to the emergency medicine needs of a country of more than a billion and granted permission to start post-graduate training in two of India’s premier medical Colleges. At this point, emergency medicine became the 30th specialty recognized by MCI in India. It was a joyous moment for more than a 1000 practising emergency physicians, most of them qualified through collaborative programs between Indian Institutes and UK or US-based academic organisations. Into this new decade, MCI has taken further steps, now expanding the accreditation to six medical colleges and also recognizing the UK-based MEM degrees, courses which are available in the country through Indian affiliates like the Apollo Hospital Group, arguably India’s biggest chain of tertiary care hospitals. MCI has also set guidelines for faculty development in EM and minimum qualifications for
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teaching faculty. While these are positive steps, they are not enough. There are 300 public medical colleges and a growing number of private institutions, all capable of conferring the emergency medicine degree. The need is undeniable. The Ministry of Health and Family Welfare and the MCI both state that the doctor to population ratio is 1:1722. Though 600,000 physicians are registered to practice, the actual number is far less due to emigration and retirements. In actuality, there are only about 50 to 60 doctors for every 100,000 people, and only about 1000 total practice emergency medicine. According to SEMI President Dr. V. P. Chandrasekharan, for India’s population of 1.2 billion, at least 10,000 emergency physicians are needed. This kind of increase in the physician workforce would take time. If today MCI were to permit two EM seats per medical college, 628 graduates would graduate every academic year (after an initial three years). That means that to attain a goal of 12,000 emergency physicians it will take 19 years (assuming that population growth rate is zero, which is impossible). Many experts in the country feel that the situation can be addressed differently: There were and still are many emergency training courses available in India. As there were no guidelines when these courses were started, training periods vary. Fellowships and degrees are still being awarded by private and foreign universities. According to Dr Chandrasekharan, the A&E training is similar to any other discipline offered by MCI. Moreover, MD A&E courses were formed in a structured manner similar to MCI recognized courses and the syllabus and curriculum set by board of studies of respective universities. These courses need to be evaluated, streamlined if necessary, and recognised by MCI to increase the number of qualified EPs. Moreover, with at least 45 publicly-funded medical colleges in readiness to have EM courses, their recognition need to be fast-tracked. Many experts, led by SEMI, also feel that MCI needs to reexamine its faculty development criteria. As it stands, the Council has ignored the existing EPs who have been trained in this specialty. The MCI notifications clearly state that MDs in general medicine, pulmonology, anesthesiology and MS (post-graduate) in general surgery/orthopedics with two years work experience in emergency medicine can be a faculty. While the 1st generation of EM teachers in the United States in the 1960s emerged from these various specialties, India needs to expedite this process and quickly raise the quality of EM training. Only then will the country be able to deliver high quality emergency care to each of its citizens. In all fairness to MCI, despite the pulls and pushes, it has taken steps to champion EM in India. Whoever, takes the credit for pushing MCI, the fact remains that the council has taken EM in right earnest, calling for frequent meetings with stakeholders, the most recent being in September 2011, to discuss expansion of EM courses and involve the private sector to speed up the development.
CLINICAL
t The Glidescope Direct Trainer has a relatively flattened American Macintosh blade shape and can be plugged into the same monitors used by the regular Glidescope. The blade is metal and currently does not come with any removable/single-use covers, although I have been told this option will be available soon. The blade must be cold sterilized between patients, not autoclaved.
Video + Direct Laryngoscopy While some debate the relative merits of direct vs. video laryngoscopy, the newest set of laryngoscopes make it easy, offering the best of both worlds. by richard levitan, md
A
t the recent Society for Airway Management conference there was a debate on Direct Laryngoscopy (DL) vs. Video Laryngoscopy (VL). While I love imaging and the mechanical and teaching advantages of look-around-the-curve video laryngoscopes, there is beauty in the simplicity, speed, and emergency applicability of direct laryngoscopy. DL is faster and does better with fluids, bleeding, and vomitus while tube delivery is much more straightforward with hyperangulated video devices. When VL is used in large series it does not perform better overall than DL, although there are cases when DL is very hard and VL easy. Alternatively, I have had some hard or impossible VL cases where DL was a slam dunk. It occurred to me after the conference that the debate was in some ways pointless, given the new array of DL/VL devices which make both options available to you. With hyperangulated devices like the Glidescope, McGrath Series 5, or Storz Dorges Blade video laryngoscope, the angulation of the blade prevents any direct view. If the video fails, from fluids or any other reason, there is no direct view. This is not the case with DL/VL combination devices. Intubation can be done via direct line of sight, just as a standard instrument would
{ The Storz C-Mac was the original of the DL/VL devices. Its metal blade has a German Macintosh shape. This refers to the relatively low proximal flange height, the full flange from base to tip, and a short light-to-tip distance. The video and light source comes through a removal cartridge that slides in and out of the blade handle. Like the Glidescope Direct Trainer the blade requires cold sterilization and there as of yet no single-use covers, although they too are in the works. The Storz product has a very bright light and a somewhat closer view of the larynx than the Glidescope Direct Trainer. It plugs into a separate monitor like the Glidescope, although the company has just created a self-contained small monitor that is part of the camera/light cartridge for a more portable solution. The power and monitor turn off when this small screen monitor is folded down. Just as different blades can be plugged in with the Glidescope, the Storz monitor also accepts its new hyperangulated Dorges Blade (which has more of a Glidescope blade shape). u The McGrath Macintosh is a new product from Aircraft Medical. It will be sold in the US by Covidien, a large and diverse medical products company whose brands include Nellcor and Mallinkrodt. The McGrath Mac is entirely self-contained with a small integrated LCD screen. It has a very low profile Macintosh blade design and uses single-use clear plastic blades that quickly fit on and off. It has been designed like the Glidescope Ranger to meet military specifications, namely that it can be dropped from 6 feet, frozen, immersed, etc...presumably able to handle the abuse it will get in the chaos of the emergency department. The device uses a small button battery pack that must be obtained from the company. A nice feature of the product, considering that it is battery-run only, is that a small clock provides information on how many minutes of run time are left on the battery pack. Relative to the Glidescope Direct or the Storz C-Mac the light (and image on the small portable screen) was not as bright, although the screen and light have just been upgraded. I have yet to test this newer version in my lab.
continued on page 10 4
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CLINICAL
3 continued
from page 9
be used, or under video, or as a combination. In the setting of emergency airways, especially trauma airways, I think this has great value. Currently available DL/VL devices include the Storz C-Mac, the new McGath Mac (now to be distributed by Covidien), and the Glidescope Direct Trainer. After many years of testing in real tissue I appreciate that hyper-angulated video laryngoscopes can provide a fuller view of the larynx than DL/VL devices in many cases. However, I have found extremely few cases where DL/ VL devices did not provide enough imaging of the larynx–under video–to successfully intubate, even if the DL view was not adequate. I do appreciate that in elective anesthesia there are advantages to using a hyper-angulated narrow flange device, like the Glidescope, that avoids excessive forces on teeth and tongue and jaw. In the elective setting there is also little concern for fluids, secretions, vomitus. While I believe many of the video devices, and particularly the Glidescope (due to its camera position and the angle of the lens over the camera) function remarkably well in most soiled airways, though things can still obscure the view. If anything obscures the view the device must be removed and wiped, or another intubation method tried, because there is no direct view of the larynx. The overall failure rate of either DL or VL (with a Glidescope) is in the 1-2% range (or less). There are as yet no large studies looking at the failure rate of DL/VL devices, but I think the emergency airway may be the best place to deploy these products. Regardless of which device you favor, or which device you use, remember a few simple rules to make your airways as uneventful as possible:
1
Apply nasal cannula to every emergency airway (under mask during pre-oxygenation) and flow it at high rate (15 lpm) throughout the DL or VL [Nasal Oxygen During Efforts Securing A Tube—NO DESAT]. It’s fun watching the pulse ox rise during apnea (after muscle relaxants). It has become
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January 2012 // Emergency Physicians International
//
Always, always, always do an epiglottoscopy before laryngoscopy – with both DL or VL devices. Find the epiglottis first, before you expose the larynx.
a major stress reducer in my airway cases. For more information look up my prior articles in Emergency Physicians Monthly (www.epmonthly.com) or check out a new article I just published with Scott Weingart on Oxygenation in Annals of Emergency Medicine.
