EPI Issue 17

Feeding the masses during a disaster The 8 steps to lasting EM development Inside mainland China’s first accredited ED Hi-tech ED design for low resource settings EMERGENCY PHYSICIANS INTERNATIONAL

ISSUE 17

. FALL 2015 . WWW.EPIJOURNAL.COM

ON THE FRONT LINES OF EUROPE’S REFUGEE CRISIS Emergency physicians are often the first healthcare workers to face the financial and societal impact of mass immigration. page 14

Curbing Violence Peter Cameron on EM’s path to safe working conditions page 34

AN 46 2.0 01/2015/A-E

Please visit our booth at the EuSEM conference

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C-MACÂŽ System: A single instrument is not a plan B

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EDITOR’S DESK

Let’s Meet Soon

R

ecently, while attending the 12th New York City Symposium on International Emergency Medicine, I was reminded of just how many new and exciting ways there are for physicians around the world to get involved in EM development and global health.

First there is the International Emergency Medicine Fellowship Consortium, which comprises most of the International EM (IEM) Fellowship Programs, and serves to coordinate their activities. The organization is starting a new initiative to write a white paper on the recommended structural requirements and curricula components for IEM Fellowship programs. If you are interested in contributing to this effort, email iemfellowshipconsortium@gmail.com).

If you’re interested in research or faculty development, consider joining the Global Emergency Medicine Academy (GEMA) of the Society for Academic Emergency Medicine. The Academy has a number of active projects, and will hold its next formal meeting and awards ceremony at the ACEP 2015 conference in Boston, in October.

Of course, a well established way to get connected is the ACEP International Section. On October 25, just prior to the start of the ACEP 2015 conference, this section will host a one-day conference on its Ambassador Program, in which ACEP members serve as resources for particular countries. In addition to handing out a number of recognition awards, the section will be holding multiple educational and business meetings during the ACEP 2015 conference, which are open to all. The section also has a scholarship program that provides financial sponsorship for physicians from other countries to attend the ACEP conference.

Finally, I’d be remiss to not urge you to join the International Federation for Emergency Medicine (IFEM). IFEM has over 20 committees, task forces, and interest groups, all actively engaged in projects. As President of IFEM, I encourage you to get involved. Check out our website – www.ifem.cc – and discover which aspects of IFEM attract your interest, and then contact us. And don’t forget to register for IFEM’s biggest meeting, the International Conference on Emergency Medicine (ICEM) in Cape Town, South Africa in April 2016. Hope to see you there!

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

editorial director C. JAMES HOLLIMAN, MD executive editors PETER CAMERON, MD TERRY MULLIGAN, DO, MPH LEE WALLIS, MD PROF. V. ANANTHARAMAN managing editor LONNIE STOLTZFOOS regional corespondents CONRAD BUCKLE, MD MARCIO RODRIGUES, MD CARLOS RISSA, MD KATRIN HRUSKA, MD SUBROTO DAS, MD MOHAMED AL-ASFOOR, MD JIRAPORN SRI-ON, MD editorial advisors ARIF ALPER CEVIK, MD ANITA BHAVNANI, MD KATE DOUGLASS, MD HAYWOOD HALL, MD CHAK-WAH KAM, MD GREG LARKIN, MD PROF. DONGPILL LEE SAM-BEOM LEE, MD ALBERTO MACHADO, MD JORGE OTERO, MD advertising RHONDA TRUITT

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

Logan@EPIJournal.com twitter.com/epijournal Cameron: Opportunities, threats for Indian EM How to design new EDs for infection control The telemedicine revolution has arrived Wilderness medicine tips for everyday care EMERGENCY PHYSICIANS INTERNATIONAL

ISSUE 15

. WINTER 2014 . WWW.EPIJOURNAL.COM

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

This map uses mobile phone data to visualize personal connectedness.

Color coding has been based on strength of social ties. page 24

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

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

ABOUT EPI With a quarterly print and digital distribution and an online network of more than 2,000 members, EPI is the essential hub connecting global emergency care, sparking dialogue and creating a space for new collaborations. Find copies of the print magazine at international EM conferences around the world, or read it online at www.epijournal.com

Emergency Physicians International is a product of Portmanteau Media LLC ©2014

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IN THIS ISSUE

EVENT CALENDAR 10/15–1/16 THE COMPREHENSIVE GUIDE TO GLOBAL EM CONFERENCES

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

Global Emergency Medicine Meeting 2015 // Shenzhen, Guangdong, China

OCTOBER 2015 11th WINFOCUS World Congress on Ultrasound in Emergency and Critical Care Conference // Boston, Massachusetts October 22-25, 2015 www.winfocus2015.com

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

NOVEMBER International ED Leadership Institute // Barcelona, Spain November 2-8, 2015 www.iedli.org

