EPI Issue 5 by Logan Plaster

New Disaster Research in Asia The Global Literature Review MSF: On the Ground in Somalia EMERGENCY PHYSICIANS INTERNATIONAL

PE I SSUE scandinavia

Will regional unity lead to EM collaborations?

france

The oft-lauded EM system struggles against the tide of overcrowding

plus

The Case for Emergency Paediatrics Dr. ffion davies

EM in the EU Dr. Abdel Bellou

Issue 5 // fall 2011

www.epijournal.com

Fall 2011 // Emergency Physicians International

Editor’s Desk

EM Efficacy: The Tip of the Iceberg

he status of Emergency Medicine (EM) varies widely across Europe. On one end you have the UK, where the specialty has been officially recognized for over 30 years (some say it predates the United States), Poland (10+ years of specialty independence), and Turkey (official since 1993). Then there are the European countries that have declared EM to be an independent specialty but have not yet developed full specialty structure (such as specialist training curricula, faculty requirements and specialist certification exams). Moving on from the latter set, the Netherlands has proven a model of EM specialty development, rapidly moving into specialty maturation after overcoming initial obstacles (read Terry Mulligan’s coverage of this story in EPI issue one – tinyurl.com/3dasxyc). Acceptance of EM as a medical specialty in the EU – and some degree of standardization – just makes sense. It would be an important step towards the EU’s goal of standardization and coordination of professional practice. It would raise the bar for patient care as passionate, fully-trained EM physicians take over the provision, direction, and administration of emergency care from less experienced, less interested colleagues. Plus, as countries like the UK and the United States have proven, having fully-trained EM specialists improves quality of care, safety, and patient satisfaction. But acceptance of EM as a new specialty in Europe will not come without resolving resistance and conflict. Older specialties like surgery, anesthesia and internal medicine in some countries are resistant to the perceived turf encroachment. There seems to be a lack of understanding about the meaning and structure of EM, even a fear that it could compete with or displace other specialties. However, the national experience in every country that has adopted EM as a specialty is that EM serves to directly aid and support the other specialties, making professional work for other specialists more focused. I saw a great example of how this benefit of EM could be applied in my work in Croatia and Slovenia. In both countries, the big university medical centers have physicians on duty all night, from multiple specialties. Each physician staffs a small room or service area just for urgent cases related to their individual specialty. The typical case load for most of these physicians, particularly at night, is extremely low. The introduction of qualified EM physicians on duty staffing a full service emergency department in these hospitals would cut down the need for these specialists to spend so much time physically in the hospital. They could potentially take call from home and come in only for the cases where their specialty expertise would be needed. Also, by not having to staff and equip multiple separate rooms for emergencies in different specialties, the hospital administrators can allocate hospital resources more efficiently. And that’s the tip of the iceberg. A recent review article in the International Journal of Emergency Medicine lists 282 published journal articles and studies which show the efficacy and benefits of this specialty (Holliman et al., IJEM 2011; 4:44). Hopefully this reference article can help correct some of the misconceptions surrounding EM adoption in Europe by showing a literature base for EM’s efficacy. The struggle for specialty recognition in Europe will not be easy, but there is certainly cause to be optimistic. The European Society for EM is more active than ever (check out their web site at www.eusem.org) and the next International Conference on EM (the biennial conference hosted by the International Federation for EM) will take place in Dublin in 2012. Now is the time to champion specialty recognition across Europe, and show the continent how this well-developed discipline will enhance medical care delivery and ultimately save lives.

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

There seems to be a lack of understanding [in some European countries] about the meaning and structure of emergency medicine, even a fear that it could compete with or displace other specialties. However, the national experience in every country that has adopted EM as a specialty is that it serves to directly aid and support the other specialties, making professional work for the other specialists more focused.

New Disaster Research in Asia The Global Literature Review MSF: On the Ground in Somalia EMERGENCY PHYSICIANS INTERNATIONAL

PE I SSUE scandinavia

Will regional unity lead to EM collaborations?

france

The oft-lauded EM system struggles against the tide of overcrowding

plus

The Case for Emergency Paediatrics Dr. ffion Davies

cover illustration

EM in the EU Dr. abDel bellou

issue 5

fall 2011

www.epijournal.com

by tracey jolliffe

About EPI With a quarterly print and digital distribution and an online network of more than 1,100 members, EPI is the new hub connecting global emergency care, sparking dialogue and creating a space for new collaborations. Find copies of the print magazine at international EM conferences around the world, or read it online at www.epijournal.com

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Letter from the publisher

The Next Big Thing

n August 17, I sat in the balcony of an auditorium at Lenox Hill Hospital in New York City. I was listening to a certain Joseph O’Neill very calmly blow the lid off of global emergency medicine. As an internist, Dr. O’Neill was a bit of an unusual keynote for an emergency medicine symposium. He was the chief architect of PEPFAR, a US-led $48 billion global AIDS relief initiative that remains the largest public health project in history. O’Neill recalled the early days of global HIV treatment and emphasized how far we’ve come. From 1981 to 2003, we went from a disease that we knew absolutely nothing about to having comprehensive retroviral therapy being administered in rural Africa. The accomplishment, no matter your politics, was astonishing. So what does the meteoric rise in HIV treatment globally have to do with global emergency advancement? According to Dr. O’Neill, a man who has seen global health development from the highest vantage point available, it’s a peek into the future. “I think where we are right now in emergency medicine is not unlike where HIV was globally in 1985 or 1986.” Is O’Neill saying that emergency medicine is going to be the next giant global health project, or that there are billions of dollars in funding waiting to be released? That would be a leap, given that O’Neill is such a newcomer to the global EM conversation. But his words offer a glimpse into a potential future, into the kinds of large scale projects that may be possible. One thing is certain, it will take more than riding the global health wave to usher in an era of advanced acute care around the globe. For starters, EM needs to learn critical lessons from its global health colleagues. Lesson one: stakeholders need to understand that things can be different. For HIV, said O’Neill, that meant helping people understand that “your child doesn’t have to die.” With EM, it might be the understanding that motor vehicle accidents and heart attacks aren’t always the end of the line. Whatever the case, the first change we seek may simply be to help people understand that change is possible. But what does it take to have real social change? Vision, competency and drive? Sure, said O’Neill, but something more. Love. A sense of humanity has to animate all that we do. Well said, Dr. O’Neill. Consider your EM colleagues ready, willing and able.

publisher Logan Plaster Logan@Plasterpub.com editorial director C. James Holliman, MD executive editors Peter Cameron, MD Terry Mulligan, do, mph Mark Plaster, MD associate editor LONNIE STOLTZFOOS regional corespondents Conrad buckle, md Marcio Rodrigues, MD Carlos Rissa, md Katrin Hruska, MD editorial advisors ARIF Alper Cevik, MD Kate Douglass, MD Haywood hall, MD Chak-Wah Kam, MD Greg Larkin, MD Prof. Dongpill Lee Sam-Beom Lee, MD Gladys Lopez, MD Alberto Machado, MD Lee Wallis, MD cover design TRACEY JOLLIFFE advertising Michelle rucks mrucks@epmonthly.com 5 College Avenue Annapolis, MD 21401

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Fall 2011 // Emergency Physicians International

mark L. Plaster, md

Executive Vice President Rebecca r. Plaster

EVENT CALENDAR 9/11–8/12

12 months of international EM c o n f e r e n c e s p In 2012, the International Conference on Emergency Medicine (ICEM) will take place in Dublin.

SEPTEMBER

III Brazilian Congress of Emergency Medicine // São Paulo, Brazil The Brazilian Association for Emergency Medicine and São Paulo University, School of Medicine will host this congress. September 22 – 25, 2011 www.abramede.com.br

The European Trauma Course // Verona, Italy The European Trauma Course (ETC) has been developed to teach a system of care for managing trauma patients that is pragmatic, reflecting the reality of emergency medicine throughout Europe. September 22 – 24, 2011 www.erc.edu

OCTOBER

Retrieval // Glasgow, Scotland The conference will focus on the full spectrum of prehospital, transfer and retrieval medicine, applicable to medical, paramedical and nursing staff. October 6 – 7, 2011 www.emrs.scot.nhs.uk

The American College of Emergency Physicians (ACEP) Scientific Assembly // San Francisco, USA The largest emergency medicine meeting in the world, ACEP’s scientific assembly will bring together the best EM educators in the United States with a large and active international interest group. October 15 – 18, 2011 www.ACEP.org

MedicReS Emergency Ultrasound Course // Vienna, Austria

The 1st Global Network Conference on Emergency Medicine // Dubai, UAE

Prof. E. Erol Unluer, MD, leads this 2-day course which teaches attendees about ultrasonography in emergency and nonemergency situations, including trauma cases. October 28 – 29, 2011 wwww.medicres.org

www.emergencymedicineme.com conference@uae.messefrankfurt.ae January 13 – 17, 2012

NOVEMBER

Symposium on Quality and Safety in Emergency Care // London, England CEM and IFEM unite to bring together this first-of-its-kind symposium, held at the British Museum November 15 – 16, 2011 www.ifem.cc

Emergency Medicine in the Developing World // Cape Town, South Africa All aspects of emergency care will be covered in the scientific and educational plenaries of this biennial, regional African conference. November 15 – 17, 2011 www.emssa2011.co.za

JANUARY/2012

2nd International Conference on Preparedness and Responses to Emergencies and Disasters // Tel Aviv, Israel IPRED II will provide a platform for the exchange of ideas and experiences related to the field of preparedness and response to emergencies and disasters. January 15 – 19, 2012 www.ipred.co.il

JUNE

First International Congress of Pediatric Emergency Medicine // Leon Guanajuato, Mexico This congress will cover topics from controversies in pediatric resuscitation to pediatric airway management to the organization of emergency service. June 14 – 16, 2012 www.anmuep.org.mx

The 2012 International Conference on Emergency Medicine (ICEM) // Dublin, Ireland The theme of ICEM 2012 is ‘Bridging the Gap between Evidence and Practice’ and topics will include Disaster Medicine, Biomedical Research, Paediatric Emergency Medicine, Prehospital Care and Resuscitation among many others. June 27 – 30, 2012 www.icem2012.org

OCTOBER

Pan-Pacific Emergency Medicine Congress 2012 (PEMC 2012) // Seoul, Korea The Korean Society of Emergency Medicine (KSEM) will host a joint meeting between the American Academy of Emergency Medicine (AAEM) and KSEM. October 23 – 26, 2012 www.pemc2012.org

L i st yo u r n e x t i nt e rnat i onal e v e nt for fr e e on t h e E P I N e t w or k

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w w w. e p i j o u rnal .c om www.epijournal.com

3 | Editor’s Desk 5 | Event Calendar 32 | IEM Fellowship Directory

EMERGENCY PHYSICIANS INTERNATIONAL www.epijournal.com

PEM

PEDS

8 | Opinion p Are children falling through the cracks? Dr. Ffion Davies lays out the case for paediatric EM training. Plus, a review of paediatric podcasts 7 | Relief An MSF medical coordinator in Southern Somalia recounts the horrors of a deadly drought. 12 | Policy EuSEM president Dr. Abdel Bellou on why emergency medicine standardization is important for the future of the European Union. 35 | Grand Rounds While some medical specialties think that medicine can be a zero risk undertaking, emergency physicians have no choice but to become risk managers.

Source 16 | Dispatches This month, physicians from 22 countries answer the question: “How would you make emergency medicine more cost effective?” 18 | France With ED visits on the rise and available beds on decline, French emergency care is entering a pivotal period of specialty development. 20 | Georgia The recovering republic seeks to make strong evidence-based healthcare advancements following years of economic turmoil.

Advertiser Directory // The Morgan Lens 2 The Latest Titles from PMPH USA 9 EuSEM 2012, Antalya 11 African Conference in EM 14 The T-Ring 19 Dubai Global Network Conference 21 SonoSite 22 IEDLI Leadership Institute 25 GE Healthcare: The LOGIQe 36

Fall 2011 // Emergency Physicians International

Reports 23 | The Best of Global EM Research SAEM’s Adam Levine reviews important new literature practice-changing studies from around the globe. 26 | New Disaster Research from Asia A new institute for the study of disaster medicine in Asia promises a fresh spate of data from a disaster prone region. 29 | Unifying EM in Nordic Europe Scandinavia’s unique level of regional collaboration could open the door to increased recognition of emergency medicine specialization.