2
Have the Yankauer in your right hand, and suction aggressively prior to insertion of any device. As you begin to insert the blade, dab the posterior pharyngeal wall–with either DL or VL.
3
Always, always, always do epiglottoscopy before laryngoscopy–with both DL or VL devices. Find the epiglottis first, before you expose the larynx. This makes the procedure reliable, since the epiglottis is the on-ramp to the larynx, at the base of the tongue where you start, and at the top of the laryngeal inlet and larynx (where you’re going). Never hyper-extend the head on the neck; ear-to-sternal-notch positioning, face plane parallel to ceiling prevents the posterior displacement of the base of the tongue and epiglottis onto the pharyngeal wall, and will make jaw distraction and epiglottis identification easier. Dr. Levitan teaches emergency medicine at Jefferson Medical College and at the Univ. of Maryland and helps run a monthly airway management course involving specially prepared cadavers: jeffline.jefferson.edu/jeffcme/Airway
SOURCE // DISPATCHES READER-SUBMITTED UPDATES FROM THE EPI NETWORK
Q. Is it possible for emergency physicians trained in other countries or regions to practice emergency medicine in your country? If so, which countries are accepted?
81 emergency physicians from 33 countries answered the question to the best of their knowledge. Read the full report and dialogue with EPs around the world on the EPI Network. www.epijournal.com
UNITED STATES “No” “Must be here over a year and there’s horrendous paperwork” “It is possible, but the applications for medical licensing are very difficult and detailed, requiring several years of testing and paperwork.” MEXICO “No” PANAMA “Yes, all the countries in Latin America, as well as Canada, USA and Europe” COLOMBIA “Yes, from anywhere.” “Yes, from EEUU”
Bolivia” BRAZIL “No, you have to have certification in Brasil.” UNITED KINGDOM “Yes. Australia, South Africa and New Zealand” “If you are registered with the GMC as a specialist, or if you are an EU citizen, you can practice. If you are not but have foreign specialist qualifications, you are allowed to do a locum as a specialist.” FRANCE “Yes, from Romania.” “Yes, from EU members.”
ECUADOR “Yes”
SWEDEN “Yes, Iceland” “Yes, from Europe.”
ARGENTINA “Yes. Argentina, Chile and
SOUTH AFRICA “Yes. UK, US, Australia, Oth-
ers on application to medical council” PALESTINE “Yes, from the United States and England.” TURKEY “No, one must be a citizen of Turkey to practice medicine in Turkey. If a citizen of Turkey trains overseas, he/she must get an ‘equivalence’ certificate from the Ministry of Education before they issue a valid ‘medical diploma’.
QATAR “Yes. USA, Canada, UK, Arab Board Of Emergency Medicine, Philippines, India, Pakistan, Egypt and Jordan.”
NEPAL “Yes. Non-Nepalese EPs must apply to Nepal Medical Council (NMC) to ask for a temporary licence/registration.”
BAHRAIN “Yes. Board certification from Arab Board of Medical specialty in EM, Saudi Arabia, USA, Canada and Australia can work as a consultant in ED.”
MALAYSIA “Yes. FRCS (A & E) UK (up to year 2010); Fellow of the College of Emergency Medicine, UK; Fellow of the Australasian College of Emergency Medicine (FACEM)
UAE “Yes, mostly from western countries.”
IRAQ “No” “Yes. USA, Turky, Egypt and Jordan.”
AFGHANISTAN “Yes, from the US, UK, Romania, Canada, Bosnia and Kenya.”
YEMEN “Yes, United States and UK” “Yes. Arabic countries, UK, USA, some EU countries.”
INDIA “Yes, from the United Kingdom.”
AUSTRALIA “Yes. USA, UK and Canada.” “Maybe South Africa?” SOUTH KOREA “No.” NEW ZEALAND “Yes. United States, UK, Australia. There may be others as well.”
l
SOURCE
YEMEN
Heavy armed conflict reveals a desperate need for advanced emergency medicine training. by dr. brendan webb
Y
emen, whose name literally means “on the right side,” is located in the mountainous and green southwest corner of the Arabian Peninsula. Yemen is set apart and completely different from its neighbors in the peninsula. Ruins of palaces and temples bear witness to the highly developed ancient civilizations founded here. Amidst the craggy landscape, a tribal structure has remained intact while the central government stayed weak. Yemen‘s per capita income is eight times less than that of Saudi Arabia. The literacy rate is only 60%. Wars are being fought on several fronts in the country and the political situation (as of the writing of this piece) is far from stable. Even so, Yemen is a rich place, the only spot in the peninsula where you can be refreshed with heavy rains, cooled down by moderate summers and witness unspoiled Arab culture and friendliness. Like many things in Yemen, the field of emergency medicine is lagging far behind the rest of the world. Since there are no emergency medicine training programs – indeed almost no training programs for medical school graduates at all – emergency departments are staffed by general practice doctors with bachelor’s degrees. They generally provide first aid
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and simply wait for specialists to come to further assess and treat the patients. Though many have long years of experience, nurses staffing the departments have no specialized training. Basic patient support and diagnostic equipment tends to be lacking. When I arrived to work in a large government hospital in a large city, the equipment in the emergency department consisted of an EKG machine, oxygen tanks and suturing instruments. I work with an NGO that trains Yemeni doctors and nurses. In addition to teaching sessions and workshops, we work alongside them to practice skills. When I began over two years ago, I found that the nurses were most enthusiastic about learning new skills. I helped them organize patient flow, improve record-keeping and establish a fully-equipped resuscitation room. A group of doctors who recently graduated were hired and were more keen to learn than the older generation of doctors. I give them practical lectures on emergency medicine topics and then work alongside them seeing patients. With access to international media they understood what the capabilities of an emergency doctor and emergency department can be and dreamed of attaining it. I am pleased to have seen their progress in applying what they
January 2012 // Emergency Physicians International
Sana’a, Yemen’s capital, is the fastest growing capital city in the world with a growth rate of 7%. If the current rate is maintained, the population of Sana’a will double in ten years.
Four bullets went through my office and one through the ER resuscitation room. A bullet went through a window and injured a man visiting an ICU patient. Shells and RPGs entered the ICU (which by then had been evacuated) and the hospital gate was riddled with bullets.
have learned and becoming proficient in the use of several types of equipment. The political unrest in 2011 in Yemen has had a great impact on the field of emergency medicine. Perhaps most acutely, the lack of emergency medicine services was felt during the severe armed conflicts in our city of Taiz. Many lives were lost because of the lack of equipped ambulances with trained personnel. An IV and some gauze alone often was not enough to treat the shelling and gunshot victims. Optimistically named “first aid” cars – the stand-in for an EMS – were often unable to enter areas to retrieve patients due to very heavy fighting and road blocks. My neighbor’s body lay on the street all night after he was shot in the chin while riding his motorcycle on an errand. War trauma patients brought to hospitals in Taiz are typically met with saline and blood transfusions and suturing of wounds. Diagnosing and treating internal injuries is often limited to plain x-rays. Emergency trauma surgery almost never happens as the patients’ families have to gather the finances and materials for the surgery ahead of time. Worse yet, the hospitals themselves became pawns in the fighting. Al Rowtha Hospital, owned by an opposition leader, received all injured people, armed or not. Al Thora Hospital (where I work) did not receive opposition patients, because it is a government hospital. Though the director asserted that people of all backgrounds would be treated equally, a lack of trust kept injured members of the opposition away, even when this was the closest or most accessible hospital. The armed opposition attacked Al Thora several times, claiming that the government was using the hospital as a military base for strikes on “Freedom Square,” the main encampment of anti-government protestors, only a few kilometers away. Four bullets went through my office and one through the ER resuscitation room. A bullet went through a window and injured a man visiting an ICU patient. Shells and RPGs entered the ICU (which by then had been evacuated) and the hospital gate was riddled with bullets. Al Rowtha Hospital also fell under attack. Shells penetrated the upper floors where patients were admitted. The entire neighborhood around Rowtha was shut down as it frequently received heavy shelling. Since different sides have been keeping their own statistics, it is unclear how many
hospital workers and patients have been injured or killed during the conflicts. Because of the fighting around the hospital, the number of patients has slowed to a trickle. The wards on the higher floors were closed, being more vulnerable to attack. Gunshot wounds of all types have now become one of our most frequent presenting complaints. Most patients have been civilians,
including a schizophrenic patient shot while wandering the streets, a homeless man shot while getting up from his bed, and a teen-aged girl shot while walking to a neighbor’s house. The economic and psychological effects of the fighting and instability permeate every case, from people not having enough money to pay for dialysis to women explaining how they feel uncontrolled anxiety after spending days
wondering if the next shell would fall into their living room. Thankfully, the sound of gunfire and shelling have all but disappeared in Taiz in the last 2 weeks and it is amazing how quickly things have gotten back to normal. Rebuilding homes and calming distressed hearts, I am afraid, will take many years longer.