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

Creating Leadership Resilience in Emergency Care // Leeds, UK November 10-11, 2015 www.fmlm.ac.uk/events/list

16th Annual Fall Conference on Emergency Medicine 2015 // Grand Canyon, Cayman Islands November 11-14, 2015 www.symposiamedicus.org/Assets/ Conference/1357/1357.html

Society of Emergency Medicine of India 17th Annual National Conference on Emergency Medicine // Hyperabad, India November 21-24, 2015 www.emcon2015hyderabad.com

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Issue 17 // Emergency Physicians International

November 24-26, 2015 www.gemhkuszh.com/w/en/index.jsp

International Congress on Disaster and Emergency Medicine // Istanbul, Turkey November 26-29, 2015 www.idem2015.org

DECEMBER German Interdisciplinary Meeting on Intensive Care and Emergency Medicine 2015 // Leipzig, Germany December 2-4, 2015 www.divi2015.de/startseite

www.epijournal.com

03 | Editor’s Desk

Field Reports 8 | The Netherlands 9 | Romania 10 | Uganda

Departments 12 | Disaster Prep Organizing a mass feeding distribution team by borrowing concepts from the hospital operation room.

14 | News and Perspectives From the front lines in EM: what will the refugee crisis mean for Europe?

16 | Profile

International Seminar in Emergency Response // Tel Aviv, Israel

Undertaking global EM development work means staying true to your roots and building from the ground up.

December 6-11, 2015 Contact: vickia@mda.org.il

18 | Guidelines

Emirates Society of Emergency Medicine Conference 2015 // Abu Dhabi, United Arab Emirates December 6-10, 2015 www.esemconference.ae

JANUARY 2016 National Association of Emergency

Medical Services Physicians Annual Conference // San Diego, CA, United States January 14-16, 2015 www.naemsp.org/Pages/Annual-Meeting. aspx

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

Presenting a global standard for working EP working conditions.

Reports 19 | DIY Development There are 8 vital components of any country’s EM system. Here’s how to start building one in your country.

24 | Asia Advances A chronological overview of the training and development process behind mainland China’s first internationally accredited ED.

29 | Design Advancing ED performance even with fewer resources.

34 | Grand Rounds Peter Cameron: What are the most effective, practicable ways to deal with violence in the ED?

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FIELD REPORT OCTOBER 2015

After hosting a record-breaking conference for the European Society of Emergency Medicine (EuSEM), the Dutch EM Society put in a bid for ICEM 2021.

Dutch Docs by the numbers

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12,195 General Practitioners

THE NETHERLANDS With 450 trained EPs now working in 85% of Dutch EDs, the EM specialty continues to gain traction in Dutch hospitals and among medical students. by menno i. gaakeer, md;

crispijn l. van den brand, md

T

he Netherlands is a small country in the northwest of Europe with 400 inhabitants per square kilometer, making it among the most densely populated countries in the world.

Primary care is highly developed and accessible to everyone through local general practitioner (GP) offices during daytime and GP-cooperatives during the evenings, nights, and weekends. GPs are considered as gatekeepers for hospital care, including emergency care provided in 89 available 24/7 emergency departments (EDs).

Modern emergency medicine (EM) has been developing since 1999 in the Netherlands, but it

wasn’t until 2009 that EM was recognized as an independent medical expertise with a three-year training program. Today, 450 trained emergency physicians (EPs) work in 85% of Dutch EDs. In 20% of Dutch EDs, 24/7 EP-staffing is already being guaranteed and this number is increasing rapidly. The Netherlands Society of Emergency Physicians (NSEP) holds the position that every ED should be staffed by EPs 24/7. One-hundred eighty residents are being trained in one of the 28 training programs.

Over the last few years EM has become one of the most popular medical disciplines for specialization amongst medical students and recently graduated doctors. With their presence, EPs bring continuity in the availability of acute medical expertise in the ED. They also introduce skills to the ED that are obvious in international EM but new in the Netherlands, like procedural sedation and analgesia, emergency ultrasound, and loco-regional anesthesia. The rise of EM in general, and EPs in particular, has

≥20K Specialists

450 Trained Emergency Physicians

750 Target number of total EPs in the future

Healthcare Costs

~

1100 Average annual health care insurance premium (2014)

360 Annual health care deductible for each insured Dutch adult ≥18 years of age (2014)

also aroused renewed interest in the ED and emergency care among established medical specialties. These developments are all either directly or indirectly of benefit to patients with an urgent medical problem.

The NSEP proudly hosted the annual European Emergency Medicine Conference (EuSEM) in 2014.

Bringing together approximately 2,500 participants from 80 countries all over the world, the conference was the most successful EuSEM conference to date. To further underline the Dutch permanent ambition with regard to EM, a bid for ICEM 2021 has been submitted.