DISASTER RELIEF

Somalia

Violence and Drought in Southern Somalia

u Dr. Hussein Sheikh Qassim is the Medical Coordinator in the Médecins Sans Frontières (MSF) hospital in Marere, in southern Somalia, where violence and drought drove people from their homes in search of medical care and shelter. On July 15, he gave the following report about the situation.

“I

n Marere, the situation is extremely dire. This is the only hospital in this part of Somalia. There are not any other clinics, not even mobile clinics, anywhere near here. People are coming here from all over the country. Word

We put the child in our intensive care unit where we resuscitated him for two hours, until finally he opened his eyes. Then we fed him specialized milk and food through a tube. After 24 hours he started moving his limbs. It was at that moment that his mother’s face suddenly lit up. You could see that she had hope again. After one week, Yusuf didn’t need to be fed through a tube any longer. He could drink milk on his own, and he could say, ‘Mum,’ and smile back if you called his name. Within 10 days, his weight had more than tripled. After three weeks in our hospital, Yusuf was playing around with the other children. He father came to collect him and he was beyond happiness. He didn’t stop thanking MSF until he’d left the hospital. As a Somali myself, I can say that if MSF was not here, we would be like a boat that has run out of fuel in the middle of the Indian Ocean. Without MSF’s help, thousands would have died. Somalia needs your help now more than at any other time. MSF saves countless lives and, with your help, will continue to save many more. Thank you.”

The hospital in Marere (pictured) is the only hospital in the region. Because of the draught, people are coming to the hospital from all over the country, overwhelming its resources. © MSF

MSF is a medical humanitarian organization that observes strict neutrality and impartiality in its operations.

Trial By Fire

Dr. Adam Levine Blogs from libya www.epijournal.com l

epi online

spreads. Recently, the numbers have gone through the roof. Even on our quiet days, we are seeing twice as many people as we did on busy days before the drought. The hospital is absolutely full of patients. Some are sick, others just need something to eat. The malnutrition ward is beyond full of young children, most of them too weak even to eat, so we have to feed them through tubes. Some of these children had to walk for over 600 kilometers [360 miles] to get here because their parents couldn’t afford transport and were too weak to carry them on their backs. There is an ongoing civil war in many parts of the country, with some towns and villages changing hands on a daily basis. These are dangerous areas and it is not safe to travel. But still the people come. Those who are lucky and are still on their feet are admitted as outpatients, 300 yesterday, 400 last Friday. But lots of children have to go straight to the inpatient feeding center. It’s only lunchtime, and we’ve already admitted 151 children today. Recently, a mother and her husband brought us a two-year-old boy called Yusuf. He was nothing more than bones and skin. He was too weak even to breathe. The family were pastoralists and all their animals had died. They told me the child had diarrhea and couldn’t eat. He was in such a bad way you had to listen to his heartbeat through a stethoscope to tell he was still alive. His parents had given up on him. They believed he had no chance of survival and they wanted to leave so they could look after their other children. The father went off to look after the other children while we convinced the mother not to give up.

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OPINION

The Case for Emergency Paediatrics The overlap of paediatrics and emergency medicine can create a no-man’s land that puts young patients at risk. New training models could turn that gap into an opportunity for improved patient care. by Ffion Davies, MD

f you work on the front lines of emergency medicine you’ve probably noticed that there is a unique skill set needed to treat acutely ill infants, children and teenagers. You’ve probably also noticed that this specialized training doesn’t necessarily reside solely with paediatric or emergency medicine trained doctors. So even when clinicians agree to disagree about “who does it best,” or children are split into different receiving areas on their presentation, acutely ill children can be at risk of being treated by an inadequately trained clinician regardless of the treating physician’s baseline training. But doesn’t that undermine the whole ethos of emergency medicine? Enter pediatric emergency medicine (PEM), a sub-speciality of either paediatrics or emergency medicine that exists in many countries. Pediatric emergency medicine says that we should be able to have one department that can handle a full range of acute care needs across the age spectrum. Doctors and nurses should be able to handle the child with the fracture who needs to have child protection issues picked up accurately, in a sensitive manner, as well as the pale, floppy 5-day-old baby and then maybe a drunk teenager just moments later. I am an emergency physician who started life as a paediatrician, then joined the ranks of emergency medicine. Nine years after qualifying as a doctor I became an attending in EM with a sub-speciality recognition in PEM. In the 12 years that have followed, I have participated in many British government and college projects, and have enjoyed training many doctors in pediatric emergency care. My day job consists of both adult and pediatric emergency medicine (in the same department), and I love both sides. I have worked in 11 emergency departments in the United Kingdom and the United States, and I’ve visited EDs in Australia, Scandinavia and South Africa. These various experiences in emergency departments around the globe have driven home for me the importance of understanding the relationship between emergency medicine and pediatrics. It helps to look at it as a venn diagram; while EM and pediatrics are unique, there is overlap between the two, and both specialities owe it to their patients to understand pediatric emergencies and care for them properly. Co-Location: The Challenge of Positioning a Pediatric ED So where should acutely ill or injured children be seen? In the main ED? In the main ED but within their own area? Or in a specialized pediatric centre? The two main issues are of staff skills and patient facilities. The United States, Canada, Australia, New Zealand and the UK were among the first countries to ensure that children were well provided for in general emergency departments. As EDs mature in their form and function, it is common to see facilities for children improve, with children often protected from the confusing, often disturbing, sights and sounds of the main department. Segregation may range from a small area with a couple of toys offset from the main waiting room to a wholly self-contained children’s ED (within or separate from adult ED areas). In my experience it is pretty easy to get local charities and businesses to donate money towards decoration and toys for a children’s emergency department. But that’s just bricks and mortar (and nice furnishings hopefully) – what about the operational benefits of co-location?

Fall 2011 // Emergency Physicians International

PEM

PEDS

Evenings and weekends are the busiest period for children, while nights and early mornings are usually quiet. Co-location of a PEM unit with the main ED helps manage the peaks and lows of activity, and ensures that the resuscitation bays for children are adequately sized, equipped and staffed at all times, with built-in flexibility for usage and occupancy. You can do this by equipping half your bays for children, and reserving the one bay furthest from your noisy adult bays as the primary bay children. One word of caution from my experience: do not compromise and allow seriously ill children to miss out on the resuscitation room by trying to keep them in the pediatric area. Mixed Staffing Model Let’s discuss the thorny issue of staff skills. There is a strong argument that EM staff can benefit from the non-surgical skills, communication skills and holistic practice of pediatric staff. However it is equally true that pediatric staff can benefit from the organisational, critical care and trauma skills of EM staff. Therefore mixing the two staff groups and/or training staff in PEM, is of benefit to all involved. The best departments (in my opinion) have a mix of doctors and nurses from paediatric and EM backgrounds – and senior staff dual trained to a high level of expertise. In countries with well-developed EM systems, paediatric EDs within an allchildren hospital are by far the minority; the majority are mixed EDs. All staff in mixed EDs who may have to treat acutely ill or injured children should be able to deal with children to the same standard as adult patients. This means not only having good clinical management of common conditions, but also having the additional skills and knowledge needed for this age group. There is, interestingly, a similar drive towards focussed skills regarding elderly patients in the ED. PEM training programmes are available in many countries for doctors (Ref 1) and nurses can often achieve competencies in their non-dominant field (EM or pediatrics) with customised learning packages obtainable either by short secondments within their own organisation or rotation to the nearest higher level centre. E-learning packages also exist (Ref 2). For a reference document containing pragmatic standards of pediatric emergency care, the International Federation of Emergency Medicine (IFEM) is publishing a document in early 2012. It is hoped that this will be a useful document for all countries looking to improve the care of children in their emergency departments. Such documents already exist in the UK (ref 3) and the United States (ref 4).

There is a strong argument that EM staff can benefit from the nonsurgical skills, communication skills and holistic practice of pediatric staff. It is equally true that pediatric staff can benefit from the organisational, critical care and trauma skills of EM staff. Mixing the two staff groups and/or training staff in PEM is of benefit to all involved.

Patient Populations Big differences can be seen between different countries, even between hospitals within each country, with respect to pediatric case-mix. The proportion of injury to illness varies hugely, as does the proportion of serious cases to “primary care” type cases. Poor, inner city areas of developed countries often see a high proportion of primary care type cases. If ED and paediatric staff have not been trained to be confident in differentiating these children from those with serious illness, they will fail to stem the tide of increasing hospital admission rates for children. Senior doctors (in EM and paediatrics) need to be accessible at the “front door”, to prevent risk-averse junior doctors over-admitting children (Ref 5). For those of us blessed with good children’s health in richer countries, serious illness in children is not common. In order to differentiate between the cases which come our way every day, risk stratification is of course the cornerstone of EM practice. This means having a good core knowledge of common diseases and pitfalls, and undertaking baseline tests (e.g. venous gas analysis, urinalysis, near-patient blood testing of white cell count, etc…) as well as easy access to short-stay facilities, because children’s conditions change in a much shorter time frame than adults. So you want a career in PEM… If you are interested in a career in PEM, what would the future look like? Depending on your country’s organisation, you could work exclusively with children and train in EM or in pediatrics. You could work across pediatric and adult emergency care, if you have trained in EM. If you trained in pediatrics, you could mix EM work with work in the intensive care unit or retrieval services, acute admissions or short stay unit, or help run outreach services (rapid access clinics, and rapid follow-up clinics), or in some cases, specialise in child protection. If you are a pre-hospital care junkie you’ll generally find that children form a low proportion of calls, so unless your work is combined with interhospital retrieval services, you may not have a full time job! If you are responsible for organising a service, there are some references which, although country specific, will probably help you (Refs 6,7,8). In my estimation, the best work day is the one that runs the gamut. On my ideal shift, I get a sick neonate, diagnose duct dependent heart disease and get them to the cardiac centre. Then, I see a 2 year old with a pulled elbow walk out waving to me and laughing after I made her cry – hopefully brandishing a bravery certificate or teddy bear as a reward. Then I see a heroin overdose and continued on page 10 www.epijournal.com

OPINION

The Case for Emergency Paediatrics from page

Pediatric EM On the Go

Two free pediatric emergency medicine podcasts that can help you stay up to date by Justin Arambasick, MD

I’m the first or only one to get the IV line in (bless those tortured days of neonatology!). I run an elderly person’s cardiac arrest, break the inevitably bad news to the family, then go back to the Pediatric ED to see some kids to cheer myself up again. Whether your core interest is pediatrics or emergency medicine, consider the venn diagram. We owe it to that overlapping subset of patients to take a serious look at pediatric emergency medicine, so that no matter where we live, we are bringing the best care possible to our most vulnerable patient population.

REFERENCES & USEFUL RESOURCES 1. Babl FE, Weiner DL, Bhanji F, et al. Advanced training in pediatric emergency medicine in the United States,Canada, United Kingdom, and Australia: international comparison and resources guide. Ann Emerg Med 2005;45(3):269–75.

PEMcast [www.empem.org] The Host: Dr. Colin Parker The Gist: The Pediatric Emergency Medicine podcast is a review of pediatric emergency medicine topics from experts in Australia. The goal of this podcast, in addition to keeping the listener up to date on pediatric emergency medicine, is to “keep you a little bit interested, a little bit educated, and occasionally amused.” Resident Insight: Great for all who are nervous about pediatric care while keeping the listener interested with humorous insight and story. The style of learning of this podcast is more round-robin discussion between practicing physicians and less of a lecture format. Within these discussions they do focus on the pertinent literature. Do not confuse PEMcast (this show) with PEMCast. Length: 20 – 60 minutes

2. Department of Health (England) recommended PEM e-portal for education on acute paediatric emergencies www.spottingthesickchild.com

Frequency: bimonthly

3. Royal College of Paediatrics and Child Health. Services for children in emergency departments: report of the Intercollegiate Advisory Group for Services for Children in the Emergency Department. RCPCH, April 2007 Available from www.rcpch.ac.uk (http://tiny.cc/fxe41)

Cost: Free

4. American Association of Pediatrics policy statement on Care of Children in Emergency Departments, 2009, available from aappolicy. aappublications.org (http://tiny.cc/fvv0c) 5. Geelhoed G and Geelhoed EA. Positive impact of increased number of emergency consultants. Arch Dis Child 2008(93):62-64 6. Emergency Care for Children: Growing Pains. Committee on the future of emergency care in the United States Health System. The National Academies Press 2007, ISBN-13:978-0-309-10171-4. 7. Maximising Nursing Skills in caring for Children in Emergency Departments. Publ Royal College of Paediatrics & Child Health and Royal College of Nursing (UK) 2010. www.rcpch.ac.uk (http://tiny.cc/tine2) 8. The role of the Consultant Paediatrician with sub-speciality training in Paediatric Emergency Medicine. Publ Royal College of Paediatrics & Child Health (UK) 2008. www.rcpch.ac.uk (http://tiny.cc/8j2pu)

How to Listen: Download at iTunes or online at www.empem.org

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

PEMCast [www.pemfellows.com] The Hosts: Dr. Zach Kassutto, Dr. Angela Lumba, and Dr. Todd Chang The Gist: The podcast series features interviews with PEM experts, discussions and newscasts on PEM-related news, research, review and journal article analyses Resident Insight: A great focus on one pediatric topic a month with great interviews with experts in a format that is straight to the point. An aspect that really separates this program from other podcasts is the focus on the guest lecturer. Instead of just focusing on what the guest is doing right now, they review how the physician got to where they are today, noting many of the most important aspects of their career. In a recent episode with Marianne Gausche-Hill, they discussed the beginnings of pediatric emergency medicine. Length: 15 – 30 minutes

Dr Ffion Davies is a consultant in emergency medicine at the University Hospitals of Leicester NHS Trust. Trained in both paediatrics and emergency medicine, Dr. Davies has authored several texts, as well as the web site www.spottingthesickchild.com.