1998 Academic study of EM begins in Iraq 2003 Only 10 physicians have master certificates in EM
IRAQ
Armed with lessons learned on the battlefield, Iraq sets ambitious EM training goals for 2013 by dr. shakir katea
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mergency Medicine (EM) is a new academic discipline in Iraq. The academic study of emergency medicine supposedly began in 1998, but in truth only 10 physicians got master certificates in EM betwen 1998 and 2003. The real starting point for developing EM in Iraq occurred after 2003 due to many factors such as the war, an increase in complex emergencies, an increase in violence and various changes in life style. In 2004, Iraqi ministry of health established a directorate called Medical Operation & Specialized Services (MOSS) which included in its organizational structure seven departments, among them emergency medicine, ambulance services and rehabilitation.
Following this, Iraqi emergency departments developed a long-term plan to develop emergency medicine and bring it up to date by 2012, in coordination with the ministry of higher education and directorate of planning. The long-term plan included achieving the following steps: 1) Established Arab Board study in emergency medicine (since 2008), continue diploma study in emergency medicine. 2) Established 20 training centers (training center in each province) 3) More than 400 physicians and 600 paramedics participated in training courses on emergency medicine internally and externally (American University of Beirut, Thailand, Japan and Korea). 4) Provide updated equipments, instruments
2004 Iraqi MOH establishes the Medical Operation & Specialized Services, which includes EM in its organizational structure 2008 Iraqi MOH establishes EM working group 2009 Plan adopted to develop EM by 2013 2009 International Medical Corps completes training of 300 EPs. 2013 Proposed opening date for regional training center for EM, established in conjunction with the EU.
and life saving drugs for all emergency rooms with continuing education for each ER. 5) Administer new electronic registration system for ERs. This system has been applied in Baghdad hospital and will cover other provinces during 2012, it’s a network communication system that connects the ER to ambulance services and operating rooms. It also provides information to the MOH about empty beds in the ER, the ICU and in burn units. It will also allow for regular data collection. 6) We recently started a pilot program in Baghdad which connects emergency patients to a physician via a free phone service (dial 404). This service, called “Call advisory services” is in coordination with ambulance services. 7) Project with European Union (EU) to establish the regional training center for emergency medicine its now under construction and the proposal date for opening is the beginning of 2013. 8) Establish Emergency Medicine advisory committee in MOH. 9) Develop guidelines and protocols for Emergency care providers. The war has had a lasting impact on our medical system in general, and emergency services in particular. There is an upside, however; the war has been a great opportunity to get practice in how to deal with mass casualties in the field. Sadly, many of our colleagues lost their lives during the war, particularly between 2003 and 2009. During these hard times, most of our infrastructures were destroyed and the national system was collapsed, but the health services in general continued to provide health care and emergency care to affected people. The horror stories of the war are many, but we look back and are proud that medical staffs are the heroes of the stories. As we look forward, we face many looming challenges, from poor security to a lack of facilities to the low number of emergency medicine providors with adequate skills. We are ultimately optimistic about the future of emergency care in Iraq, but it will be a challenging road.
l
Rapid Economic Growth Despite Global Downturn Skyscrapers under construction dominate the view of Doha’s Dafna/West Bay area. Despite the global financial crisis, Qatar has prospered in the last several years – in 2010 Qatar had the world’s highest growth rate. The GDP rebounded in 2010 largely due to the increase in oil prices. Oil and gas account for more than 50% of GDP, roughly 85% of export earnings, and 70% of government revenues. This oil-rich nation now has the highest per-capita income ($179,000) and the lowest unemployment in the world. Proved oil reserves of 25 billion barrels should enable continued output at current levels for 57 years. Qatar’s proved reserves of natural gas exceed 25 trillion cubic meters, about 14% of the world’s total and third largest in the world. The government plans to spend billions of dollars on infrastructure upgrades in the run-up to the 2022 World Cup in Qatar.
QATAR
The resource-rich nation sets its sights on becoming an EM leader in the Arab world by khalid abdulnoor saifeldeen, md
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mergency medicine in Qatar has grown rapidly at a rate and on a scale unparalleled anywhere in the world. It has produced results that are hard to imagine without seeing the sheer volume and expectations placed on the service, and set against a background of comparable Western models achieved over several decades, with a fraction of the clinical workload and already highly evolved systems of training, service integration and healthcare strategy to support its growth. Emergency medicine developed as the result of the increasing demand for around-theclock primary and acute care, and nowhere is this more evident than in Qatar, where the consumer first choice for both primary and acute care is currently the main emergency department based at Hamad General Hospital, which sees around 1500 patients daily. During the last decade, emergency medicine in Qatar has made dramatic advances in terms of becoming a specialty, and during that time has recruited a specialty-trained, diversely skilled international workforce, delineated and stratified acute care areas within ED including a see-and-treat facility able to process almost one thousand patients per day and observation medicine within its short stay bays. The department practices advanced emergency medicine such as critical care, invasive monitoring and the use of bedside ultrasound. Since its inception in 2000, the Arab
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Board of Emergency Medicine (ABEM) residency program in Qatar has gone through various developments. Its curriculum has been modified from being process-based to a more outcome-based emphasis. As part of the department’s strategic staffing plans two and half years ago, the EM board-certified faculty (specialists and consultants) has also multiplied to a more comfortable number with better faculty-resident ratio. Its academic activities have witnessed multiple expansions, with the incorporation of numerous formats including regular didactic sessions, grand rounds, and bedside teaching, procedure skill workshops, to name but a few. All these have, over the years, translated into better pass rates of its candidates in the ABEM examinations, and patient care. Over the last 3 years, more than 40 residents successfully completed their training and were certified as physicians in emergency medicine. In line with HMC’s efforts towards accreditation by the American Accreditation Council for Graduate Medical EducationInternational (ACGME-I), the ABEM residency has been identified as one of the promising programs. The challenges are many, both from within the program/department and the corporation, but it has achieved the following significant milestones: 1. Its 4-year master schedule for new intakes 2. Graded responsibility and supervision 3. Scheduled & verified multiple evaluation
January 2012 // Emergency Physicians International
POPULATION BREAK-DOWN 10% Iranian 14% Other
18%
Indian
18%
Pakistani
40% Arab
tools 4. Competency-based assessment 5. Active academic e-group amongst residents and the faculty 6. Program director with 50% protected time 7. Assistant Program Director with 50% protected time 8. Chief Resident with 50% protected time 9. 6:1 Resident to Core faculty Ratio 10. 1:1 Resident to faculty ratio 11. Protected weekly educational day
Research & Training
The department is aiming to develop in to an academic emergency unit and is pursuing subspecialisation in emergency medicine with emphasis on high quality research and publications. Future plans are shaping up to develop subspecialty training fellowships in disaster medicine, paediatric emergency medicine, ultrasound, toxicology, observation medicine and towards developing academic emergency medicine frameworks and practices. The definition of a subspecialty is less clear, and subspecialty development has historically grown up on a case-by-case basis, but the basic requirement is certification in an existing core specialty. As EM has matured as a specialty, many physicians have focused on discrete areas of practice and research. Some of these are shared with other specialties, and some are unique to EM. Some of these subspecialties are now recognized with certification examinations and certification in conjunction with other specialty groups. Through the tremendous support it has been receiving from the department’s leadership and administration, medical and nursing personnel, as well as the corporate medical education, the ABEM residency is progressing towards becoming an excellent and exemplary training program in the region.