Various challenges remain, however. Established medical specialties and governmental agencies must be convinced of the added value of EM as a medical specialty with at least a five-year training program.

Both the specialization and the fiveyear training program are required according to the NSEP and the European Union of Medical Specialists (UEMS). In 17 out of 27 other European Union countries, EM is already a specialization with a five-year training program. Besides extending the training program to five years, the NSEP strives for regionalization of the 28 hospitalbased teaching programs, aiming instead to consolidate into eight regional teaching programs. The scientific basis for the discipline needs to be strengthened as part of further emancipation and in order to improve quality of emergency care for patients continuously. The affordability of healthcare in general is a subject of debate in the Netherlands, therefore access to EDs is increasingly under pressure for patients seeking urgent care. Despite these challenges, emergency medicine in the Netherlands is without any doubt there to stay!

f The Untold 2015 Music Festival was organized in Cluj-Napoca, and drew 240,000 participants over four days. The Advanced Medical Point run by SMURD Cluj treated 800 patients at the concert venue, with 43 more participants seeking help at the local ED.

ROMANIA Twenty-one years after its first ED was delivered from Scotland, in 18 trucks, Romania’s emergency health care system enjoys strong public trust and confidence. by eugenia muresan, md;

gabriela gagu, md; sorin lacan, md

& adela golea, md

W

ith 22 years of experience in the field of emergency medicine (EM), Romania aims to meet the European standards in EM, and is therefore investing not only in technology development but also in professional skills development.

Credited with a high level of confidence by the general population, the Romanian EM systems have a rather brief history, especially “SMURD” (The Emergency Mobile Service for Resuscitation and Extrication). Romania, a southeastern European country with a population of 19.96 million, has been undergoing a continuous transition from communism to capitalism since 1989. The EM 8

specialty was officially recognized in 1993, and Romania currently has around 400 EM specialists and 250 EM residents, and the 5-year-long training program follows the European curricula. A peculiarity of the Romanian system is the integrated prehospital-hospital structure (ERSMURD) and its population-based development. SMURD is a complementary system of the county ambulance services (SAJ), including EM and anesthesiology physicians, nurses, paramedics, firefighters, and medical student volunteers.

The effectiveness of the prehospital service is due in part to the existence of a designated emergency number (112) and to the integrated dispatch system (ambulance, firefighters, police), thus achieving shorter response times.

The first mobile intensive care team (TIM) of SMURD was founded in Târgu Mureş in 1990, beginning the transformation of the prehospital system from “scoop-and-run” to “stay-andtreat.” SMURD currently coexists with the SAJ, which includes transport ambulances and nurse/ physician consult crews, along with SMURD’s firefighter paramedics (since 2000), TIM, helicopters and

Issue 17 // Emergency Physicians International

SMURD: THEN & NOW 1994 The first Romanian ER was delivered to Târgu Mureş in 18 trucks from Scotland 88% In a national survey, 88% credited SMURD with “high” and “very high” levels of confidence 3.68 seconds The time in which an emergency “112” call is answered

medical aircrafts. The vision and the translation belong to Mr. Raed Arafat, MD, a Palestinian anesthesiologist who graduated in Romania and is currently Internal Affairs State Secretary and Head of The Emergency Situations Department.

According to Mr. Arafat, “the EM services need to remain state-guaranteed systems. It is a sign of civilization,” this being a governmental obligation and a social right.

The first emergency department (ED) was built in Târgu Mureş, in 1994, as an auxiliary building of the Mureş County Hospital, which is a training center today and has recently hosted EuSEM’s Refresher Course 5. In 2006–2007, the legal framework for operating the EM system was created, along with a complete modernization of 63 county EDs. Today, the 9 regional centers operate with EM physicians only and have 24-hour access to ultrasound, x-ray, and CAT scans. In order to provide better services in the lower-ranking EDs, a telemedicine system has been implemented, allowing real time transmission of medical data and videos. A similar system operates in the prehospital setting, offering support to paramedics and nurses.

FIELD REPORT OCTOBER 2015

Several shortcomings of the present situation include the small number of polytrauma centers (except in Bucharest, the capital) and the fact that two large regional centers, Cluj-Napoca and Iaşi, still function as pavilion hospitals, where most of the departments have their own distinct buildings.

The development of the EM system included not only setting the legal framework and providing modern equipment but also developing EM professionals through numerous educational opportunities: Soros scholarships, REMSY III and IV courses, and national conferences. In 2013, the European financed project “Professionals in the Integrated Intervention for Mass Casualty Accidents and Disasters” trained more than 1,200 EM physicians, nurses, paramedics and firefighters during a program of e-learning and computer simulations. Furthermore, within the universities of medicine and pharmacy there are EM departments that provide scientific development for medical students, along with research and educational programs.