Fall 2011 // Emergency Physicians International

Frequency: bimonthly How to Listen: Download at iTunes or online at www.pemfellows.com Cost: Free

www.epijournal.com

abdelouahab bellou, md

POLICY

President of EuSEM

EM in the EU: A Call for Homogeneity

Greater homogeneity in emergency care is important in the EU given the increasing mobility of EU citizens.

The WHO seeks to establish EM standards through the creation of a new European Inter-Ministerial Panal additional reporting by Drs. Gunnar Ohlen & David Williams

W.H.O. recommendations on legislation and finances short-term recommendations:

n 2008, the World Health Organization published a review of the Emergency Medicine Health Care System in the European Union. Twenty seven national representatives designated by the ministries of health of each EU country contributed to the project, as did a group of EM experts. The working group explored concepts from legislation and financing to pre-hospital to crisis management. Perhaps the most important outcome of the project has been the creation of the European Inter-Ministerial Panel on Emergency Health Care, a group of experts in the field of EMS, appointed by all concerned ministries of health. This report, which we’ll explore here, remains an important examination of EM in the EU, and is a strong case for greater homogeneity across the continent.

Pre-Hospital Meets In-Hospital Professional standards, organizational structures and coordination mechanisms for emergency care vary widely across the European Union (EU). One standard, the Pre-Hospital Emergency Medicine Care System (PHEMCS) has medical care delivered at the scene of the emergency event. All professionals and services involved in giving emergency medical care in an out-ofhospital setting, from the dispatching center (DC) to the police to the medical providers themselves, fall under the PHEMCS, which works together to coordinate the best strategy for emergency response. The DC will decide to send nurses, paramedics or doctors depending on the severity of the case. In 70% per cent of EU countries, prehospital emergency care is doctor-based, but doctors are sent to the scene only for severe cases. The PHEMCS works in conjunction with In-Hospital Emergency Medicine Care Systems (INHEMCS), which is composed of hospitals that have the capacity to deliver continuous emergency care on a 24/7 basis. One of the most important components of the in-hospital care, of course, is the ED itself, where the majority of patients come by their own means or are sent by the dispatchers. Together, the PHEMS and INHEMS constitute the Emergency Medicine Health

Care System. Financing emergency care: Public or Private Affair? Depending on which EU country you are in, emergency care services could be publicly or privately financed. The PHEMCS and the INHEMCS are respectively financed by state budget in 19 and 15 EU countries, public sources in 11 and 10 EU countries, private in 4 and 5 EU countries, and mixed in 7 and 9 EU countries (see table, page 13). Greater homogeneity in the financing of emergency care is important in the EU given the increasing mobility of EU citizens. In the WHO report, EU representatives declared that their national laws guaranteed “free access to in-hospital emergency care for all.” In reality, some countries or regions – or even individual hospitals – invoice patients for emergency care. This usually affects non-EU residents and, occasionally, persons from a “socially marginalized group.” However, co-payment for emergency care is waived in life-threatening situations. The WHO study found that only 13 EU countries have a special budget allocated to crisis/disaster preparedness and only 12 EU countries have a specific reserve budget to be promptly mobilized in the event of a crisis/disaster. Of these, 10 EU countries have funds allocated

Fall 2011 // Emergency Physicians International

Common European minimum standards in Emergency Medical Services should be introduced by a recognized and authoritative institution, namely on: • Education of professionals. • Equipment to be available for in-hospital emergency services and out-of-hospital emergency services. • Inter-connectivity between dispatch centres across borders. long-term recommendations:

The European Commission or another recognized institution should introduce common European minimum standards, namely on: • Inclusion of an Emergency Medical Services’ representative in the national crisis management team. • Creation of mechanisms to mobilize funds for Emergency Medical Services disaster preparedness and response.

W.H.O. recommendations for improving the Pre-Hospital Emergency Medicine Care System short-term recommendations:

A recognized and authoritative institution should: • Provide a list of quality indicators concerning out-of-hospital Emergency Medical Services (PHEMCS used in this paper). • Propose internationally recognized curricula of first aid for first responders such as fire brigade, volunteers and police. All the Member States of the European Union should: • Ensure effective coordination and response to avoid delay in case of medical emergencies. • Improve access of minorities and foreigners to all Emergency Medical Services systems in Europe. • Ensure emergency calls are dealt with by Emergency Medical Services, only with type B and C ambulances. • Report on the percentage of patients (in the highest coding category) reached within eight minutes of receiving the emergency call. long-term recommendations:

A recognized and authoritative institution should: • Pave the way for a common research strategy in the European Union strategic paper. A recognized and authoritative institution should: • Improve systems to allow sharing of real-time information between medical services and dispatch centres. • Place the activity of medical first responders, when dealing with medical emergencies, under the operative management of medical dispatching.

W.H.O. recommendations for improving the European In Hospital Emergency Medicine Care System

W.H.O. recommendations on education and specialisation in EM

long-term recommendations:

short-term recommendations:

A recognized and authoritative institution should: • Introduce European mechanisms of performance for hospital Emergency Departments. • Set up quality monitoring systems especially for Emergency Departments. All the Member States of the European Union should: • Support the development of European protocol guidelines for most frequent emergency cases including triage. • Review how the psychosocial needs of patients are detected and treated within Emergency Departments. • Establish nationwide triage systems for patients at Dispatch Centres, ambulance and in-hospital level, to ensure proper and prompt access and equity in quality of care delivered.

All the Member States of the European Union should: • Extend and regulate specialization in Emergency Medicine for doctors, in line with European Union directive 2006/100/EC. • Introduce and regulate specialization in Emergency Medicine for nurses. • Include in the pre-graduate curricula of medical and nursing schools a mandatory teaching course on emergency and disaster medicine. • Endorse continuous training for non-medical medical Emergency Medical Services’ providers. • Regulate the utilization of non-medical professionals and volunteers responding to a medical situation in out-of-hospital settings and provide lay volunteers with appropriate training.

for both crisis/disaster preparedness and response. Regarding this crisis budget, most EU countries appear to assume that the government will promptly mobilize state funds according to needs. Emergency 1-1-2: An EU Directive The PHEMCS covers primary care professionals and facilities, first aid posts, volunteer organizations, private medical services and fire fighters. When needed, the system is activated by dispatch centers that organise the appropriate response to an emergency situation or a disaster event. The emergency call number in Europe is 112. The 1991 and 2002 EU directives define the number 112 as the European emergency call number. The directives demand that each EU country ensures that citizens, apart from being able to call other emergency numbers, can activate an emergency response by calling 112. Article 26 of the Universal Service Directive deals with the single European emergency call number and provides for the following: 1) Member States shall ensure that, in addition to any other national emergency call numbers specified by national regulatory authorities, all end-users of publicly available telephone services, including users of public pay telephones, are able to call the emergency services free of charge, by using the single European emergency call number 112. 2) Member States shall ensure that calls to the single European emergency call number 112 are appropriately answered and handled in a manner best suited to the national organization of emergency systems and within the technological possibilities of the networks. 3) Member States shall ensure that enterprises that operate public telephone networks make caller location information available to authorities handling emergencies, to the extent technically feasible, for all calls to the single European emergency call number 112. 4) Member States shall ensure that citizens are adequately informed about the existence and use of the single European emergency call number 112.

Who Funds EM in the EU? State

Public

Private

Mixed

Pre-Hospital

In-Hospital

In some EU countries, the 112 is the only phone number used in case of emergency situations (Cyprus, Denmark, Estonia, Finland, Luxembourg, Netherlands, Portugal, Romania, Sweden, Slovenia). Twenty-one countries report having an integrated DC that coordinates the dispatch of vehicles and personnel of at least two principal emergency management agencies (security services, EMS, fire brigade, etc.). In seven EU member states, when an individual dials 112, security services take the call. According to data collected by the EC in 2000, in the context of its regular Eurobarometer surveys, only 19.2% of the total European population could cite 112 as the number to call in the event of an emergency. Due to obvious geographical differences, the number and distribution of medical DCs across EU member states varies. Region-based distribution was reported in 15 countries and sub region-based in 11 countries. Three EU countries (Estonia, Luxembourg and Malta) have only one national emergency coordination centre due to their small geographical areas. Interconnectivity between DCs was identified in 20 EU countries. In-Hospital Care The creation of emergency departments is a trend that started in the 1990s in Europe and represents the most important change in recent years in the structure of hospitals and provision of health care in the EU. Before this reform, the emergency care in EDs was done by interns. Now, triage protocols exist in 24 EU countries and those protocols are computerized and nationally standardized in 10. Across Europe, there are no limitations on who can visit an ED, but in 5 EU countries an identification document or a referral is required.

Many studies show that a percentage of patients admitted to EDs are more in need of social assistance than medical care and that if social care is provided, some admissions could be avoided. And yet, social workers work in EDs in only 7 EU countries. The same number holds true for the prevalence of intercultural mediators and/or interpreters in the ED (five of which are pilot projects). The aim of EM is to apply the most experienced and appropriate knowledge and expertise available in a short time and in the most cost-effective manner, with the aim of returning patients to their previous health status. A comprehensive and integrated emergency care system that meets a country’s needs requires that EM practitioners possess a body of specific knowledge, skills and attitudes. EM education and training is well established in the EU but varies widely between individual EU countries. At undergraduate level, EM is a mandatory medical school subject in 16 EU countries. At postgraduate level, emergency care providers, such as physicians, nurses and paramedics, receive specialist education and training in programmes offered by government agencies, universities, and private training institutions or as part of continuing professional education. European bodies that can recognize specialty training include national medical or nursing associations, colleges of medicine and Ministries of Health. Twenty one EU countries report board certification or similar accreditation for physicians while 12 EU countries also accredit nurses. A survey conducted in 2003 highlighted a similar lack of uniformity in EMS education worldwide. In seven EU countries, the content of most EM education programmes is not driven by national guidelines. EM is listed in the “Doctors’ Directive”, first issued by the EC as 93/16/EC81 (24) and more recently updated by the 2006/100/EC82 (25), as one of the 53 recognized medical specialties in EU countries. But Emergency Medicine is still represented by the term “Accident and Emergency Medicine”. In these 2 Directives, the primary specialty is recognised in 9 EU countries (Czech Republic, Ireland, Hungary, continued on page

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African Conference in Emergency Medicine Accra International Convention Centre, Ghana save the date:

30 October to 1 November 2012

www.afcem2012.com

Fall 2011 // Emergency Physicians International

source Firsthand reports of specialty development around the globe

dispatches 16 Physicians from 22 countries answer one question: How could you make emergency care more cost effective?

france 18 georgia 20

The Paris EM dispatch service (SAMU) provides medical service to high-speed trains and Air France.