R Report Journal Scan
Global Research Review by Adam C. Levine, MD, MPH on behalf of the Global Emergency Medicine Literature Review Group
Bangladesh_Green banana-supplemented diet in the home management of diarrhoea in children Rabbani GH, Larson CP, Islam R, Saha UR, Kabir A. Green banana-supplemented diet in the home management of acute and prolonged diarrhoea in children: a community-based trial in rural Bangladesh. Trop Med Int Health. 2010; 15(10):1132-9.
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his cluster-randomized field trial evaluated the effectiveness of green bananas for in-home management of acute and prolonged childhood diarrhea. The authors identified 72 clusters in the rural Mirsarai sub-district of Bangladesh, each containing approximately 3,000 persons. Eighteen clusters were randomly chosen and assigned to standard diarrhea care based on WHO guidelines (12 clusters) and standard care plus green bananas (6 clusters). To evaluate children with prolonged diarrhea (defined as symptoms longer than seven days), the 12 standard care clusters were further randomized to standard care (6 clusters) and standard care plus green bananas (6 clusters), commencing only after the seventh day of symptoms. Nonhospitalized children aged 6-36 months with active diarrhea were followed for 14 days by a network of local women and trained fieldworkers. Over 20 months, 2968 children were enrolled, of whom 198 were further evaluated for prolonged diarrhea. The cumulative probability of symptomatic cure was higher in the green banana group for both acute diarrhea (hazard ratio = 0.63, P < 0.001) and prolonged diarrhea (hazard ratio = 0.38, P < 0.001). Recovery rates of children receiving green bananas were significantly higher for acute diarrhea at day 3 (79.9% vs. 53.3%, P < 0.001) and at day 7 (96.6% vs. 89.1%, P < 0.001). Children with prolonged diarrhea also benefited from green bananas, with recovery rates at day 10 of 79.8% vs. 51.9% (P < 0.001), and at day 14 of 93.6% vs. 67.2% (P < 0.001). Green banana is an inexpensive traditional remedy for childhood diarrhea, and was shown in this study to be effective in decreasing the duration of illness for children treated for diarrhea at home. The cluster randomization, large sample size, low rate of attrition (0.1% dropout rate), well-defined study protocol, and use of an intention-to-treat analysis led to very strong internal validity of the conclusions. The lack of blinding, and reliance on self-reported data from mothers were identified as potential sources of bias and addressed by the authors. Data on maternal education and breastfeeding habits, which are other known confounders in diarrheal illness, were notably missing from this study. Nevertheless, the study findings provide health care professionals in resource-limited settings with a potentially useful adjunct to the management of childhood diarrhea, which is a common source of infant and child morbidity and mortality in the developing world. Further research is necessary to determine whether other similar starch-based remedies might also be efficacious when green banana is not available. Generalizability of the findings to other regions, and the relative cost-effectiveness of the treatment compared to other therapies for diarrhea, must also be studied before widespread implementation of green banana can be recommended at the policy level.
-AL, TT
Iraq_Injury burden within the Baghdad Governorate of central Iraq in 2009 Donaldson RI, Hung YW, Shanovich P, Hasoon T, Evans G. Injury burden during an insurgency: the untold trauma of infrastructure breakdown in Baghdad, Iraq. J Trauma. 2010;69(6):1379-85.
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he authors of this study attempt to quantify the injury burden from insurgent conflict to the population within the Baghdad Governorate of central Iraq. The study was conducted from October 2009 to November 2009. By describing the injury burden, including the indirect injury from the breakdown of infrastructure, the authors hope to help guide appropriate areas of injury prevention and treatment. Previous attempts to quantify injuries in the country have focused mainly on direct mortality. In this study, a two-stage, cluster sample was used and households were randomly selected for inclusion. The Iraqi Ministry of Health staff then administered a cross-sectional survey to the heads of the households. The survey asked participants to recall all injuries incurred in the last three months, and injuries resulting in death in the last year. The authors define injury as any type of physical harm to an individual In 2009, viothat created the loss of at least one day of normal activity, or that caused the individual to lence accounted seek health care treatment. The Iraqi Ministry for less than 9% of Health staff administered the survey to a total of all injuries in of 1,172 households, obtaining data regarding 7,396 individuals. For the three month recall the Baghdad period, there were 103 reported injuries, three Governorate of of which were injury-related death. There were Iraq, with injury seven cases of injury-related deaths within the 12 month recall period. As such, there was a incidence great1.7% (95% CI = 0.7% to 3.5%) proportioner in men, disate mortality for injuries. Of these injuries, placed persons, only 8.9% were recorded as intentional. Injury incidence was much greater in men, displaced and those with persons, and those with less education. less education. By describing the injury burden through the application of a cross-sectional household survey, this study emphasizes that a significant proportion of injury is related to conflict and infrastructure breakdown. Furthermore, it is evident that intentional injury, which is often publicized and discussed, makes up only a small proportion of the total injury burden. In an area of conflict, study limitations include survey respondersâ&#x20AC;&#x2122; fear to participate, and the dynamic state of security during any specific time period. It should be noted that extremely insecure zones were deliberately avoided, providing some selection bias. Finally, this was a retrospective study based on recall and selfreporting. As such, overall injury burden, intentional injury, and mortality-related injury were all most likely underestimated. It is also important to acknowledge that continued on page 16 4
AL: ADAM LEVINE, MD, MPH; TT: TIMOTHY TAN, MD; AW: AMBROSE H. WONG, MD; JMJ: JOSHUA MATTHEW JAUREGUI, MD
www.epijournal.com
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R Journal Scan YOUR PATIENTS ARE ON THE CUTTING EDGE...ARE YOU?
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from page 15
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a state of conflict often serves to prevent other forms of otherwise more common injuries such as motor vehicle-related injuries. This study effectively emphasizes the injury burden in an area of conflict, including the effect of social and infrastructure breakdown. -AL, JMJ
Bangladesh_Influenza is a major contributor to childhood pneumonia in a tropical developing country Brooks WA, Goswami D, Rahman M, Nahar K, Fry AM, Balish A, et al. Influenza is a major contributor to childhood pneumonia in a tropical developing country. Pediatr Infect Dis J. 2010;29(3):216-21.