A significant contribution to this continuing process comes on behalf of The SMURD Foundation, an NGO functioning since 2006. The foundation organizes fundraising activities for the modernization of the Romanian EM system, along with training programs and humanitarian activities, as SMURD’s image has a tremendous positive endorsement among the general population.

Mulago National Referral Hospital, in Kampala, was founded in 1913 and serves as the teaching hospital for the Makerere University College of Health Sciences.

UGANDA Ugandans may struggle against a lack of standardized acute care and serious time delays in receiving such care, but at least in Dr. Joseph Kalanzi they have a tireless EM advocate. by crystal bae

I

magine arranging to meet your friend in Kampala, Uganda for dinner one night, and then seeing his body at the dissection table at the medical school the following week. For Dr. Joseph Kalanzi, hearing news of a loved one in a motorcycle accident was and is still commonplace in his hometown of Kampala. This particular fatal incident, however, provoked him to dedicate his life to improving acute care in Uganda.

Currently, acute care in Uganda is not universal and not standardized. Ambulances, which are only accessible to those living in cities and with private insurance, are only for transport—no care is provided en route. “Good Samaritans” who drive injured patients to the hospital themselves are almost non-existent since the police will question them on why one would perform such an altruistic act. Upon arrival at the hospital, the patient could be triaged or sent to the back of a queue, depending on which hospital the patient is taken to—not based on the condition of the patient. Doctors are only exposed to emergency medicine through a short training course during their anaesthesia block in medical school. Most nurses do not understand the concept of triage, and few are trained in basic first aid. Dr. Kalanzi recalls a good friend who lost her three-year-old www.epijournal.com

9

p Dr. Joseph Kalanzi, among other positions, is the membership committee chair for the African Federation for Emergency Medicine (AFEM) and the president of Emergency Medicine Uganda (EMU).

daughter from choking on a candy; ambulances is an imperative. So his friend is a nurse who did not many lives are lost due to the time have basic life support training to delay from the accident to receivsave her own daughter. It is, thereing definitive care. And if patients fore, not surprising that the average do make it to the hospital, there are life expectancy of a Ugandan is 53 problems with infrastructure, reyears and 56 years for a man and sources, and a lack of trained health woman, respectively (2015 est.). care workers.

Dr. Kalanzi vividly remembers The biggest challenge he faces losing three of his closest now is the bureaucracy in colleagues during medthe creation of training Follow ical school from easily programs in the exKalanzi’s journey treatable conditions, isting structure. For on the Ugandan EM and he discovered example, the globofficial blog. that improving al agenda has forced www.emergency acute care systems Uganda to put in medicine uganda.com was the best way to place a system for put a halt to these unHIV, tuberculosis, and necessary deaths. He is maternal & child health. currently part of a technical These are separate entities, working group at the Ministry of however, and do not cover the hoHealth in the development of the listic and systematic improvements Ugandan National Ambulance Serneeded for a coordinated, nationvice (UNAS), and he is also part of al emergency medical system. As the Emergency Medicine Developa result, there are problems at the ment Committee at Makerere Unicommunity, district, and nationversity. al levels, wherein certain diseases Dr. Kalanzi believes that a deare “prioritized” with funding, and veloped and functioning acute care millions of lives pay the price. system with trained professionals Dr. Kalanzi recognizes the need and well-equipped hospitals and to advocate for his specialty at the 10

Issue 17 // Emergency Physicians International

p A mother and newborn baby in a clinic in Mukono, Uganda. 93.3% of expectant mothers have at least one antenatal care visit, and 57.4% give birth with the assistance of a skilled attendant (2008–2012) Photo by World Bank

national level in order to push for the development of acute care systems. There is a need for acute care services, but general awareness is nearly non-existent. Simultaneous coordination is also needed at the local level: within the community, within all allied health professionals (nurses, paramedics, and doctors), and communication across all of those levels. Only then can there be a shift in paradigm toward efficiency and time-sensitive delivery of care.

In addition to his roles in the Ministry of Health and Makerere University, Dr. Kalanzi is also the membership committee chair for the African Federation for Emergency Medicine (AFEM) and the president of Emergency Medicine Uganda (EMU). Guided by his belief that access to acute care services is a basic human right, no matter where or who you are, Dr. Kalanzi works tirelessly to bring Uganda to an international standard of care and to hold the right people accountable for it, regardless of Uganda’s resource limitations.

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11

R

Disaster Prep

Southern Baptist Disaster Relief Response with their organized feeding station after Hurricane Ike.

Safe, Efficient Mass Feeding Strategies Healthcare professionals can help organize a food distribution team as one would the activities in an operating room, dividing team members into Operators, Circulators, and Monitors. by kenneth v. iserson, md

D

uring mass feeding situations following disasters, food safety poses a potentially catastrophic health issue. Yet, despite the work of international organizations to educate their workers, many food preparers and servers have little or no training in food safety.