France report on page 18

www.epijournal.com

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

Q. What is one change you would make (or have made) to make EM more cost-effective?

_______________________

1 CANADA “(1) apply the Ottawa ankle and foot rules at triage. (2) implement an expedited 1-hour pre-medication protocol for CT-contrast allergic patients, and not the silly 13 hour protocol we currently use at our institution. (3) push clinicians to use generic broad-spectrum antibiotics, and combination coverage instead of reaching for Timentin and PipTazo. (4) dip all urine samples before sending them to the lab for analysis.” _______________________

2 UNITED STATES “Determine the QALY-DALY/cost

ratio for testing and stop doing those with little marginal benefit. Like ECGs for 25 year olds with chronic chest pain and CTs for people with pain “just like the kidney stone I passed last year.” -------------“standardizing and simplifying the health insurance reimbursement forms and mechanisms (using the same forms and limited number of reimbursement codes for all insurers)” _______________________

3 MEXICO “Improve coordination with EMS services, primary care clinics and ambulatory care systems. I think that will diminish at least 10% of EMS transports to the ER. On the other hand standardize treatments and procedures

Fall 2011 // Emergency Physicians International

so the amount of resources needed can be predicted, controlled, etc...” _______________________

4 ECUADOR “[There is] no ambulance system; emergency consultations are staffed by general practitioners and recent graduates; [there is a] lack of training for health professionals.” _______________________

5 COLOMBIA “Increase the nurse/patient ratio. In many services in Medellin, the number of patients exceeds the number of nurses and the capability of the service in the

initiation of treatments and taking of blood/urine and other tests. This causes a long waiting time of observation for a medical decision and probably increasing risks and costs (complications of the disease, hospital acquired infections, falls, food, etc).” _______________________

6 CHILE “Keep a senior consultant permanently on board.” _______________________

7 FINLAND “A change we’ve already made is that many patients are not transported by an

the responsible primary care doctor through our common computer system to one of the two predetermined appointments at their GP station. We would inform the patient the time of the appointment and that he or she hereby saves $40 (seeing GP costs $10 and presenting in ED costs $50). The patient would not have to pay me, only the GP the day after.” _______________________

18 19 20 21 22

9 GHANA “In my hospital, the main cost is delay in auxiliary investigations and review of requested test, thus prolonging hospital stay. I would want to reduce this delay and make physicians and other doctors review patients and take definitive management decisions and execute them early to reduce hospital stay.” _______________________

10 FRANCE “[We should] staff emergency departments with qualified EM physicians to diminish unnecessary laboratory and radiology exams.” _______________________

ambulance to ED but instead are treated on the scene and then released. Unsuccessful CPR attempts are terminated on the scene and ongoing CPR to ED is only used in the case of hypothermia.” _______________________

8 SWEDEN “I would have a specialist in the triage or close by, supporting the nurse whenever a patient presents with a non-acute problem that can be better taken care of by the patients GP the day after. I would make sure - after having met the primary care physicians a few times drawing up the frame work - that every GP station in town would have 2 spares in their appointment book for ED patients. My nurse would book the patient to

ITALY “I would optimize shifts. At the moment physicians work on 3 shifts of 6 hours in the morning (4 physicians) 6 hours in the afternoon (4 physicians), and 12 in the night (3 physicians). I think would be better to work on 3 shifts each of 8 hours with 3 physicians in the morning and night shifts and 4 in the afternoon shift.” -------------“Short observation Unit period audit, plus the review of diagnostic and therapeutic track according to EBM and GL.” _______________________

12 GREECE “Need more education and training in emergency medicine”

_______________________

13 ISRAEL “Change the standards and expectations of the public and of the state systems, so that not every patient can come to the ED, and those coming to the ED do not have to have every test required for 99% diagnostic accuracy but rather 98 or less. Examples: no CT for minor head injury without neuro signs/risk factors.” _______________________

14 SAUDI ARABIA “Lower the litigation threshold against EM Physicians based on professional good will. EM Physicians tend to order far more tests and investigations as well as referral to avoid missing any issue that can lead to court case with huge compensation or loss of work/ position.” _______________________

15 BAHRAIN “Need to recruit more board-certified emergency physicians along with fellowship training from well recognized centers. I hope after such training EPs can select the areas in EM where cost effectiveness can be applied after doing research in that area, developing evidence based clinical protocols and developing triaging system for patients visiting emergency room and to send minor cases which accounts 45-55% of total ED visits which can be sent to clinics.” _______________________

16 THE NETHERLANDS “Triage patients fit for primary care directly away from ED to a primary care facility, or incorporate this facility in or very near my ED.” _______________________

17 UNITED KINGDOM “Non-refundable ‘admin’ fee for all patients, refundable in cases of true emergency. For example £5 or £10 per visit - in the UK. There are a number of patients report-

ing to emergency departments in UK who attend simply because they are not able to get appointments with their own general practitioners. Most people pay £5 to £10 for a meal or movie, so I do not think it would be unreasonable. People have to take some responsibility for their own health and not use emergency departments for “second opinions” (at least in the UK).” _______________________

18 ESTONIA “The biggest change needed in our hospital, in order to improve costeffectiveness is to establish the institution of EM specialized NURSES who independently serve/manage lower priority cases in the ER.” _______________________

19 SINGAPORE “Invest in focused, dedicated, community-wide first-responder training. Set up primary prevention programs for the five commonest emergencies -- these should be focused, intensive, protracted, community-wide programs for best effect.” _______________________

20 HONG KONG “Further development of government funded primary care.” _______________________

21 REPUBLIC OF KOREA “In Korea, the expense of ED management is low, even in tertiary care centers. This leads to the patients visiting the ED with mild problems.” _______________________

22 AUSTRALIA “Have all significant clinical decisions made by senior doctors as early as possible. This will largely eliminate wasted investigations and unnecessary treatments.” -------------“Employ physician’s assistants.”

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Source

In France, EM is directed by central dispatch agencies called SAMU (Service d’Aide Médicale Urgente). Because of aggressive triage, only about 65% of requests to SAMU actually receive an ambulance response.

The Franco-German Model: Prehospital EMS

>14 million

ED visits last year (up 50% in 10 years)

81%

Discharged

france

17%

Admitted

With ED visits on the rise and available beds on the decline, French emergency care is entering a pivotal period of specialty development.

Transferred

by eric revue, md

here are 616 emergency department in France, which, as of 2004, had a total of 14 million visits. The rising rate of emergency admissions to hospitals is a result of an increasing population with an increasing number of visits. Periods of ED overcrowding are becoming increasingly common in many parts of France, which frequently results in rationed access to inpatient beds, particularly acute beds in Paris. In France, triage is done to detect cases in need of priority care, and the law forbids EDs from denying emergency care to selected patients on the basis of chief symptoms and vital signs. The French healthcare model provides broad access to comprehensive health services for a population that is older than average in Europe. Lack of sufficient personnel has been cited as one of the causes of the high mortality observed in the particularly hot summer of 2003, or in winter epidemics.

Not surprisingly, the French follow the famed Franco-German model of emergency medicine, in which qualified physicians treat patients at the scene, during transport, and in the hospital. EMS services can be reached by dialing “1-5” everywhere in France. EMS crews have access to an emergency physician via telephone, who are stationed in regional dispatch centers of the “Service d’aide médicale d’Urgente” (SAMU) taking a direct “hands-on” approach to prehospital care. Emergency response to medical calls are conducted by the “Service Mobile d’Urgence et de Réanimation” (SMUR) with teams including an emergency physician, an emergency nurse, and a nurse aide. The median response time with a SMUR EMT is 20 minutes. Emergency medicine (EM) is a relatively young specialty in France. As in most European countries, EM is at an early stage of development, with 4-year training programs. The French Society of Emergency Medicine (SFMU), with over 3,000 members, is making efforts to establish and support the development of the specialty of EM in France. A weakness of the French healthcare system lies in the lack of coordination and continuity of care. The interface between hospital care and ambulatory care on one hand,

Inpatient Utilization and Performance, 1980–1998 1980

1985

1990

1995

1996

1997

1998

Number of beds per 1000 inhabitants

11.1

10.5

9.7

8.9

8.7

8.5

Occupancy rate

81.4

81.8

80.4

80.7

80.9

81.6

81.8

Number of hospital stays per 1000 inhabitants

193

210

232

228

230

229

Avg. length of stay (days)

17.1

14.9

12.3

11.5

11.2

11.0

10.9

6.2

5.7

5.2

4.6

4.5

4.3

4.2

79.0

79.1

77.3

75.9

76.4

76.1

Number of hospital stays per 1000 inhabitants

175

189

209

203

204

203

Avg. length of stay (days)

10.2

8.6

7.0

6.2

6.1

5.9

5.8

all inpatient care

acute care Number of beds per 1000 inhabitants Occupancy rate

Fall 2011 // Emergency Physicians International

Source: IRDES/DREES 2001

visits

(in millions)

French emergency departments saw a dramatic increase in patient visits over the last decade

YOUR PATIENTS ARE ON THE CUTTING EDGE...ARE YOU?

T-RING ADVANTAGES:

15 14 13 12 11 10

1996

1997

1998

1999

2000

2001

number of acute hospital beds per pop. in select eu countries

2.5 sweden

3.25 netherlands

2002

2003

2004

1,000

4.2

italy

france

6.3

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“ONE SIZE FITS ALL!” “BLOODLESS EXPLORATION THROUGH CAREFUL TOURNIQUET APPLICATION IS “CRITICAL” TO MINIMIZE RISK!” (ACEP’s Emergency and Primary Care of the hand).

germany

Source: WHO Regional Office for Europe health for all database (2000)

and between health care and social care on the other hand (especially for disabled or elderly people), is also often a problem. ED overcrowding should be defined as a period when ambulances are diverted to nearby hospitals because all critical care beds in the ED are occupied, and/or patients are occupying hallway spaces. Inadequate inpatient capacity for a patient population with increasing severe illnesses forces the ED to serve as a holding area for admitted patients. “Boarding” – the practice of admitted patients to the hospital but leaving them in the ED – sometimes lasts for more than 24 hours because of the lack of beds. Patients who arrive at an ED during crowded periods may at times wait 30 minutes longer for an ED bed. Crowding is associated with increased door-to-needle time for patients with suspected myocardial infarction, and high ED occupancy levels have also been associated with delayed pain assessment. However, visits by patients with nonurgent complaints were not associated with the most severe crowding at large hospitals. Culturally, the French tend to consult their general practitioner first (except in emergencies). They consult with their doctors more often, are admitted to the hospital more often,

and purchase more prescription drugs than in most highly-developed countries. There is no public perception in France that health services are “rationed” or otherwise limited. French people have an average of 4.7 contacts with a general practitioner per year; they can visit several general practitioners; they are free to choose their doctor, regardless of specialty; and they do not need a referral from a general practitioner in order to consult a specialist. Doctors benefit from total freedom to choose where they wish to practice, but, as a result, geographical disparities in the distribution of doctors are common. A number of policies exist to encourage methods of providing care that are alternatives to complete hospitalization, such as day care surgery, or treating patients in their homes (known as “hospitalization at home”). In each case, the extension of capacity must be authorized. Authorization is granted in return for closing down acute beds, with a theoretical exchange rate of one place for two beds, which may be adjusted at the regional level to account for the existing number of beds. In spite of the incentives available, the development of alternatives to complete hospitalization remains limited by international standards.