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ecause pneumonia and influenza are both major sources of child mortality worldwide, the authors sought to determine the epidemiology of influenza infection and its association with pneumonia among poor urban children in Bangladesh. Respiratory and febrile disease surveillance was conducted through weekly home visits by trained research assistants from April 2004 to December 2007 in a cohort of 5,000 children younger than 5 years old in Kamalapur, southeast Dhaka. They were then referred to an onsite clinic to be evaluated by a physician if they exhibited clinical signs suspicious for a respiratory illness. Research partners collected nasopharyngeal wash (NPW) specimens on every fifth child referred to the onsite clinic. During this period they identified 7,515 cases of pneumonia and 24,696 cases of URI in 16,043 child-years, creating a pneumonia incidence of 511 pneumonia episodes/1000 child-years. Out of 2,370 NPW specimens submitted, an isolation rate of 13.5% was obtained, translating to an incidence of 101.8 influenza episodes/1000 child-years. Fever and rhinorrhea were independently associated with influenza. The authors calculate the incidence of influenza-specific pneumonia to be 28.6 episodes/1000 child-years, with Influenza A having the strongest association with pneumonia. The authors conclude that the high influenza incidence of 511 cases/1000 child-years, and the large percentage (28%) of influenza-positive children who developed pneumonia, reveal influenza to be a major contributor to childhood pneumonia in this low-income urban tropical setting. This study investigates part of the surveillance cohort of the International Centre for Diarrheal Disease Research, Bangladesh, which has worked in Dhaka since 1998. The paper is significant as one of the rare, large-scale pediatric cohort studies of respiratory illnesses performed in an international setting with a poor urban population. The materials and methods should be carefully noted for those researchers considering undertaking a similar longitudinal prospective study. It is important to note that although 28% of influenza positive children had pneumonia, an even larger percentage (56%) of influenza-negative cases were diagnosed with pneumonia. Despite this, the authors were able to corroborate data from Thailand, India, and Hong Kong, which show a contribution of influenza to childhood respiratory infections and pneumonia across tropical and subtropical Asia. They also discuss a need for influenza vaccination availability in the region to reduce disease burden, acquiescing that the inverse annual time frame of influenza infection as compared to the Northern Hemisphere and current production practices might complicate vaccine preparation and distribution. More research is necessary to further characterize influenza infection in tropical Asia and to define the role of influenza vaccination in this setting. -AL, AW
R Report / Sudan
In Khartoum, Class is in Session In March 2011, the first class of 27 emergency medicine residents started their training in Khartoum, Sudan. I met with one of the coordinators of the program, Dr. Nada Rahman, at last November’s Cape Town Conference on Emergency Medicine in the Developing World. by Katrin Hruska, MD
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ix years ago, the Sudanese government started their work on improving the quality of emergency care. Up until then, the emergency departments of the three training hospitals had been staffed with junior doctors from orthopedics, surgery and medicine, which lacked necessary training and experience in emergency medicine. The emergency department now started to employ and train their own medical officers and a handful of doctors and nurses were sent to Malaysia for specialist training in emergency medicine. Internal medicine specialists were hired as consultants in the emergency department, to supervise the medical officers. Dr. Rahman was one of the internal medicine specialists who joined the emergency department, a change that meant more than just changing departments. It changed her mindset. “In medicine they like to stand back and discuss cases,” says Dr. Rahman, “but in emergency medicine we have to act hands-on immediately. While they are contemplating the causes of fever, where are treating it.” The government saw the need for specialist training in Sudan and a committee was appointed to lead the process. They started to develop their own curriculum. A workshop was held with representatives from all major specialties who got to have their say about what qualifications an emergency physcian would need and the UK curriculum was used for reference. This procedure ensured that the curriculum was relevant to the Sudanese setting, but also served to inform the other specialties about the concept of emergency medicine. They used to be very skeptical, says Dr. Rahman. “The surgeon would come down and talk about his patients. ‘They are not your patients,’ I would reply, ‘they are our patients until we call for you to pick them up.’ But when they saw what we could do for patients they started to respect us.” The Sudanese EM training program takes four years to complete. After two years in Sudan, the residents will go to the UK for another two years of training. When they finish, their role will be to lead the development of emergency care all over Sudan. They will work in resource-limited settings, something their training has already prepared them for. “Yes, we constantly run out of things,” says Dr. Rahman with a laugh, “so we know how to manage with whatever is available.” Even if the resources are limited in the hospital, most investigations PH OTO BY M A R K F ISCH E R
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can be bought from surrounding laboratories. CT scans can also be ordered from private clinics, but the results take too long to come back, especially if you want to send an intubated patient, since there are no ventilators in the ED. “For a population of four 02 million, we have six ICU beds with two ventilators. When the speakers here at the conference were talking about their 300 ICU-beds, I thought they must be joking. We are so far from each other. We know the standard of care. We can read journals. But who is going to bring the change? We need to make the government understand what emergency medicine is and to prioritize its development. Right now only 2–2.5% of our GDP is spent on health care.” With good training and clinical skills you can come a long way, says Dr. Rahman, even with limited resources. Rahman tells the story of how young men suddenly started to come in, seemingly intoxicated, and die in the ED. The deaths were investigated, but no common source of poisoning could be identified. Twenty eight patients had already died when Dr. Rahman discovered that one of the patients had gone blind, which led her to believe that the patients were suffering from methanol intoxication. It was not possible to get serum levels of methanol, but she was convinced and demanded that the patients be treated with ethanol. Alcohol consumption is illegal in Sudan and to give ethanol to patients was highly controversial, but despite dire resistance from her superiors, she managed to ensure treatment for 65 patients who survived. Pathology reports confirmed that methanol was the toxic culprit and further investigations revealed the source to be methanol used in perfume production, passed on to dealers who sold it in the belief that it was ethanol. It will take several years before Sudan has a significant amount of qualified emergency physcians, but Dr. Rahman is optimistic about the future. “Our patients in the emergency department need us to be well trained and we are improving. Our medical officers have taken ACLS and ATLS courses and have an experience of emergency care that the junior doctors from the other departments did not have. Now I will work to make emergency medicine an important part of graduate medical education.” Dr. Rahman’s combination of patience and impatience – impatience with the current situation combined with the patience to work for long term goals – seems to be an essential characteristic of emergency medicine development in under-resourced areas.
01 A “whirling dervish” at the Al Nil mosque, just outside of Khartoum 02 Khartoum Teaching Hospital
For a population of four million, we have six ICU beds with two ventilators. When the speakers here at the conference were talking about their 300 ICU-beds, I thought they must be joking. We are so far from each other.
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ID In-Depth / Saudi Arabia
Quality Care Beyond the Veil Dr. Judith Tintinalli on visiting Saudi Arabia as a female emergency physician Additional reporting by Sameer Masoud Alhamid & Asaad Suliman Shujaaa
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didn’t know what to expect. I was excited, curious, but also somewhat apprehensive about being a woman in Saudi Arabia. The reason for my visit was the ‘2nd Up to Date Emergency Medicine Practice’ conference, sponsored by the King Fahad Medical City in Riyadh. Several western women with their families were in the customs line, and they had put on their Abayas before leaving the plane. I was a bit uncomfortable because I didn’t have one yet. But Dr. Abdullah Al Sakka greeted us and expedited our passage through customs. I had met Dr. Al Sakka several times before at international meetings. I had to switch my mental image of him from an emergency physician in western clothing to my host in the Thobe, Ghutra, and Egal. The conference organizer, Dr. Mohammed Alnabi, is the director of the King Fahad Medical City arm of the Saudi Emergency Medicine residency program. Mohammed arranged a personal session with a group of Saudi emergency medicine residents. Although at this session and in the conference, women and men sat on separate sides of the room, both sides were inquisitive and active participants in our discussions. There were many questions – how could only three years of training result in a skilled emergency physician? How are journal clubs organized? How can Saudi residents get more medical students interested in emergency medicine? Do American EM residents have mandatory rotations in psychiatry and anesthesia? Residents described their training likes and dislikes as very similar to those in the United States. Their assignment to medical duty to Hajj – the massave annual pilgrimmage to Mecca – was reported by all as a culmination of their training as emergency physicians. Medical duty at Hajj consists of extremely intense 12-hour workdays, with no translators, no common language, and
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the need for pointing and gestures to identify chief complaint and obtain a history. Saudis are magnificent hosts – excellent conversation, warmth, and lots of congeniality. I must say I was treated like ‘one of the guys’. It was only after my return to the United States that I realized I often was the only woman in the room, or the only woman at the dinner table. By the second day I was wearing my abaya – a loose robe-like overgarment – which was gifted to me by Dr. Amal Yousif, a pediatric emergency physician on the faculty of King Abdulaziz Medical City and the National Guard Hospital. The abaya does become part of you, and western women that I passed going down the stairs quietly said ‘be careful going up and down stairs, make sure you lift up the hem so you don’t fall’. There were a few shocks during this trip, the first being the 114°F weather. Saudis accommodate to summer heat by moving quickly from one air-conditioned environment to another. The crush of traffic in Riyadh was a surprise as well. It could take hours to move short distances in the city. As an emergency physician, the highlight of my trip was the visit to the National Guard Hospital, hosted by Dr. Ra’ed Hijazi, the Department Chairman. Dr Hijazi, who is probasketall tall, is notable for his wit and his charming, engaging smile. He has organized an efficient department – census at least 1,000 patients/day – has tried every trick in the book to decrease access block and ED overcrowding, and has now convinced the hospital that the next needed step is decreasing hospital length of stay. I saw an ultrasound machine in every ED bay, electronic medical records, white boards tracking patient advancement through the system, and men and women physicians seeing all types of patients. There was even a sophisticated pediatric ED, run by pediatric emergency medicine specialists. It
January 2012 // Emergency Physicians International
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was hard for me to keep from grabbing a chart and stepping right in! The reality of health care and emergency medicine in the Kingdom of Saudi Arabia is complex. The government provides national health care services through a number of government agencies, but the private health sector is growing. In 1970 in the Kingdom, the population was about 5.7 million and there were 74 hospitals with 9039 beds. By 2005 the population was nearly 28 million and there were 350 hospitals with 48,000 beds. The Ministry of Health (MOH) operates 62% of the hospitals and 53% of the clinics and centers; other government agencies, including the Ministry of Defense, the National Guard, and the Ministry of the Interior, operate facilities for their employees; and private facilities, including the Saudi ARAMCO Hospital, and the German Hospital serve other groups of individuals. Three Mothers University Hospitals (King Khalid University Hospital In Riyadh, King Abdulaziz University Hospital in Jaddah and King Fahed University Hospital in Alkhobar), and now King Fahad National Guard University Hospital in Riyadh, focus on research and the training of medical students and residents. The Saudi Red Crescent Authority provides
01 As the culmination of their training, EM residents are assigned to medical duty to Hajj – the massave annual pilgrimmage to Mecca. 02 Dr. Tintinalli (center) with emergency medicine residents at a conference in Riyadh.