While safety parameters to minimize food contamination are well established, they may be difficult to transmit to novice personnel during disaster situations. The problem becomes magnified as the number of food preparation/serving teams and personnel involved increase.

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When healthcare professionals are included in the process (as they should be), they can help organize the food distribution system as one would the activities in an operating room (OR; theatre). The clearly defined roles and the need for standard precautions in the OR can be easily adapted to a post-disaster scenario.

The following simple, easily understood organizational structure can improve the food service team’s understanding of and compliance with basic food safety principles.

As in hospital operating rooms, the food delivery team can be divided into Operators, Circulators, and Monitors.

Issue 17 // Emergency Physicians International

The Operators wear gloves and are instructed to touch nothing but the food itself. If they need to touch anything else, including the food packaging, they must change gloves immediately.

The Circulators, generally including the team’s leader, never touch unwrapped food. Rather, they provide the operators with the materials they need to prepare the food, supply wrapping for food, and then, as food distribution proceeds, they unwrap food trays, remove them when empty, replacing them with filled food containers.

Before food preparation begins, the team leader, a Circulator, plans how the team will distribute food to clients and ensures that food is maintained at proper temperatures.

Preplanning is vital, since how the food will be distributed affects how food is then prepared. For example, quartered oranges need to be distributed by an Operator, while whole oranges can be accessed by the client without assistance.

The best food distribution arrangement begins with a hand sanitizer/washing station for clients, followed by an area for assisted food PHOTO BY KENNETH ISERSON

In 2014, World Food Programme Logistics responded to 41 Special Operations worldwide to combat food scarcity, at a total cost of USD $1.2 billion. Five of these operations were Level 3 corporate emergencies (the most critical rating), including the crises in Central African Republic, Iraq, South Sudan, Syria, and the Ebola outbreak.

Ocular Irrigation: As Easy as 1-2-3

~

selection. In that area, plates are only handled by gloved food team Operators. Clients point to the food they want and Operators put it on their plate. If the client touches the plate, the process stops for them and they receive their plate with whatever is already on it.

At the end of the assisted food selection area, the client receives their plate. The client then selects from a variety of prepackaged condiments, sides (e.g., potato chips), desserts (e.g., whole fruit, packaged cookies), prepackaged utensils/napkin, and beverages.

The Monitor’s job is to ensure that the instructions for food preparation and distribution are being followed, and to help correct errors (preferably in a low-key manner).

Some groups that routinely provide disaster food services use similar methods with great success, albeit without this conceptual model. For example, in the aftermath of many hurricanes and other disasters, the Southern Baptist Disaster Relief Response implemented a safe and effective food distribution system with near military precision (see accompanying photograph). Other large organizations that operate disaster shelters and other mass feeding sites do not use such models and often struggle to implement these basic food safety principles. Adopting this organizational approach can simplify both the training and the implementation of mass food service delivery.

Dr. Iserson is the author of “The Global Healthcare Volunteers’ Handbook: What You Need to Know Before You Go”.

WFP Food Stats (2014)

1

3.2 million metric tons of food distributed 5,000 trucks

2

Patient enters, eyes inflamed.

Start flow, then insert the Morgan Lens.

20 ships 70 aircraft 650 warehouses around the globe under WFP management

~

Source: WFP: “WFP Logistics in 2014: Excellence in Service Provision”

3 • • • • • •

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13

News & Perspectives

Emergency Care Workers on Front Lines of Europe’s Refugee Crisis An emergency physician practicing in Vienna gives a first-hand look at Europe’s refugee crisis, and what it will mean for EU healthcare – and society – moving forward. by keith a. raymond, md

A

teenager pushes his grandfather across the desert in a wheelchair. A thin line of asylum seekers stretches ahead and behind him. A journalist asks the teenager where he is from, and his only response is, “It’s hot.

It’s hot.”

Asylum seekers are a leading news story in Europe. In Sicily, the streets are inundated with asylum seekers who loiter, are unemployable, and steal food from the locals, even in the shops. The police are overwhelmed, and the Mafia don’t help (in fact, they encourage asylum as the human smugglers represent a new income stream). As 14

Issue 17 // Emergency Physicians International

of this writing, several million people are heading toward Europe from the Middle East and Africa. They are escaping war, rape, murder, and genocide motivated by greed, fundamentalist fervor, tribal dispute, and criminal zeal. It is a mass casualty event of epic proportions, and its effects will be felt for generations.

The health and welfare of the asylum seekers are embedded in the politics and social erosion of their homelands. They don’t want to leave their home country, but they must in order to survive. As of now, only the generally healthy are arriving; the exodus is killing off the weak or unfortunate. Their route is through Libya from Africa, or through Hungary via Serbia, and Macedonia from Lebanon. One quarter of the population of Lebanon are transient asylum seekers.