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Source

Mikheil Saakashvili, the president of Georgia, visits a healthcare facility in the Racha region (2011).

population 4.6 million

geography 69,7000 km2

borders

Georgia

The recovering Republic seeks to make strong evidence-based healthcare advancements following years of economic turmoil. by konstantinos karavasilis

n 1991, when Georgia reacquired its independence following the dissolution of the Soviet Union, the country adopted a representative democratic constitution and has since focused on strengthening its democracy and economy. Georgia’s GDP grew more than 10% from 2006 through 2007, but progress was delayed following a 2008 conflict with Russia, which drained economic resources. GDP slowed to 2.1% in 2008, and leveled at 3% in 2009. The economic downturn also affected Georgia’s healthcare sector. The Georgian Health Care System demise, following the Soviet Union breakdown, is well documented, and rebuilding has been slow, and, on occasion, ineffective. However, the current administration is enacting policies that promise a new era of healthcare access and delivery for the Georgian people [1]. Dr. David Sergeenko, the Director of Sachkhere’s Hospital, a regional hospital with

150 bed capacity, 60% occupancy rate, and more than 120,000 annual outpatient visits, states that: Given a fixed budget we need to optimize between access to healthcare and quality of care. We have made real progress regarding access to healthcare. Initially, government programs were geared towards making healthcare accessible to the poor, the elderly, and the children. Current government programs are enhanced over the previous ones, in making healthcare accessible regardless of the patient’s social status. Improvement of the quality of care has been slow. Georgian medical establishments continue to use an outdated medical accreditation process. This is exemplified in the certification of hospitals and professional licensing. For example, physicians are licensed for life upon completion of their residency—neither periodic skill assessments, nor reexaminations or continuing medical education (CME) are prerequisites for a medical

Fall 2011 // Emergency Physicians International

Armenia Russia Turkey Azerbaijan The Black Sea

capital Tbilisi

independence

from Russian Empire: 1918 from Soviet Union: 1991

license renewal. English language is another barrier to CME. Most of the world’s peerreviewed medical literature is published in the English language. The medical establishment in Georgia is encouraging the study of English as a second language, but this leaves most mid-career practicing physicians out of the mainstream of medical information. Although medical literature translations will benefit mid-career physicians, selection guidelines to provide required and relevant information are not in place. The Ministry of Labor, Health & Social Affairs (MoLHSA) is cognizant of the challenges presented by the current accreditation, certification, and licensing process. The Georgian government decided to divide the responsibilities for accreditation and CME between the Ministry of Education and MoLHSA, the latter being responsible for licensing and all postgraduate educational and training curricula. The Ministry of Education is responsible for all educational programs and curricula prior to licensing. All state universities have the responsibility of implementing educational programs to graduate appropriately trained professionals to meet population healthcare needs. The Rector of Tbilisi State Medical University (TSMU), Georgia’s largest medical university, with almost 5,000 undergraduate and 2,000 postgraduate students, states that one of the priorities of healthcare reform is the development of human resources (healthcare providers). Another priority is the optimal distribution of healthcare providers throughout the country. These ongoing priorities will be supported by an effective management system designed to foster the implementation of robust healthcare services, legislative regulations, and empowering professional associations. A real shortage and lack of coordination of appropriately trained Georgian general practitioners and primary-care nurses persists. In the former Soviet Union nursing was considered a profession suitable for high school dropouts, and nursing schools provided minimal training to their students. Today, there are new beliefs about the importance of the nursing profession. A new Department of Nursing Education was established in 2007 at TSMU. The 3-year curriculum is patterned after the WHO European

The Georgian College of Emergency Physicians was formed in January 2008 and now has 151 members. GCEP joined EuSEM in June 2011. Strategy for Nursing and Midwifery Education. Currently, 250 students are enrolled in the program. Training includes Public Health, Health Maintenance, Patient’s Education, Epidemiology and Management of Chronic Diseases, Behavioral Sciences, Biological Sciences, Research Skills, Communication Skills, Health Ethics (Code of Ethics for Nurses— ICN 2000) and Law, Information Management and Information Technologies, Administration and Leadership disciplines. In 2007, in order to improve the access and quality of care, a “100 New Hospital Plan” was introduced, intended to replace and/or upgrade outdated healthcare facilities. This plan was marred by corruption, and existing and outdated institutions, located in a prime downtown area, were traded to real estate developers in return for constructing new facilities on the outskirts of cities without any structural or operational guidelines. The “100 New Hospital Plan” was scrapped and in the Fall of 2008 and replaced with the “82 Newly Built and Reconstructed Hospitals by 2012 Plan.” Land and building swaps with real estate developers were stopped, and the plan will be implemented using combined government and private investors, pre-screened for their economic solvency and funding. The present healthcare reform is moving towards universal coverage and is relying on insurance providers’ participation. The reform calls for subsidizing health coverage for individuals living below the poverty line, approximately 20% of the total population. Health insurance subsidies are also available for teachers and municipal workers. In 2000 health insurance was virtually unheard of in Georgia. By 2004 only a handful of companies catering mainly to the expatriate community, and a few international companies requiring health insurance for their employees, were in existence. Since 2004 the number

of purchased insurance policies has increased exponentially. The chief executive of the Georgian Insurance Association stated that as of June 30, 2010, 1.5 million individuals were insured in Georgia—one-third of the population. Approximately 1.1 million individuals are insured through government programs, of whom 900,000 are socially and economically vulnerable, 100,000 are teachers, and 100,000 are employees of the Tbilisi municipal program. The remaining 400,000 are insured privately or through an employer. To reach the remaining three million uninsured, health insurance premiums are kept low, often leading to questionable practices of limiting reimbursements and setting fixed prices paid to healthcare providers for specific medical procedures, which are often underpriced. The current situation in Georgia highlights the need for an evidencebased decision-making process at all levels of health policy. The long-term goal is to develop evidence-based practices in public health, medical care, and health administration. This approach requires research “capacity building” and justifiable priority setting for the use of scarce resources. If enacted successfully, this researchbased approach combined with skill training will help establish an evidence-based preventative and clinical care practice by 2015. The need for adopting proper regulatory policies of healthcare reimbursements is selfevident. The Georgian health system demise was rapid, the rebuilding is slow, but there is hope that the future will bring new improvement in overall population health. The change should be apparent by 2012, and Dr. Dolidze is inviting the world medical community to take part in the celebration of Georgia’s medical and public health achievements.

The 1st Global Network Conference on Emergency Medicine 13 – 17 January 2012 Dubai International Conference and Exhibition Centre, Dubai United Arab Emirates www.emergencymedicineme.com

Workshops– 13-14 January, 2012 • Ultrasound • Simulation • ECG • Non-Invasive Ventilation

Conference Topics– 15-17 January, 2012 • Intensive Care • Administration • Cardiovascular • Education • Disaster Medicine • Pre-Hospital • Research • Trauma • Paediatric • Toxicology • Architechture & Design • Economy Aspects of EM • Haemostasis & Thrombosis Tel: +971 4 389 4500 Fax: +971 4 358 5511 Email: conference@uae.messefrankfurt.com

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ID In-Depth Global Lit Review

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

part I: Defining Boundaries and Tracking Trends

n recent years, the growth of emergency medicine around the globe has been exponential, with nearly 70 countries now granting some form of formal recognition to the field. At the same time, interest in Global Emergency Medicine (GEM) as a unique subspecialty of emergency medicine has also grown rapidly over the past decade. International sections, interest groups, and committees now exist within many emergency medicine organizations across North America and Europe, and in some cases have become the largest special interest sections within these organizations. One of the barriers, however, to the development of the nascent field of GEM has been the lack of an easily accessible literature base that can be used to guide its development. Both research articles and communiquĂŠs of value to various stakeholders in GEM are spread throughout the general medical literature, the emergency medicine literature, the public health literature, the health policy/health systems literature, and the humanitarian/disaster literature. Many publications with GEM relevance exist only in the gray literature in the form of assessments or reports by international agencies, national or local governments, foundations, donor agencies, financial institutions, or non-governmental organizations. Furthermore, GEM research may be published in a variety of different languages, further limiting its accessibility to a global audience of emergency medicine practitioners. Recognizing the need for a clear and accessible literature base to guide the growing field of GEM, the International Emergency Medicine Literature Review Group was formed in 2005. Publishing annually in the journal Academic Emergency Medicine, this review gathers together a number of articles from disparate sources, presenting the ones chosen as having specific relevance or value to the field of global emergency medicine. The goals of the review are to illustrate best practices, stimulate additional research, and promote further professionalization of the field of global emergency medicine. Before we can review the global emergency medicine literature, however, we must first define the

boundaries of the field. For the purpose of our review, we have created a framework that divides GEM research into one of three categories: development of emergency medical care systems in both developed and developing nations, delivery of emergency care in resource limited settings, and provision of humanitarian and disaster relief. Emergency medicine development encompasses clinical, educational and systems components at both the national and local levels. Included within this rubric would be efforts as diverse as developing a national disaster relief plan,

Our 2010 review found a shift towards articles falling within the realm of emergency care in resource limited settings, especially those related to maternal and child health. creating a city-wide EMS system, and training rural health practitioners to provide basic emergency services. Emergency care in resource limited settings deals with adapting old methods and developing new methods for providing acute medical care and trauma care in rural areas and low-income countries, where advanced technology and specialist physicians may not be available. The field of humanitarian relief also encompasses several different domains, and is rapidly becoming more organized through critical analyses of operations executed. Both humanitarian relief agencies and donor governments are looking closely at ways to improve humanitarian response, including the conduct of rapid needs assessments, the deployment of personnel and supplies, and ongoing monitoring and evaluation. Each year, we perform a Medline search of the published literature using a set of structured terms that we have honed over time, as well as a search of the grey literature using a variety of databases and algorithms. Our multilingual team of reviewers then

screens the thousands of citations captured by our search to find the few hundred studies that clearly fall within the realm of GEM, as defined above. Our reviewers then read and score each manuscript, using a set of questions that evaluates the clarity, methodology, ethics, importance, and likely impact of each study in order to find the top GEM articles published each year. Finally, our reviewers provide a summary and critique of each article, for the benefit of our readers. In addition to reviewing the highest quality and most important research studies of the year, the review also identifies and tracks emerging trends in GEM research. Our 2008 review, for instance, noted an explosion of articles related to pandemic response, as well as articles detailing the importance of international collaboration in the development of emergency care systems around the globe. In our 2009 review, we found many more articles focusing on issues related to disaster response, including the evaluation of various triage systems, methods of rationing care in humanitarian emergencies, and the ethics of both humanitarians responding to disasters and conducting research to study the humanitarian response to disasters. Our 2010 review, in turn, found a shift towards articles falling within the realm of emergency care in resource limited settings, especially those related to maternal and child health. Indeed, we saw several excellent studies identifying better methods for diagnosing and treating acute respiratory infections, diarrhea, and malaria in children in the developing world, as well as a number of randomized controlled trials aimed at preventing complications of obstetric emergencies such as post-partum hemorrhage or preterm labor. The 2010 review also noted a number of new studies specifically analyzing trauma care in the developing world, including road traffic accidents and domestic violence, looking at the systems-level barriers and solutions to improving care for patients with traumatic injuries. Overall, our annual reviews have also noted a consistent improvement over the past several years in the methodological quality of global emergency medicine research. Clearly, global continued on page

ID GLOBAL LIT REVIEW emergency medicine research is finally coming into its own as a rigorous scientific field. In this current issue of EPI, we highlight a few of the top research articles identified by our 2010 International Emergency Medicine Literature Review. In future issues of EPI, we will continue to pro-

vide additional snapshots of cutting edge global emergency medicine research from around the globe. For a more in-depth discussion of the methodology and results for our annual review, as well as for summaries and critiques of the top 27 GEM articles of 2010, please see our full review at www.aemj.org.

part II: three must-read papers from the global em community

GERMANY Understanding the causes and effects of road traffic crashes in developing countries Schmucker U, Seifert J, Stengel D, Matthes G, Ottersbach C, Ekkernkamp A. Road traffic crashes in developing countries. Unfallchirurg. 2010; 113(5): 373-7.

his article, published in the German medical journal Unfallchirurg, provides a systematic review of the causes and effects of road traffic accidents (RTA) in low and middle-income countries (LMIC). Globally, more than 1.25 million people die every year in RTAs and more than 50 million people sustain trafficrelated injuries, with over 90% of this morbidity and mortality occurring in LMIC. The authors point out that the available statistics on RTA likely underestimate their impact, as many LMICs have very limited abilities in adequately documenting and investigating RTA, and there are few scientific publications from LMICs that deal with the medical impact of road traffic accidents. Nevertheless, the authors identify major trends in RTA in LMICs based on the available data. The majority of lethal injuries in LMIC involve pedestrians, in contrast to high-income countries (HIC). The use of motorcycles, cars or other means of transportation (e.g., rickshaws) varies greatly between HICs and LMICs and even among LMICs. The majority of fatal RTA is not associated with driving under the influence of ethanol; however, only 25% of LMICs have implemented drunk driving limits and less than 50% of LMICs document ethanol levels in injured drivers. In addition, use of seat belts is not mandatory in half of all LMICs. The authors also point out that early emergency care is limited in most LMICs. 40% have neither a uniform emergency call number nor an organized EMS system. Ambulance personnel often lack even basic BLS skills, such as splinting (50%), while only 6% underwent formal ATLS training. In addition, EMS services are only rarely available in remote areas, while traffic conditions in urban areas interfere with adequate response times. Although the authors offer information about general trends in the epidemiology of RTA, they acknowledge that the data is limited, and the general trends identified should be interpreted cautiously when dealing with RTA in a particular region or country, as local circumstances may influence the relevance of some of the findings. Nevertheless, this article will likely stimulate further research to better understand the epidemiology of RTA in specific countries and contexts, which may ultimately lead to more precise preventive measures. Preventive measures become increasingly important in view of the growing urbanization in many LMICs and the associated surge in road traffic density. The article also underlines the importance of multidisciplinary approaches to minimizing the morbidity and