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prehospital care in all five administrative regions of the Kingdom. Large MOH or Ministry Hospitals also have their own prehospital ambulance systems for their own patient populations, but can also serve the surrounding geographic area. The Kingdom also has 8 medical helicopters for transport to University or other tertiary care hospitals. Emergency medicine in Saudi Arabia began in 2000 after a group of young Saudi physicians, trained in USA and Canada, returned to the Kingdom and established the Saudi Board of Emergency Medicine. Professor Musaad Alsalman was the first chairman of the 1st Scientific council of the Saudi Emergency Medicine Program at SCFHS (Saudi Council For Health Specialists). The first emergency medicine residency program started in October 2001 at the King Fahad National Guard Hospital in Riyadh with 7 residents, and Dr. Abdullah Alhudaib was the first residency program director in Saudi Arabia. As of 2011, 60 residents have graduated and are board-certified, and there
are currently 120 residents, men and women, in the residency program. The residency program itself is shared by multiple hospitals, and there are discussions about separating the current large program into several separate hospital/university programs. Currently less than 5% of the emergency physicians in Saudi Arabia are trained in the field, and there will be a long journey before the Kingdom’s need for emergency physicians is met. Emergency Medicine training begins with a one year rotating internship, followed by a 4-year EM residency, with 25 months in adult and pediatric EM, 16 months of rotations in major subspecialties, EMS, and research; and 7 elective months. One half day each week is dedicated conference time. There is a yearly in-training examination and an oral and written board examination. I learned once again that the principles of EM training, practice and administration are similar worldwide. Emergency physicians adopt practices from other countries to meet
Kingdom Developments An in-depth report on the current medical infrastructure and emergency care developments in Saudi Arabia By Asaad Shujaa, MD and Sameer Alhamid, MD
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he Kingdom of Saudi Arabia has endured major developmental changes in the past few decades, resulting in substantial urbanization and an increase in the inner city populations. The developments, which have resulted in more buildings, highways and cars, have also increased the number of major traumas, burns and toxicological syndromes. In addition, there has been a significant increase in the occurrence of urban diseases, such as ischemic heart disease, cerebrovascular accidents, and diabetes mellitus.
Healthcare in Saudi Arabia The healthcare system in Saudi Arabia can be classified as a national healthcare system in which the government provides health services through a number of government agencies. At the same time, there is a growing role and increased participation of private health organizations. The Ministry of Health (MOH) is the primary government agency entrusted with the provision of preventive, curative and rehabilitative healthcare for Saudi citizens. The Ministry provides primary healthcare (PHC) services through a network of healthcare centers, consisting of 1,925 centers throughout the Kingdom. The ministry also uses the referral system, which provides curative care for all members of society, ranging from the level of general practitioners
at health centers to advanced technology specialist curative services, through a broad base of general and specialized hospitals (220 hospitals). The MOH is considered the leading government agency that is responsible for the management, planning, financing and regulation of the healthcare sector. The MOH also undertakes the overall supervision and follow-up of healthcare related activities that are carried out by organizations in the private sector. In 1970, there were 74 hospitals with 9,039 beds. By 2005, there were 350 hospitals with nearly 48,000 beds. The MOH operates 62% of the hospitals and 53% of the clinics and centers. The remaining facilities are operated by government agencies, including the Ministry of Defense, the National Guard, the Ministry of the Interior, and several other ministries, as well as private entities. Ministry of Health Facilities serve the general public and are located in both large cities and small towns throughout Saudi Arabia. Military hospitals serve members of the Saudi Arabia armed forces and members of their families, according to the branch of the military in which the individual serves. The Saudi Arabian National Guard (SANG) is the branch of the military that is involved in the defense against external and internal threats. SANG has four hospitals that provide care to the soldiers of the Saudi Arabian National Guard and their dependents. The Saudi Arabian
their patients’ needs, and adapt to meet challenges. In western societies, the individuality of clothing, how people dress, is a major determiner of identity. Traditional Saudi dress was an eye-stopper for me, but I quickly learned that the individual himself or herself, not the ‘wrapping’, was what was important. The eyes. The face. The personality. It seems to me that Saudis are bridging the gap between the timehonored customs of culture, religion, and family (which many western societies have lost) and the global society in which we all live together. Our participation in International Emergency Medicine provides support and resources for our colleagues who are just starting to establish Emergency Medicine in their countries. It is even more important for us as physicians and as people to work with our international colleagues, because it opens our mind, eyes and hearts to other cultures, and allows us to see the world as it should be. We are a band of brothers and sisters practicing in the most exciting specialty there is!
Ministry of Defense and Aviation (MODA) provides defense against primarily external threats and includes the Saudi Arabian Army, the Royal Saudi Naval Forces, the Royal Saudi Air Force and the Royal Saudi Air Defense. MODA operates nine hospitals that provide care to the soldiers of MODA and their dependents, including the 1000+ bed Riyadh Military Hospital Al Kharj. In addition to this, every citizen is eligible to go to one of four referral hospitals for specialized care. There are also university hospitals, like King Khalid University Hospital, which opened in 1982. This facility is an 800-bed facility with all general and subspecialty medical services. The hospital contains a special outpatient building, more than 20 operating rooms, radiology services, pharmacy services, and a fully equipped and staffed laboratory. In addition to all other supporting services of King Abdulaziz University, the first university hospital was King Abdulaziz University Hospital, which was originally founded in 1956 but only became affiliated with the college in 1976. This facility now specializes in ENT and ophthalmology. These two departments are among the largest in the Middle East in these specialties. They employ extremely skilled physicians in all subspecialties of ENT and ophthalmology, as well as world class researchers. In addition to military and university facilities, there are a number of private healthcare facilities in Saudi Arabia, ranging from the Saudi German Hospital to the 480 bed Saudi Aramco facility, which serves employees of the oil company, Saudi ARAMCO, and their family members. The Saudi Red Crescent Authority (SRCA) was founded in 1963 and provides emergency medical services in five administrative regions of Saudi Arabia. By 2009, SRCA had 447 First Aid Centers which were run by 5,507 staff and had 1,300 ambulances. These www.epijournal.com
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ID In-Depth / Saudi Arabia staff and ambulances are distributed in all hospitals and centers around the country. The Red Crescent has a specific role during Hajj (the annual pilgrimage to the Holy City of Makkah), which is to provide on-the-spot first aid and to use its fleet of vehicles for emergency transport to the nearest medical facility. SRCA also offers medical first aid services to citizens and foreign laborers who are staying in the Kingdom, and contributes to relief efforts abroad, according to Islamic morals and instructions. The SRCA provides the working staff with special attention by training them and providing them with incentives and facilities. The SRCA is also implementing an Air Traffic Management (ATM) service that consists of an evolutionary development towards a free air ambulance flight operation, flying routes anywhere in the KSA region. A robust air ambulance service would allow the more rapid transportation of accident victims – particularly in remote areas – by professionals with specialized skills. As of 2010, the Saudi Air Ambulance fleet consisted of eight helicopters. Slowly, the specialty of emergency medicine is growing in Saudi Arabia. After receiving the approval of the American College of Emergency Physicians, a group of young Saudi physicians trained in the USA and Canada returned to Saudi in 2000, where they worked as a group to establish the Saudi board of Emergency Medicine. In 2001, 7 residents were enrolled as emergency medicine residents. It started mainly at the King Fahed National Guard Hospital in Riyadh. Professor Mussaad M. S. Al-Salman was the first chairman of the scientific council of the Saudi emergency medicine program that was started in October 2001. Professor Musaad Alsalman was the Director of the ED at King Khalid University Hospital, King Saud University. Dr. Abdullah Alhudaib was the first program director. The emergency medicine program was accredited by the Saudi Council for Health Specialists. The first graduates of the program were 4 residents in 2004. Currently, more than 60 emergency residents have graduated, and there are 120 residents in the program. Currently, less than 5% of the emergency physicians in Saudi Arabia are trained in the field, so it will take many years for the Saudi Board of Emergency Medicine to meet the country’s great demands.