Syrians, Kurds, and Afghanis are in the majority, but there are a great many more ethnicities and languages included in the mix.

When they finally come to rest, asylum seekers are not welcomed with open arms. Not only the Neo-Nazis but the average European fears that they will erode their way of life. And not without reason; certain changes will be inevitable. Asylum seekers are driving up taxes that are already extreme for the average worker. Governments are slow to respond, budgets are tight, and NGOs spend more time watching than assisting. Volunteers are few and easily thwarted by rigid restrictions. Physicians who are asylum seekers themselves are not allowed to practice in the refugee camps where they live owing to Medical Boards’ refusal to license them.

As a board certified physician from the United States, I have worked in Afghanistan, in the Middle East, and Africa, from where many of these folks are traveling. Wanting to assist them here in Austria where I currently practice, I decided to approach Doctors Without Borders. Their plan was to send me to South Sudan.

Instead, I signed on with the Rotes Kreuz (The Red Cross), and

began working with asylum seekers a mere ten-minute ride from my home. Here is what I witnessed.

The language barrier is stark. I speak broken Arabic – as it is common not only to the Arabic natives but to those who speak Farsi, Persian, and Kurdish, as it is the language in which the Quran is read. When my Arabic fails, I speak English, or into smartphones with translation applications. The depth of the conversations is limited both by language and cultural embarrassment.

When the language divide is breached, the healthcare picture is often bleak and complex. Recently, I saw a married 19-year-old Persian woman. She had been incontinent of urine since childhood. Her words: “I grew up in bad condition.” Exam revealed sphincter incompetence, likely from early and frequent sexual abuse. The tall, thin, proud, and beautiful woman changed her clothes six times a day due to soiling.

Afterwards, we sat down and she broke down crying, frustrated. We spoke with the Chapter administrator about a urology referral; both practitioners were men, and only accepted private payment. My wife, a nurse, brought her several boxes of female hygiene pads the next day. Her gratitude shone brightly on her face, and she hugged my wife for a long time.

Right now, before major health issues can be addressed, there is the more immediate quagmire of where these families will land. The doors to peaceful Arab states like Saudi Arabia, the Emirates, Bahrain and Qatar has been shut – and even if it opened, refugees would likely find similarly impoverished living conditions from whence they fled. The United States has agreed to accept a mere ten thousand asylum seekers, cherry picked. As of this printing, the EU had agreed to distribute 120,000 migrants across Europe, which, for all its controversy, represented a mere 20 days worth of immigrants.

The long-term economic and social outlook of the migrant crisis in Europe is still unclear. The UK’s Home Office reported in July that the daily cost to UK taxpayers for looking after asylum seekers amounted to nearly £786 million from 2010– 2015, with a 46% overall increase occurring during the same period of time. Germany, which has Europe’s largest economy, and has been the favored destination for many of the current migrants, is expected to spend nearly €10 billion on asylum seekers in 2015 alone. In EU countries with far less wealth, however, such as Italy, Hungary, and Greece, there is great concern that absorbing migrants will immediately destabilize public budgets and services already under great strain and, in the long-term, fundamentally alter their way of life.

Right now, there are more questions than answers, and few places is that more clear than on the front lines of emergency medicine, where societal sores are so often laid bare. Check back next issue – and online at epijournal.com – for personal stories of the refugee experience, and how the decisions being made will affect not only the EU but the world as a whole.

Profile EPI: You have a long and substantial history of EM and public health work in Pakistan. What is some of the work in Pakistan that you’ve been involved in that you’re proudest of?

From Karachi to Johns Hopkins, Dr. Junaid Razzak is Leaving His Mark Karachi, Pakistan, is among the world’s largest, densest cities, with a population exceeding 23 million people. It is where Dr. Junaid Razzak, a native of the city, has helped shepherd EM development for the past decade, and along the way becoming very well attuned to the challenges of this work that are inherent in such highly complex settings.

After completing his medical training, and following several subsequent clinical and academic posts in the United States, Dr. Razzak returned to Pakistan’s Aga Khan University in 2004 as an assistant professor of Emergency Medicine. He is a member of the Global Emergency Medicine Acadamy (GEMA), which has over 150 members worldwide.

The core purpose of GEMA is to improve the global delivery of emergency care by leading the advancement of academic emergency medicine.

With this purpose in mind we have created a series of articles where leaders in academic emergency medicine and global health share their experiences.