Fall 2011 // Emergency Physicians International

mortality of RTA, including a combination of better education, engineering, and regulation, while also optimizing access and quality of early emergency medical care. Reviewed by Adam C. Levine, MD, MPH and Torben Kim Becker, MD on behalf of the Global Emergency Medicine Literature Review Group

UNITED KINGDOM British military experience with pediatric trauma in Afghanistan Walker N, Russell RJ, Hodgetts TJ. British military experience of pre-hospital paediatric trauma in Afghanistan. J R Army Med Corps. 2010; 156(3): 150-3.

his retrospective analysis describes the pediatric experiences of the British militaryâ&#x20AC;&#x2122;s helicopter borne pre-hospital Medical Emergency Response Team (MERT) while on deployment in Afghanistan. A MERT team consisted of 1 physician, 1 nurse, and 2 paramedics. During a 20-month period spanning 2006 and 2007, the MERT team transported 78 pediatric patients, reflecting a far greater proportion of pediatric trauma than the team would normally manage in a non-conflict setting. In most cases, the injury mechanisms and triage categories were significantly more severe than what the MERT team would typically see when not deployed abroad. The distribution of triage categories, with 88% of triaged patients categorized as T1 or T2, reflects high-energy transfer mechanisms of injury. Local medical services were significantly limited in their ability and availability, requiring long transport times for injured patients. Trauma is the leading cause of death in children greater than 1 year of age. Morbidity and mortality in this age group can be minimized if pre-hospital health care providers of pediatric patients get the training they need to care for very sick children. However, familiarity with treating severely injured children can only be gained and maintained by appropriate training and continued medical practice. Childrenâ&#x20AC;&#x2122;s size, unique physiology, and anatomy produce different injury patterns when exposed to the same mechanisms of trauma. It is pertinent that all military pre-hospital emergency health care providers gain training and exposure to the care of the seriously injured pediatric patient. In order to best train providers how to triage, treat, and transport these patients, courses such as PALS (Pediatric Advanced Life Support) and PHPLS (Pre-Hospital Pediatric Life Support) should be implemented for military personnel providing pre-hospital trauma care in conflict settings. Reviewed by Adam C. Levine, MD, MPH and Gabrielle A. Jacquet, MD on behalf of the Global Emergency Medicine Literature Review Group

ISRAEL Reducing secondary traumatization following war and terror Berger R, Gelkopf M. An intervention for reducing secondary traumatization and improving professional self-efficacy in well baby clinic nurses following war and terror: A random control group trial. International Journal of Nursing Studies, 2010.

nfants and children exposed to war and terror frequently develop devastating long term mental health complications such as posttraumatic stress disorder, anxiety and depression, as well as poor daily functioning. Health care providers that care for such patients are at risk of developing secondary traumatization, leading to compassion fatigue, poor professional sense of self-efficacy and burnout. This prospective, quasi-randomized control trial evaluated a 12-week intervention for pediatric nurses in war and terror-affected regions of Israel. The intervention consisted of weekly 6-hour sessions designed to provide nurses with knowledge pertaining to stress and trauma in infants and young children; tools for identifying children and parents at risk of developing stress-related problems; and to equip them with stress management techniques for both children and adults. The sessions also included team building, support groups and self-

maintenance skills designed to allow nurses to better cope with secondary traumatization. Nurses enrolled in the intervention demonstrated significantly improved professional self-efficacy, compassion, satisfaction and burnout compared to nurses placed on the waiting list during the same time period. The authors conclude that training health personnel in civilian war zones to better understand and deal with trauma and secondary traumatization can yield better professional functioning. The issue of secondary traumatization in war and terror-affected regions is of critical importance. This study demonstrated a well designed, but time-intensive, intervention that demonstrated improved job satisfaction and decreased burnout among pediatric nurses. However, the sample size is small, and only two regions in a single country were examined, suggesting implementation and evaluation in other locales and among other types of health professionals, such as physicians and non-pediatric nurses, should be completed before considering universal utilization. Reviewed by Adam Levine, MD, MPH and Herbie Duber, MD on behalf of the Global Emergency Medicine Literature Review Group

International Emergency Department Leadership Institute 24-28 October, 2011 Boston, Massachusetts, USA As the number of interdisciplinary emergency departments grows internationally, where can ED leaders acquire the administrative skills they need to build and sustain successful emergency departments? The International Emergency Department Leadership Institute (IEDLI) was created by Harvard Medical School faculty and other international experts in order to provide ED leaders with the skills and knowledge they need to successfully operate emergency departments in any part of the world. In this one-week course of over 35 hours of interactive lectures and workshops, leaders will explore strategies to: • Establish the ED’s role within the hospital • Improve efficiency and control costs • Decrease overcrowding • Develop quality improvement programs • Educate and motivate ED doctors and nurses • Develop an emergency medicine training program • Form a strong administrative structure This program is designed for doctors, nurses and administrators.

IEDLI LOGO

International Emergency Department Leadership Institute

Save the date: IEDLI 2012 October 22-26 Leuven, Belgium www.IEDLI.org The International Emergency Department Leadership Institute is a collaboration between Harvard Medical Faculty Physicians at BIDMC and Brigham and Women’s Hospital. www.epijournal.com 25

R Report Disaster Medicine

New Disaster Research from Asia Last April, Oxford University and the Chinese University of Hong Kong came together to form a new institute for the study of disaster medicine in Asia, promising a fresh spate of data from a disasterprone region. by Drs. Kevin Hung & Colin Graham

sia is the most disaster-prone region of the world â&#x20AC;&#x201C; both natural and man-made â&#x20AC;&#x201C; and yet disaster research and training in the Asia-Pacific region is limited. Improved understanding of disaster epidemiology in the region and the impact that disasters have on human health would enhance our ability to prepare for and respond to disasters. Disaster preparedness can help to mitigate the effects of disasters on individual and population health. Until now, there has not been an academic research unit dedicated solely to the study and research of public health and medical care in disaster and humanitarian response in Asia. Enter the CERT-CUHK-Oxford University Centre for Disas-

Fall 2011 // Emergency Physicians International

ter and Medical Humanitarian Response (CCOUC), which was inaugurated on 19 April 2011 at the Chinese University of Hong Kong (CUHK). The CCOUC is a collaboration between the Chinese University of Hong Kong and the University of Oxford, with funding provided by a generous donation from CERT (HK) Ltd for three years (2011-2013). The centre will focus on academic research and training in disaster preparedness, relief and response in Greater China and in the Asia-Pacific region. The centre is located in the School of Public Health and Primary Care of CUHK at the Prince of Wales Hospital in Shatin in Hong Kong. Supported by the technical expertise and network of Oxford Asia through the University of Oxford, CCOUC will undertake research, training, and academic exchanges in disaster and humanitarian medicine. In addition, the centre will facilitate enhanced disaster relief responses and help to mitigate the adverse impact of disasters in the region. The mission of CCOUC is to serve as a platform for research, education and community knowledge transfer in the area of disaster and medical humanitarian crisis planning, response and policy development. This bold undertaking will be supported by a team of dedicated staff from the areas of public health, primary care, emergency medicine and epidemiology under the leadership of Professor Emily Chan, an academic public health specialist with extensive practical experience of delivering medical care in disaster zones throughout the world. As the former president of the Hong Kong MSF, Emily has been

THIS PAGE CUHK PHHI team member Dr. Sergio Koo performs a physical exam on a newborn baby affected by a fire disaster in Bhutan. OPPOSITE CUHK PHHI team delivered a “rescue bag” – containing a whistle and a hand-powered torch – to the participants after the health education program

operationally and clinically active at the Kashmir earthquake (2005), the Sichuan earthquake (2008) and many other lesser known disasters in countries as diverse as Bhutan, Timor, Cambodia, Laos, Vietnam, Myanmar, Indonesia, the Philippines, Brazil and Zimbabwe. The combination of her leadership skills, clinical abilities in healthcare delivery and organisation, and her academic attributes as an accomplished teacher and researcher will provide the centre with an enthusiastic and effective drive to complete its mission. The CCOUC builds on the experience built up over recent years by the Public Health Humanitarian Initiative at CUHK. A number of field trips to China and other parts of the Asia-Pacific region have been conducted under its auspices, focusing on disaster preparedness general health education in rural impoverished communities. This Initiative will continue to work closely with the CCOUC as its programs develop, and longer term research into disaster preparedness in rural China is currently in progress. One of the flagship projects in China for the Initiative is the Ten Village Project. The goal of this project is to mitigate the adverse human impact of natural disasters through evidence-based health education campaigns in remote resource-poor communities in rural China. The main aims of the project are to empower extreme poverty communities to mitigate the adverse impact of natural disasters; to continued on page

No. of natural disasters reported 1900–2010 1900

2010

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–asia–

–americas–

–africa–

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engage in knowledge transfer of technical expertise from academic settings to field practice for disaster preparedness in these communities; to build capacity to work in these communities by offering practice and training; to document our experiences and lessons learnt; and to increase global awareness of disaster issues in remote communities in developing countries. Ten sites across China, where communities have little knowledge or material resources to improve disaster preparedness, are being selected to build model cases for future knowledge transfer. Implementation sites include villages at the origin of the Yangtze River, Tibetan Plains, High Plateau of the Yellow River, an Island Population in Hainan, the Northeastern River and Yunnan province. Each project site will require around three to four field visits over 36 months. We recruit both students and professional volunteers to support these projects. Technical and local community project partners also contribute to ensure the cost-effectiveness and sustainability of our programs. The centre also engages in examining the clinical effectiveness of health preparedness and clinical interventions in disaster and humanitarian crises. Currently, the mental health research team is conducting a prospective randomized controlled trial of the effectiveness of the psychological first aid training among 900 uniformed emergency responders in Hong Kong. The main study aim is to examine the effectiveness of pre-disaster psychological training on enhancing disaster mental health knowledge, self-efficacy and effectiveness in emergency responders. Further details on the new CERT-CUHK-Oxford University Centre for Disaster and Medical Humanitarian Response can be found at www.cuhk.edu.hk/ccouc Dr. Kevin KC Hung is an assistant professor and Dr. Colin A. Graham is a professor at the Chinese University of Hong Kong.

Fall 2011 // Emergency Physicians International

CUHK PHHI team member Ms Christy Chan is teaching food pyramid to a group of local children CUHK PHHI team members delivered disaster preparedness message under sub-zero degree temperature in the field

R Report Scandinavia

Unifying EM in Nordic Europe Scandinavia’s unique level of regional collaboration could open the door to increased recognition of emergency medicine specialization. by Katrin Hruska, MD

he Nordic region is a well established concept in Northern Europe. Over hundreds of years, wars and unions have intertwined the history of our peoples, and though Norway, Finland, Sweden, Denmark and Iceland are now all independent states, this cultural unity persists. After the Second World War, the Nordic countries started to formalize their cooperation, which resulted in the establishment of the Nordic Council in 1952 and a passport union with free movement of labor in 1954. Though Denmark, Finland and Sweden have since joined the European Union, this arrangement has remained. Because Denmark, Sweden and Norway have similar languages, doctors and nurses have – after some minor paperwork – moved freely between the countries for locums or longer medical assignments, with the direction of flow determined by exchange rates and the countries’ current economic growth. For Icelandic physicians, completing at least part of their post

graduate training abroad has been a necessity, due to the small domestic population of only 310,000 inhabitants. Two-thirds of Icelandic graduates seek specialist training in the other Nordic countries, while a majority of the rest go to the United States. Dr. Jón Baldursson was one the Icelandic doctors to steer west in the late 80s. After completing his emergency medicine residency training at the University of Cincinnati, Baldursson returned to Iceland, determined to establish emergency medicine as a specialty there. Luckily, he wasn’t the only one to see the need for reorganization of Iceland’s multi-specialty ED model heavily reliant on junior doctors. Emergency medicine gained specialty recognition in Iceland in 1992 and Dr. Baldursson was the first EM specialist on the island. Almost twenty years later, the scene in Iceland has shifted dramatically in the direction of emergency medicine. There have also been some noteworthy milestones in prehospital care, where the medical direction has gradually shifted over to EM, while maintaining good collaboration with anesthesiology in this common field of interest. According to Baldursson, who now works full time for the Icelandic Ministry of Welfare, the biggest and most important challenge facing EM in Iceland is, and has been for quite a while, faculty development. With the exception of Iceland, the development of emergency medicine in the Nordic countries started only a decade ago. In Sweden this process was started as local projects led by a group of ED directors who saw an opportunity to improve work environment and increase effectiveness when physicians could work in all areas of the EDs, instead of in the traditional separate sectors for internal medicine, surgery and orthopedic trauma. In 2006 emergency medicine was recognized as a supraspecialty, making it possible to combine EM training with any other clinical specialty. This arrangement prolongs the postgraduate training in emergency medicine to a minimum of 7 years after the compulsory 1.5 years of internship. The system is currently being revised, hopefully with the result that EM becomes a primary specialty in 2012. continued on page 30