Education Objectives in Emergency Medicine The specific pre-requisite knowledge,and the skills that the residents in emergency medicine should acquire in order to achieve the terminal education objectives in each of the core content categories, will determine the program enabling education objec-
tives. These enabling educational objectives should be identified prior to each rotational experience and should be developed in the formal teaching program. A formal assessment of whether these objectives have been achieved should be provided through the end-ofrotation evaluations and in the training examination of each resident. During the course of training, the candidate must acquire satisfactory knowledge and skills in the following areas: 1. Primary care of the patient and declared emergencies, including the recognition, evaluation and initial management of the illness or injury. 2. Triage of patients with major illness or injury. 3. The natural history of illness or injuries that commonly present as emergencies and the long-term care and follow-up that is essential for these conditions. 4. Supervisor and administrative aspect of emergency services, ambulance services communication systems and disaster planning. 5. Research areas of emergency medicine. 6. Social and family implications of illness or injury To achieve these goals, there are general and terminal education objectives. The resident in emergency medicine is expected to demonstrate consultant level abilities in the recognition and understanding of illness and injury treatment. During the course of the education program, the resident must acquire and demonstrate satisfactory competence in knowledge, clinical skills, technical skills and administrative skills, as well as an attitude, that are consistent with the practice of the breadth and depth of emergency medicine. To be accepted into a training program, the candidate must (1) hold a Bachelor degree in medicine, (2) have successfully completed a rotating internship, and (3) provide three letters of recommendation, (4) pass the interview (may include an oral exam, with or without a written exam) with EM Board-Certified Physicians and the Program Director, (5) provide a letter from a sponsoring organization approving the candidate to join the full-time training for the program’s duration of 4 years, and (6) register as a trainee at the Saudi council for health specialties. Male and female candidates should be given an equal chance of enrollment. Training will be a full-time commitment, conducted in an institution that is accredited for training by the Saudi council for health specialties/the Saudi board of emergency medicine. Training will be comprehensive and will include emergency, inpatient, and ambulatory care. Trainees will be actively involved in patient care, with a gradual progression of responsibility, and they will abide by training regulations and obligations set by the Saudi board of emergency medicine.
Four years of training is required to expose the resident to the broad scope of EM. This will be divided into: Mandatory rotation; electives; academic halfday; courses and conferences; evaluation. Mandatory rotations are as follow: 25 Months: Emergency medicine, including pediatric emergency 2 Months (per section): Internal medicine, general surgery/trauma, ICU 1 Month (per section): Orthopedic surgery, plastic surgery, neurosciences, PICU, CCU, anesthesia, psychiatry, OB/GYN, EMS and transport, research. Electives ranging from toxicology to neonatal to family medicine should be used to enhance the experience of the resident in areas that are related to emergency medicine. Electives must also have appropriate objectives and evaluation. It is essential that the resident develop his/her objectives and discuss them with the program director and clinical supervisor. The evaluation of the resident will be based on meeting the objectives. Didactic teaching is also an important part of any emergency medicine training, and can consist of lectures given by residents, lectures organized and given by emergency consultants, and guest speakers from other specialties related to EM. Since emergency medicine has an active, continuous medical education program, the residents are encouraged to become instructors in ACLS, PALS, ATLS,and so forth. The residents will be evaluated at the end of each completed rotation by the supervising consultant/ team. It is the responsibility of each resident to acquire and submit his or her written evaluation to the Program Director. Towards the end of each training year, there will be an in-training exam (written +/- oral) conducted by the in-training program committee that will focus on emergency medicine. The final board examination is given to candidates after the successful completion of training, as evidenced by an acceptable final in-training evaluation. The exam is held at least once per year in one or more of the training centers. Candidates are allowed a maximum of three attempts to pass this examination within a period of three years after the completion of training. The final examination consists of two parts, a written part designed to evaluate knowledge and an oral part designed to test clinical judgment. Candidates who fail the third attempt and wish to sit for the exam have to complete an extra year. Then, the candidate will be allowed three more attempts.
REFERENCES
healthcare-system-of-saudi-arabia.html
1. Health Indicators, 2006. Ministry of Health, Department of Statistics
3. www.srca.org.sa
2. www.hziegler.com/locations/middle-east/saudi-arabia/articles/
4. Manual of Saudi Board of Emergency Medicine
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January 2012 // Emergency Physicians International
THE THIRD EURASIAN CONGRESS ON EMERGENCY MEDICINE (EACEM 2012) " Emergency Medicine: Different Countries - One Language " RIXOS SUNGATE PORT ROYAL HOTEL, ANTALYA, TURKEY 19-22 SEPTEMBER, 2012 www.eacem2012.org eacem2012@flaptour.com.tr
Sccenttffc Secretarrat Ass. Prof. Cem Oktay Akdennz Unnverssty Faculty of Meddccne Department of Emergency Meddccne Phone: +90 (242) 249 61 80 E-maal: cemoktay@akdennz.edu.tr
Organnzatton Secretarrat BBrllk 8. Cadde No:1 Cankaya - Ankara, 06610/ TURKEY Phone: +90 (312) 454 00 00 Fax: +90 (312) 454 00 01 E-Maal: eacem2012@@aptour.com.tr www.epijournal.com 21
P Photo Essay / Beijing
Eastern Promise A day in the life of the Peking Union Medical College Emergency Department, plus an interview with ED General Secretary Dr. Wang Zhong.
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photos by Jeff Taylor interview by Veronica Pei, MD
Dr. Wang on the Chinese College of EM, how it came to be, and where it stands today. The Chinese College of Emergency Physicians was started in August 2009. It is a branch of Chinese Medical Doctor Association (AMDA). The main purposes of CCEP is to get the emergency physicians all over China together to push emergency medicine forward in the country. The Chairman of CCEP is Dr. Xuezhong Yu, the 03
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01 The main ED entrance 02 The new outpatient clinic and ED building 03 A nursing student 04 Case disscussions with EM residents 05 Dr. Wang walks to work 06 Dr. Zhong Wang, The vice Chairman of ED and the first resident of the department 07 Design drawings of new emergency department which would be opened in 2012 08 A nurse in front of a cabinet of medications 09 Dr. Ji-hai Liu, the attending physician of the ED, stands in the EICU 10 PUMC’s new emergency department under construction 11 A patient is wheeled into the emergency department 12 PUMC’s green inner courtyard 13 The ED welcome area 14 Emergency department registration
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Chairman of Emergency Department of PUMC Hospital. I am the General Secretary. Now there are 62 members coming from different hospitals in 31 provinces. Most of them are the chiefs of the emergency departments of their hospitals. From 2009, we have held two large conferences attended by over 1500 doctors. We have also produced some useful medical guidelines.
On the state of emergency medicine in China, including top challenges and innovative Chinese solutions. While emergency medicine has really existed for 24 years in China, there is still no fixed model of EMS or emergency care delivery in the various Chinese cities. That means that each emergency department is different from the next one. The patients receive different emergency services in different hospitals, and we cannot ensure
the quality of care. So the Chinese ministry of health set up the Quality Control Center of Emergency Medicine this year. Another issue is the provision of emergency care by physicians who have a background other than emergency medicine, such as internal medicine. They are not qualified to work as emergency physicians in time-stressed situations. We want to do something to address this situation. 1) To rewrite “The Guideline of Emergency Department building and Management” which was written years ago. The purpose is to standardizes the emergency department. 2) To make more guidelines in emergency clinic services. 3) To teach and train the emergency physicians in low level hospitals and some poor provinces to rise their clinical ability.
www.epijournal.com
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P Photo Essay / Beijing
On “lessons learned” during the establishment of the EM residency in Beijing. As one of 13 residency programs in Beijing, we had trained 62 residents in the past 6 years. I am the director of the program and I use the “4 steps method” of training: lessons learned, simulating learned, guiding, and individual practice. The residents should learn and practice in the program for 3 years. There is a supervisor for all residents each year.
On becoming an emergency physician Twenty five years ago, emergency medicine was just a concept in China. No one got to know what the future would be. But I thought it was a new field of medicine that could give me more of a chance to develop myself – and I liked challenge. That was why I became an emergency physician. 09
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Are you involved in improving emergency medicine & acute care services for your hospital, region or country?