We asked Dr. Razzak to be the first to share some of his stories in EM development with EPI. interview by lonnie stoltzfoos

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Issue 17 // Emergency Physicians International

Razzak: There are a couple of areas, both very critical for healthcare systems. The most important area is developing the capacity of individuals and the institutions. The challenge in many settings is not the lack of money—it is the lack of a critical mass of well trained people. We have put a lot of effort into building that capacity at various levels. For example, we now have a nationally accredited five-year EM residency training program in Pakistan. It took a long time, and we had the program approved just during the past three years. The second area of capacity building was the prehospital phase, where we were able to set up a paramedic training academy. The academy, called the Aman Urban Health Institute, has now trained several hundred paramedics in the country and done a fairly good job at providing EMS services in the city of Karachi. Third, we’ve had a big focus on developing researchers—those who can think about issues and work to find local solutions. Over the last ten years, we have sent ~10 researchers from Pakistan to Johns Hopkins School of Public Health for training.

Later on, we started a local research training program that includes mentorship from faculty members at Johns Hopkins. There are several young men and women who are completing their formal research training in this program. These are the broader areas I’m very proud of.

The second area of our focus was to try and develop a health system that is relevant to the local needs and resources and not necessarily a replica of a system that works well in a differently resourced setting. When we set up an advanced life support ambulance in Karachi, over half of the patients using the service were critically ill or injured, many of whom ended up at the wrong hospital and required inter-hospital transportation. We had to recruit and train physicians to effectively care for these patients in the ambulance. We also had to work on developing capacity of peripheral hospitals—a reversal of roles whereby EMS was leading a hospital-based practice. As a city of 23 million people, Karachi is a very complex setting; people hear about the violence and the terrorism there all the time. During the five years that it took to establish this EMS system, we were actually providing care to almost 150,000 people a year.

I was also involved in setting up a telehealth service. We had a simple, direct goal with our telehealth initiative: 24/7 availability of physicians, nurses, and mental health professionals. Anybody from anywhere can call in, register themselves, then have an opportunity to ask for medical advice, for help with an appropriate referral, or to receive counselling from a mental health worker/ psychologist. Callers trying to find the best community medical resources were given options closest to their place of residence, the cost of service, contact number, and an estimate of the out-ofpocket expense. Our intent was to make healthcare access easier for the population.

EPI: You recently moved to the US for a position at Johns Hopkins. What are you working on?

EPI: What is the trick to making your work sustainable and giving it longevity?

Razzak: I’m working in the Department of Emergency Medicine, Razzak: Again, if you develop people, they make the system suswhere I have a couple areas of focus in addition to working in the tainable. By that I mean you have to engage in long-term developemergency department at the Johns Hopkins Hospital. My main ment of leaders in the regions you’re working in. Outsiders will academic focus is developing the application of telemedicine in need to leave at some point and local leadership will have to carry emergency medicine. Telemedicine is a global approach to makon their work. And if they are leaders and not followers, then they ing emergency care accessible through the use of information and will find the ways to strengthen and evolve the program. So on the communication technology for those who do not have access to it, programmatic side that’s how I look at it. in the US as well as abroad.

Of course, programs and continuous work within communities There are two broad approaches we are taking to telemedicine. require funding. On that note, I believe that in my work—in any As we all know, there are overcrowding issues in the EDs all over business, really—you have to add value and reexamine your busithe world. In the common triage model, patients are first ness value proposition now and then. In academic EM, triaged by a nurse, then they wait to be seen by a we have to constantly reevaluate: how are we changIn doctor or a physician assistant, who will then oring the business model to respond to the needs of academic der a few labs and tests, and when labs come a society, and to find donors or users to support EM, we have to back decisions are made. What we’re trying to it? That’s always the struggle. constantly reevaluate: do is to flip that process a bit. How about how are we changing the if a physician sees a patient early on at the EPI: If you could ask for one business model to respond time of triage and orders what needs to be thing that would make your to the needs of a society, ordered, and the patients can then be seen by development work easier, what and to find donors or users care providers inside the ED, who will then would it be? to support it? That’s alhave all the information they need to make ways the struggle. their treatment decisions. A lot of places are Razzak: I guess I would say a research base that doing that. Telemedicine plays into this process, is not linked to a single project or idea. Many because much of the decision process of what the businesses, for example, will invest in developing a patient needs relies on the patient’s complaint and the new product. They will put in high-risk money knowing caregiver’s discussion with the patient, and does not always require that the venture may not work out. They would still invest in the a physical examination of the patient. idea and hope that it would mature into something that would However, sometimes it is simply not possible to have physiproduce “profit” eventually. The problem with a lot of academic cians with the appropriate training to make informed decisions work, especially in EM, is that its funding is very project-based. It available on the front line. So we thought, “How can we make allows for small increments forward in producing data and other telemedicine apply to this scenario?” In this instance, that meant results, but it very often does not allow for the freedom to do having physicians screen patients remotely, from a variety of locasomething very innovative. Innovation comes through the traditions. Similar systems can be implemented not just for screening tional model of center grants or endowments that people or large but for supporting the local patients in other parts of the world organizations give because they want the larger ideas to develop who want to have a discussion with a caregiver or seek a second and not just to fund a short-term project. opinion. In that case, again, the telehealth consultant hears the When looking at the global EM community, I feel a lot of peostory, talks to the provider, and helps make the decision. ple want to do a lot of interesting work; they seem to be excited about getting engaged in various activities, but I think there is a EPI: How much work and work-related travel do lot more strategic thinking to be done around—again—developyou self fund? ing the leadership in the country they are interested in, and getting engaged with them long-term.