Dan Brun Pedersen, President of DASEM, constructs a rib cage for a chest tube insertion training course.

www.epijournal.com

Lars Petter Bjoernsen, the president of NORSEM

Finland and Norway, two countries with a scattered population and many remote rural areas, already have well-functioning prehospital organizations staffed with anesthesiologist specifically trained to manage prehospital emergencies. Both countries rely on primary care centers to provide urgent care and refer patients to the emergency department when deemed necessary. Subspecialization among the other specialists and the increased complicity of emergency diagnosis and treatment have, however, created a competence gap in the emergency departments. In Finland emergency medicine is now on the verge of primary specialty recognition, after a few years of status as a particular medical competence. Norway, on the other hand, is just about to start the development of emergency medicine as a specialty. “We are way behind the other Nordic countries,” says Dr. Lars Petter Bjoernsen, an EM specialist trained in the United States, who founded the Norweigan Society for Emergency Medicine (NORSEM) in 2010. The Norweigan Board of Health Supervision seems to agree with Dr. Bjoernsen that there is potential for improvement. After reviewing 27 out of 54 EDs in Norway they concluded that, “In most of the accident and emergency units where supervision was carried out, much of the day-to-day activities depended on competent individuals who rolled up their sleeves and stretched themselves to the limit to find solutions to problems related to awkward situations, everyday crises and bottlenecks in the system. The general picture seems to be that ad-hoc solutions rather than systematic management prevent stressful situations from developing into adverse events and deficiencies in the services.“ A subsequent report in 2008 led to the recommendation that emergency medicine be given the status of particular competence, but not recognized as a separate specialty, since an emergency phy-

Fall 2011 // Emergency Physicians International

sician-based system would not be able to meet the different needs of the different regions. Dr. Bjoernsen emphasizes the need to make haste slowly and in close cooperation with all parties concerned. Specialty recognition will be a later issue in Norway. The first priority is to improve the quality of care in the emergency departments through better teamwork, supervision and education from an emergency medicine perspective. In Denmark, the emergency departments have been put under the Departments of Orthopaedics, with junior doctors providing the first line of care. This is slowly changing with the reorganization of Danish healthcare where emergency care is concentrated to fewer hospitals with higher levels of care. Emergency medicine has gained the status of particular medical competence, a first step to improve the quality of care. Building and maintaining that competence in the new organization will form the basis for the development of a primary specialty. The Nordic countries are all moving in the same direction towards advanced emergency care, but they are moving along different paths, and at different pace. The societies for emergency medicine value sharing each other’s experiences and try to gather in connection with other meetings. Physicians are moving freely over the borders to learn and take part in the development. Icelandic and Danish doctors are among the EM residents in Sweden and the first EP to graduate in Sweden is working in Finland.

EM in the EU: A Call for Homogeneity

POLICY

continued from page

abdelouahab bellou, md

Malta, Poland, Romania, Slovakia, United Kingdom, and Bulgaria). The Directive also requires that training in this specialty should be for a minimum of five years. Hungary established EM as an academic branch in 1979 and United Kingdom in the 1980s, while seven countries established it in the 1990s and 6 other EU countries followed over the last 10 years (Belgium, Italy, Latvia, Luxembourg, Slovenia, and Finland). France is in process to create the primary specialty in 2013. Four EU countries implemented a 2 years supraspecialty (France, Denmark, Greece, and Sweden). In Belgium co-exists a 6 year primary specialty and a 2 year supraspecialty in EM. Two EU countries implemented a three year training programme in EM (Estonia and Netherlands). Finally,

in 6 EU countries, there is no primary specialty or supraspecialty or training programme (Austria, Cyprus, Germany, Lithuania, Portugal, and Spain). A non published survey managed by the MJC of UEMS estimates that more than 3,000 people are trainees in EM and shows that a national exit examination exists in 10 EU countries while in 5 EU countries, the primary specialty exists but without examination. These results demonstrate the heterogeneity of EM education organisation in Europe. The training required to work in EMHCS varies greatly across Europe. Fifteen EU countries require physicians (both out ofhospital and in-hospital) to be a specialist in at least one or more medical areas (e.g. intensive care, anaesthesiology, EM or emergen-

cy surgery, traumatology, cardiology, general internal medicine, and others). In 11 and 9 EU countries, a specialisation is not required in pre hospital EM setting or EDs respectively. In 11 and 12 EU countries, EM specialisation is required in pre hospital EM setting or EDs respectively. One of the most important findings of the WHO study is the lack of uniformity in training and accreditation of specialists in EM. The adoption by all EU countries of EM as a primary speciality following a common core curriculum is the most suitable way to fulfil the EU Doctor’s Directive and assure free exchange of EM physicians between EU countries. Table 5 shows the WHO short term recommendations to improve training in EM.

Bibliography

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World Health Assembly Resolution n. 60.22.

Boersma E, Mercado N, Poldermans D, Gardien M, Vos J, Simons ML. Acute myocardial infarction. Lancet 2003 ;361 :847-858.

International Federation for Emergency Medicine (http://www.ifem.cc/ index.html, accessed 16 September 2008. Council of the European Society for Emergency Medicine. Manifesto for emergency medicine in Europe. European Journal of Emergency Medicine, 1998, 5:1–2. European Society for Emergency Medicine EUSEM. Policy statements. (http://www.eusem.org/Pages/About_EuSEM/Policy_Statements/Policy, 2008. Paper of Holliman, Terry…. Emergency Medical Services Systems. Report of an assessment project co-ordinated by the World Health Organization, 2008. Directive 2002/22/EC of the European Parliament and of the Council of 7 March 2002 on universal service and users’ rights relating to electronic communication networks and services. Dated 24 April 2002. Official Journal of the European Union, 2002, L(108):51. Knowledge of the single European emergency call number 112. European Protection Agency.(http://ec.europa.eu/environment/civil/prote/112/112_ knowledge_en.htm, accessed 16 September 2008. Sasser S et al. Prehospital trauma care systems. Geneva, World Health Organization, 2005. Fischer M et al. Comparison of the emergency medical services systems of Birmingham and Bonn: Process efficacy and cost effectiveness. Anasthesiol Intensivmed Notfallmed Schmerzthe, 2003 Oct, 38(10):630-42. The Thrombolysis in Myocradial Infarction (TIMI) trial. Phase I findings. TIMI Study Group. N Engl J med 1985;31:932-936. The effects of tissue plasminogen activator, streptokinase, or both in coronary-artery patency, ventricular function, and survival after acute myocardial infarction. The GUSTO Angiographic Investigators. N Engl J Med 1993;329:1615-1622. O’Neil W, Timmis GC, Bourdillon PD, et al. A prospective randomized clinical trial of intracoronary streptokinase versus coronary angioplasty for acute myocardial infarction. N Engl J Med 1986;314:812-18. Zijlstra F, de Boer MJ, Hoomtje JC, et al. A comparison of immediate

Antman EM, Anbe DT, Amstrong PW et al. ACC/AHA guidelines for the management of patients with ST-elevation myocardial infarction-executive summary: a report of the American College of Cardiology/American Heart Association Task Force on practice Guidelines (Writing Committee to Revise the 1999 Guidelines for the management of patients with Acute Myocardial Infarction). Circulation 2004;110:588-636. Van de Werf F, Ardissino D, Betriu A, et al. Task Force on the management of Acute Myocardial Infarction of the European Society of Cardiology. Management of acute myocardial infarction in patients presenting with ST-segment-elevation. Eur Heart J 2003;24:28-66. Kalla K, Christ G, Karnik R, Malzer R, Norman G, Prachar H, Schreiber W, Unger G, Glogar HD, Kaff A, Laggner AN, Maurer G, Mlczoch J, Slany J, Weber HS, Huber K; Vienna STEMI Registry Group. Implementation of guidelines improves the standard of care: the Viennese registry on reperfusion strategies in ST-elevation myocardial infarction (Vienna STEMI registry). Circulation. 2006 ;113:2398-2405. Kennedy K et al. Triage: Techniques and applications in decision-making. Annals of Emergency Medicine, 1996; 28(2):136-144. Arnold J et al. A survey of emergency medicine in 36 countries. Journal of the Canadian Association of Emergency Physicians; 2001, 3:2. Halpern P, Waisman Y, Steiner IP. Development of the specialty of emergency medicine in Israel: Comparison with the UK and US models. Emergency Medicine Journal, 2004,21:533–536. Bodiwala GG. Emergency medicine: A global specialty. Emergency Medicine Australasia, 2007, 19(4):287-8. Rainer TH. Emergency medicine—the specialty. Hong Kong Medical Journal, 2000, 6(3):269-75. Council Directive 93/16/EEC of 5 April 1993 to facilitate the free movement of doctors and the mutual recognition of their diplomas, certificates and other evidence of formal qualifications. Dated 7 July 1993. Official Journal of the European Union, L(165). Directive 2005/36/EC of the European Parliament and the Council of 7 September 2005 on the recognition of professional qualifications. Dated 30 Sept 2005. Official Journal of the European Union L 255/22.

www.epijournal.com

The IEM Fellowship Directory global

The United States

IFEM Fellowship Regional Focus: Global Contact: Peter Cameron, MD 8peter.cameron@med.monash. edu.au

California

australia/ new zealand Australasian College of Emergency Medicine (ACEM) Regional Focus: Global, Australia, NZ & South Pacific Contact: Peter Cameron, MD 8peter.cameron@med.monash. edu.au and Gerard Oreilly 8oreillygerard@hotmail.com

canada University of Toronto / Canadian Association of Emergency Physicians (CAEP) Regional Focus: Global, Africa Contact: Valerie Krym 8v.krym@utoronto.ca

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

south africa South Africa: Univ. Cape Town / Stellenbosch Univ. / EM Society of South Africa (EMSSA) Regional Focus: Africa, South Africa Contact: Lee Wallis, MD 8leewallis@bvr.co.za

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

Fall 2011 // Emergency Physicians International

( (909) 824-4344 8 dwashke@llu.edu Stanford International Emergency Medicine Fellowship Contact: S.V. Mahadevan and Matthew Strehlow Stanford University 701 Welch Rd. Bldg C Palo Alto, CA 94304 Fax: 650 723-0121 Length: 1-2 years Positions: 1-2 Salary: Please contact Hours per week: approx. 15 Degree: MPH possible for 2 yr candidate Deadline: ACEP Scientific Assembly ( (650) 723-0063 8 jgalfin1@stanford.edu : emed.stanford.edu/ fellowships/international.html UCLA-CIM International Medicine Fellowship Contact: Nicole Durden, UCLA Medical Center Dept. of EM 924 Westwood Blvd., Ste 300 Los Angeles, CA 90024 Length: 1-2 years Salary: Competitive Shifts: 5 per month Degree: MPH, PhD Positions: 1 Deadline: October 15 ( (310) 794-3086 8ndurden@mednet.ucla.edu :http://cim.ucla.edu

Connecticut

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

Delaware

Christiana Care Health System Regional Focus: Africa Contact: Susan E. Thompson, DO Christiana Care Health Systems Dept. of EM Administration 4755 Ogletown-Stanton Road Newark, DE 19718 Length: 1 – 2 years Shifts: Between two and three 8or 9-hour shifts/week Degree: MPH with 2-year program Deadline: November 15 ( (302) 733-3904 8susthompson@christianacare. org

District of Columbia

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

florida

University of Florida College of Medicine - Jacksonville Contact: Elizabeth DeVos MD, MPH Department of EM 655 W 8th St Jacksonville, FL 32209 Deadline: Check with department ((904) 244-4405 8elizabeth.devos@jax.ufl.edu

Georgia

Emory University Contact: Scott Sasser, MD Department of EM 531 Asbury Circle - Annex Suite N - 340 Atlanta, GA 30322