We Can Help. At the University of Maryland International Emergency Medicine Program, we understand the complex nature of emergency medicine and acute care systems development... Starting in 1984, our Emergency Medicine Program has grown into one of the premier EM education programs in the USA, earning an international reputation for excellence in training and academic leadership in emergency medicine. For the last 15 years, our International Emergency Medicine Program has been involved in EM education, research, administration and management, EM residency and EM systems development all over the globe. Working with physicians, departments, hospitals, universities, governments and other organizations, we offer short, medium and long-term programs, including courses, exchanges, research and consultation to provide comprehensive EM systems development in multiple areas:
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Policy & Systems Development
Research
Department of Emergency Medicine Department of Emergency Medicine International Emergency Medicine Program 110 S. Paca Street, 6th Floor, Suite 200 Baltimore, Maryland USA 21037 Phone +1 410 328 8025
For more information, contact: Terrence Mulligan, DO, MPH IEM Program Director, at tmulligan@umem.org
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January 2012 // Emergency Physicians International
Department of Emergency Medicine
INTERNATIONAL EMERGENCY MEDICINE PROGRAM
More than 15 years of experience in international collaborations in the field of emergency medicine... H HHH H HH H H H H H HH H H H H H H H H H H H HH H HH H H H
H HH H H H HH H H H university of maryland, baltimore, maryland
H primary projects H collaborative projects & major conference involvement
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Prof Brian Browne, MD Department Chair Operations & Systems Development
H H H Prof Amal Mattu, MD Department Vice Chair Faculty Development, EM Cardiology & EM Geriatrics
HH Michael Bond, MD Director, EM Residency EM Education
Michael Winters, MD EM / Internal Medicine / Critical Care
Brian Euerle MD Emergency Medicine Ultrasound
Terrence Mulligan DO, MPH International EM Management, Policy & EM Systems Development
Robert Rogers MD EM Education Teaching Fellowship Director
Stephen Schenkel MD, MPP Patient Safety and Quality Improvement
Veronica Pei MD, MEd, MPH International EM Fellowship
Larry Weiss MD, JD Health Law, Advocacy and Policy
Robert Corder MD International EM Tawam Hospital, Abu Dhabi, UAE
Ben Lawner DO, EMT-P EMS / Pre-hospital Systems
Jon Mark Hirshon MD, MPH, PhD Research & International EM
Prof Lee Wallis MD Visiting Professor, University of Maryland Univ of Cape Town / Stellenbosch Univ, Cape Town, S.Africa
Emilie Calvello MD, MPH International EM
For more inf orm a tion, c onta c t: Te r re nc e M ull i g a n , D O , MPH / / I E M Pro g r a m D i re c t o r / / t m u l l i g a n @u m e m.o rg www.epijournal.com
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Grand Rounds
WITH PETER CAMERON, MD
Benchmarks Beyond Borders In November, London hosted a symposium on EM quality that opened the door for a global consensus
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Benchmarking quality, standards of care, and ensuring safe practice mean different things to different people. These differences are even greater when you compare regions and countries. This difference in perspective was rammed home last year when I spent some time in the UK looking at the impact
of the “4 hour standard” (ensuring all patients are out of the ED in 4 hours) on patient outcomes. It was clear that although the policy had made a massive difference to crowding in emergency departments, there had been little assessment of improvements in patient outcomes. In the USA, over a similar time frame, there had been a myriad of process measures introduced both locally and by the Agency for Healthcare Research and Quality (AHRQ), quickly followed by a tirade of criticism about the impact of these process measures on patient outcomes. Other countries such as The Netherlands were watching these developments with interest, but had not yet developed a comprehensive framework for measuring quality and safety themselves. It is into this benchmarking milieu that the International Federation for Emergency Medicine (IFEM) has stepped, beginning the work of developing a more global framework for measuring quality of care delivered by emergency departments. The hope is that an international consensus might act as a catalyst for driving improvements in emergency department (ED) care. Although the concept of striving to deliver the highest possible quality of care is a “no-brainer”, what we mean by this – and how we measure it – is a lot more complicated than it first seems. There are issues regarding the resources, geography, desired outcomes and processes that should be measured. Each country has different approaches to data collection, data definitions and funding – all of which make the aims of any framework for improving quality of care fraught with danger. Fortunately a decision was made by the IFEM executive to collaborate with the UK College of Emergency Medicine to organise a symposium in London, England to explore how to go forward. The UK College put on a fantastic show last November, hosting about 150 EM Safety and Quality experts and enthusiasts from around the world in the British Museum. Delegates were predominantly from the “founding societies” of IFEM – as many of the more recent members have not had a chance to develop a comprehensive quality framework for EM in their countries. Expert speakers included such luminaries as John Heyworth, Art Kellerman, Greg Henry, Pat Croskerry, Sandy Schneider, Jonathan Benger, Suzanne Mason, Michael Schull, Ian Stiell, Ellen Weber and Jim Ducharme. Importantly, some perspectives were heard from under-resourced countries such as Malawi and the West Indies, where Elizabeth Molyneux and Ian Sammy gave their views on what was needed to improve quality of care and what could be done. From these diverse perspectives, it was obvious that although quality and safety are dependent on context, geography and available resources, there are common structures, processes and outcomes that can be measured and compared between countries. An equally important perspective was given by Suzanne Shale on the way patients see quality and how we should monitor patient perceptions of quality. The numerical or percentage patient satisfaction survey probably doesn’t give the necessary information to drive quality improvement – a more qualitative approach is necessary to understand patient and relative’s concerns. During the symposium, a
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January 2012 // Emergency Physicians International
range of quality initiatives in a number of countries were discussed and compared and much discussion occurred about what was needed to progress towards a consensus on this topic. At the end of the meeting Fiona Lecky (symposium convenor) and I had the unenviable task of “summing up” the learnings and attempting to define a way forward to facilitate international consensus. It was clear that despite differences in funding and policy between the various participating countries, there was a lot of commonality in approach and good reason to be optimistic that over the next 12 months we might be able to develop a framework for measuring quality in emergency medicine that would drive improvements. The main focus for quality measurement in emergency medicine has been the use of indicators of timeliness and efficiency. These are generally easy to collect, important for patients and liked by administrators. The use of these indicators has driven major change in the provision of care in the UK and other countries such as Canada, USA, Hong Kong and Australia. Waiting times to be seen by a doctor and total length of time in the ED are the most common measures. However, many other process times are routinely tracked by individual EDs, such as laboratory turnaround time, time for inpatient consultation, and so on. Many participants felt a much broader approach to quality should be adopted, measured and reported. It was agreed that the domains of quality used by the Institute of Medicine (IOM) is a good starting point. Unfortunately, although everyone would agree that domains such as patient-centred care and patient safety are essential components, there is little agreement about how to measure and what data sources to use. It is likely that for many EDs routine collection of data that is not available on administration and tracking systems would represent a large clerical burden. For low resource countries, even routine data is difficult to access. It is probable that there will need to be several approaches to collecting data, depending on IT and clerical resources. In developing a flexible approach to implementation, it is essential that there are common data definitions and standards. Also, for benchmarking purposes, guidelines would have to be developed to enable a standard approach to sampling of ED populations – if data was not available through routine information systems. Clearly targets and standards will vary according to local infrastructure. However, by using standard data definitions, collection methods, population sampling techniques and analysis, it should be possible to compare quality of care for key indicators between similar regions. Ideally this would happen through national societies, with IFEM coordinating international comparisons. Importantly, the mechanics of comparison between regions are secondary to the principle of standardisation of definitions, data collection and interpretation to allow valid comparisons. The participants at the symposium agreed to participate in a process of developing a framework for comparing quality of care internationally by commenting on an evolving document by email until the time of the Dublin ICEM conference in June 2012. At that time a forum will be held to discuss the topic, and hopefully a consensus document will be agreed upon. The potential for this consensus building to enable benchmarking of quality of care across the global EM community is high. Where differences between jurisdictions are clear and result in poor outcomes or poor service to the community, it is likely that local EPs can use these data to drive change to improve care. I am very excited by the involvement of key global opinion leaders and invite others to be involved, at whatever level you are able. Dr. Cameron is the president of the International Federation for Emergency Medicine (IFEM)