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

Illinois

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

Maryland

Johns Hopkins University Contact: Alexander Vu, DO, MPH International Emergency Medicine Center for Public Health and Human Rights 5801 Smith Avenue, Suite 3220 Baltimore, MD 21212 Fax: (410) 502-8881 Length: 2 years Salary: Competitive Positions: 1-2 Degree: MPH Deadline: September 15 ((410) 735-6436 8avu3@jhmi.edu University of Maryland Regional Focus: China, Egypt, South Africa, Botswana, The Netherlands Contact: Veronica Pei, MD, MPH University of Maryland Department of Emergency Medicine 110 S. Paca Street, 6th Floor, Suite 200 Baltimore, MD 21201 Length: 2 years Salary: Competitive Positions: 1 Degree: MPH Deadline: Open ( Phone: (410)328-8025 8veronica.pei@gmail.com massachusetts Harvard University / Beth Israel Deaconess Medical Center Contact: Philip D. Anderson, MD Department of EM One Deaconess Road W/CC -2 Boston, MA 02215 Length: 2 years Salary: Competitive, benefits, CME benefits and MPH tuition Positions: One Degree: MPH Deadline: December 1 ( (617) 754-2324 8 pdanders@bidmc.harvard.edu Harvard University / Brigham and Women’s Hospital Regional Focus: Various Contact: Stephanie Rosborough, MD, Department of EM 75 Francis Street

Boston, MA 02115 Length: 2 years Positions: One Salary: Competitive with excellent benefits Shifts/Week: 1-2 Degree: MPH Deadline: November 20 ( (617) 732-5813 8 iem@partners.org : www.brighamandwomens. org/dihhp/iem

minnesota

Regions Hospital Contact: Matthew Morgan, MD Regions Hospital Department of EM 640 Jackson St. St. Paul, MN 55104 Length: 2 years Degree: MS in development policy or certificate in tropical medicine ( (651) 254-3336 8matthew.w.morgan@ healthpartners.com :www.regionsem.org/ fellowships/internationalmedicine

New York

Bellevue Hospital Center/ New York University School of Medicine Contact: Michael Mojica, MD Emergency Care Institute Room 345A, Bellevue Hospital Center 27th Street and First Avenue New York, NY 10016 Length: 1 - 2 years Salary: Competitive Positions: 1 ( (212) 562-8147 8mojicm01@nyumc.org Kings County Hospital/SUNY Downstate College of Medicine Contact: Christina Bloem, MD SUNY Downstate Medical Center Department of EM 450 Clarkson Avenue Brooklyn, NY 11203 ( (718) 245-4790 8christina.bloem@downstate. edu

New York - Presbyterian: The University Hospitals of Columbia and Cornell Regional Focus: Africa (Uganda, Tanzania, Kenya, Sudan, Ghana, Malawi, Sierra Leone); India, Sri Lanka, Montenegro, Dominican Republic, Burma; WHO in Geneva Contact: Rachel T. Moresky, MD, MPH Columbia University Medical Center - Center for EM 622 West 168th Street PH 1-137 New York, NY 10032 Length: 2 years Salary: Competitive Positions: 2 Degree: MPH Deadline: November 1 ( (212) 304 5745 8rtm2102@columbia.edu : www.nypemergency.org/ fellowships North Shore - Long Island Jewish Health System Contact: Sassan Naderi, MD Dept. of EM 270-05 76th Ave New Hyde Park, NY 11040 Length: 1 year Positions: 1 - 2 Salary: $90,000 Hours per week: 18 Deadline: Rolling ( (718) 470-7501 8 snaderi@nshs.edu St. Luke’s Roosevelt Hospital Center - Global Health Fellowship Focus: HIV/TB/Tropical Contact: John D. Cahill, MD Dept. of EM 1111 Amsterdam Avenue New York, NY 10025 Length: 2 years Positions: 2 Salary: $87,000 Hours per week: 20 Degree: MPH optional Deadline: Rolling ( (212) 523-3330 8applications@ slredglobalhealth.com : www.slredglobalhealth.com

www.epijournal.com

The IEM Fellowship Directory University of Rochester Medical Center Contact: David H. Adler, MD Dept. of EM 601 Elmwood Avenue, Box 655 Rochester, NY 14642 Length: 2 years Salary: $80,000 - $100,000/year depending on clinical time; CME, benefits, 5k/year travel Positions: 1 Degree: MPH, clinical investigation, or medical management Deadline: April 15 ( (585) 463-2945 8david_adler@ :www.urmc.rochester.edu/ emergency-medicine/education/ international.cfm North carolina Duke International EM Fellowship/Global Health Residency Program Focuses: East Africa, Casualty department epidemiology, trauma epidemiology research, validation of trauma scoring in resource limited settings Contact: Charles J. Gerardo, MD Duke University, DUMC 3096 Durham, NC, 27710 Length: 2 years Positions: 1 Salary: Competitive, including tuition for advanced degree Degree: MS in Global Health (MSc-GH) Deadline: September 24 ( 919-681-4458 8 gerar001@mc.duke.edu : www.dukeglobalhealth.org :globalhealth.duke.edu

Oregon Oregon Health & Science University - Global Health Fellowship Contact: Amy Marr, MD OHSU Dept. of EM 3181 SW Sam Jackson Park Road, CDW-EM Portland, OR, 97068 Length: 2 years Positions: 1-2 Salary: PGY level, CME allowance, benefits Shifts per week: 1 Degree: Master’s or certificate options (tuition support provided) Deadline: Rolling ( (503) 494-8220 8 marra@ohsu.edu : www.emergencyresidency. com Pennsylvania University of Pittsburgh Contact: Allan B. Wolfson, MD Dept. of EM 230 McKee Place, Ste. 500 Pittsburgh, PA 15213 Length: 2 years Salary: Negotiable Shifts per week: Negotiable Degree: MPH offered from the University of Pittsburgh Graduate School of Public Health ( (412) 647-8265 8wolfsonab@upmc.edu : affiliatedresidency. health.pitt.edu

Rhode Island Rhode Island Hospital Regional Focus: Liberia, Rwanda, Uganda, Kenya, and Haiti Contact: Lawrence Proano, MD University EM Foundation 593 Eddy Street, Providence, RI 02903

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

tennessee

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

texas Baylor College of Medicine / Texas Children’s Hospital Regional Focus: Various Contact: Charles G. Macias, MD, MPH Texas Children’s Hospital 6621 Fannin, MC 1-1481 Houston, TX, 77030 Length: 4 years (pediatrics trained); 3 years (EM trained) with Board eligibility in PEM at completion Salary: PGY level Positions: 1 Hours per week: 32-40 Conferences/week: 4 hours, except PICU rotation Degrees: MPH, MEd, MS, MBA

Deadline: August 31 through ERAS (apply for PEM Fellowship) ( (832) 824-5468 8pwomack@ :texaschildrenshospital.org University of Texas Southwestern (DallasParkland) Regional Focus: Mexico/Latin America. Others negotiable. Contact: Robert E. Suter, DO, MHA Div. Emergency Medicine UT Southwestern Medical Center at Dallas 5323 Harry Hines Boulevard CS2.122 Dallas, TX, 75390-8579 Length: 2 years Salary: Competitive Positions: 4 Hours: 56 clinical hours/month Degrees: MPH Deadline: December 1 ( (214) 648-3916 8robert.suter @utsouthwestern.edu

utah University of Utah Regional Focus: Ghana, Thailand, India, Peru Contact: Erik Barton, MD, MS, MBA University of Utah Health Care 30 North 1900 East, Rm 1C26 Salt Lake City, UT 84132 Length: 1 to 2 years Salary: competitive Positions: 1 or 2 Shifts: 7 per month/54 hours Degrees: MPH Deadline: Rolling ( (801) 581-2417 8erik.barton@hsc.utah.edu

Have your fellowship listed in the most comprehensive global EM directory Send program description to info@plasterpub.com 34

Fall 2011 // Emergency Physicians International

Grand Rounds

with peter cameron, MD

Real Medicine = Managed Risk EPs fill a critical gap in medical care by becoming experts at risk/benefit analysis

Following a successful meeting of the Asian Society of Emergency Medicine in Bangkok, where leaders from all over Asia and many other countries converged, I had a chance to reflect on what makes emergency physicians different.

My ruminations were partly due to my participation in a session on trauma. I enjoyed being part of a panel discussing the role of “pan – scanning” in trauma patients as a routine for patients with a significant mechanism but without obvious injury. As everyone knows, the main reason for ordering pan-scans in this situation is the possibility of missing occult injury. There are a number of papers to support this contention, although the significance of the occult injuries and the impact of delay in diagnosis (by not scanning initially) on final outcome is open to debate. The main objection to routine pan - scanning, is excess radiation exposure (which may cause ~1/1000 deaths from malignancy in younger patients). There are other arguments that may be important – such as “overloading” radiology and slowing patient flow. There is also a risk that detection of unrelated or unimportant abnormalities, may result in unnecessary treatment and further investigation. A further argument is that radiologists, given an overwhelming number of normal scans, may not read the scans as thoroughly and miss important injuries. Despite some attempts to generate controversy on the panel and despite the divergent backgrounds of the participants, the panel was quite congenial and had a high degree of consensus on when patients should be pan-scanned and when they shouldn’t. We agreed that some patients with obvious head injury, altered conscious state and significant mechanism, were at high risk of concurrent injury, had little chance of accurate clinical evaluation and should therefore be scanned from head to pelvis. A lower threshold for scanning should be used for older patients because they have a higher risk of traumatic bleeding and serious skeletal injury (even from trivial mechanism) and the risk from radiation exposure is less because they will be dead before a malignancy can develop. The converse is obviously true for children. Importantly, when a patient is young, alert and clinically evaluable with no physiologic impairment, the role of pan-scanning is small – as the risk of the procedure outweighs the benefit (finding something that you might treat). So there is a risk to scanning, which is small, but this becomes important when the risk of an important injury is very small (<1/1000). Clinicians must weigh that risk in every patient, based on the clinical scenario. In spite of this congenial, agreeable, panel experience in Bangkok, when I then went back home and talked to my colleagues in surgical and other specialties in my own hospital. I found a much different approach. Some notable quotes are listed below…… “Clinical assessment has little utility in multi-trauma patients”. “You may as well scan them as it is too easy to miss injuries” “If they have that mechanism, they are at such high risk, that clinical examination has little place”

“There is no room for error in the multi-trauma patient”. “In our trauma unit we cant afford to miss any injuries”. So what error rate would you expect in your unit? “zero” Why do I find it so easy to communicate with a group of very diverse emergency physicians and reach consensus quickly on how to approach a difficult clinical problem? As emergency physicians, our main role is to balance risk. We do this through processes such as triage – where we assess the likelihood of one patient deteriorating rapidly versus another, and prioritize the order of treatment. We do it through admission/discharge decisions, where we decide, after clinical evaluation, that the risk of an adverse event is very low (not zero) and the patient can be discharged home. We also do it with our diagnostic strategies where we decide to proceed with high cost and potentially risky procedures in patients at high risk of a disease and we chose not to do these procedures in other patients. This is always done on the balance of risk. Rarely do we believe that there is “zero” risk in any of our treatment decisions. In virtually every clinical decision we make, it is a matter of choosing the “least risky” option. In the potentially chaotic and unstructured world of emergency medicine, to follow a pathway that absolutely excluded a diagnosis or meant that there was no risk of sending home a patient with a serious disease could cause potential harm to the patient (eg prolonged immobilization (in the case of potential cervical spine injury), radiation exposure (in the case of unnecessary ordering of radiology) and of equal importance, would paralyse the flow of patients through the ED and the hospital. In many ways, emergency medicine involves a thought process similar to disaster medicine. Where we are always thinking of the “greatest good for the greatest number” of patients. This is in stark contrast to some of our subspecialist colleagues who have the luxury of managing a small group of patients that are already selected to be at high risk (by virtue of referral). They can indulge in a microscopic focus on an individual without necessarily directly impinging on the treatment of other patients being managed in the system. Our role in minimizing risk at an individual patient level and at a system level, is a unique and important component of modern emergency care. We must educate our colleagues that there is no such thing as “zero risk” and “no errors”. This is a fallacy that has spilt over from manufacturing and other controlled processes, where it is possible to have near complete control over the environment and the individual. In real medicine, this does not happen, there is however a path that delivers the “least” risk to the individual patient and to other patients in the system. Future research should focus on clinical outcomes that include risk as well as benefit. It is not sufficient to identify diagnostic accuracy or procedural effectiveness without examining the adverse impact of introducing the intervention on both short and long term outcomes of the individual patient. It is also necessary to look at systemic effects of new management algorithms on the ED and hospital. It is likely that emergency medicine physicians will lead this development. Dr. Cameron is the President of the International Federation for Emergency Medicine. www.ifem.cc

www.epijournal.com

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