Razzak: None. My work is largely supported through grants. I Locally, GEMA allows for like-minded people to come together believe there are enough resources around, and if a project is well in a community to share ideas and innovations. To strengthen conducted, society will pay for the emergency care work. This is global emergency medicine, we need research, mentorship, educaperhaps one of the biggest misconceptions people early in their tion, and collaboration. These must occur simultaneously to creglobal health career have. Sustainable efforts cannot be pursued on ate a base not only for research but also for training and systems a part-time basis, as a volunteer, or while you’re on holiday. Well development. conducted projects that have a lasting effect will require resources, Within the next year my goal is to establish the first set of exinfrastructure, and—most importantly—time. changes between US institutions and other international EM establishments.

Guidelines

IFEM Presents a Global Standard for EM Working Conditions This position statement, titled, “Creating Sustainable Working Conditions for the Emergency Physician,” was published in June 2015. Its aim is to be the foundation of a set of materials that can be used by EPs to help provide better structure to their clinical careers.

M

odern society requires strong, resilient systems of care delivery for their populations who may need emergency healthcare at any time of day or night. The International Federation for Emergency Medicine (IFEM) has previously described the standards required for such systems. These should be available in order for an emergency physician (EP) to be able to practice safely and effectively in caring for the critically ill and injured or those with undifferentiated disease. There are, however, increasing pressures being placed upon developed and developing systems worldwide that compromise the delivery of such care at even a basic level as well as hampering delivery of the most cost effective standards in well-resourced systems. There is also a tremendous need to develop strategies to help

CONTRIBUTORS

Sally McCarthy Australasian College for Emergency Medicine

Tajek B Hassan (Chair, Sustainable Working Conditions Task Force); Royal College of Emergency Medicine (RCEM)

Jill McEwen Canadian Association of Emergency Physicians (CAEP)

Heike Geduld Emergency Medicine Society of South Africa/African Federation for Emergency Medicine (EMSSA/AFEM) Colin Graham Hong Kong College of Emergency Medicine (HKCEM) Dafydd Hammond-Jones Trainee, Royal College of Emergency Medicine

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guide the many parts of the world where even the most basic emergency healthcare delivery is a daily challenge.

The EP is therefore faced with unique challenges in a specialty which remains amongst the most stimulating, exciting and fulfilling in modern medicine. Increasing evidence shows that not enough attention has been paid to creating working environments that will create sustainability and longevity in a clinical career in emergency medicine. This leads to a lack of clinical expertise and increasing fragility for an emergency care system locally or even a country. Equally important are the significant healthcare concerns for the individual EP. In an increasing number of cases this leads to acute and/or chronic illness, ‘career burnout’, or even early retirement from the specialty. This results in a tremendous waste of

Edgardo Menendez Sociedad Argentina de Emergencias (SAE) Alastair Meyer Australasian College for Emergency Medicine Howard Ovens Canadian Association of Emergency Physicians

Nick Jouriles American College of Emergency Physicians (ACEP)

Hendry Sawe Emergency Medicine Association of Tanzania/African Federation for Emergency Medicine (EMA Tanzania/ AFEM)

Anne-Maree Kelly Australasian College for Emergency Medicine (ACEM)

Eillyne Seow Society for Emergency Medicine in Singapore (SEMS)

Alana Killen CEO, Australasian College for Emergency Medicine

Judith Tintinalli American College of Emergency Physicians

Issue 17 // Emergency Physicians International

valuable expert resource. These stressors are magnified in those countries where the specialty is still evolving and EPs require added support.

In 2013, the IFEM Executive recommended that a Taskforce be developed to review the best working practices of EPs worldwide and agree on a set of core principles that would provide guidance and support a sustainable, fulfilling career in emergency medicine. This position statement provides guidance in this key area and aims to be the foundation of a set of materials that can be used by EPs to help provide better structure to their clinical careers. Much more importantly, governments, commissioners of healthcare and employers need to understand the importance of caring for their EPs and others within the broader emergency healthcare workforce. The central aim should be to create resilience and sustainability of care delivery that aspires to excellent practice. Governments should recognize that their medical staff are their most valuable and expensive resource, and the premature loss of an EP through inadequate career support leaves further pressures on those that remain and leads to the risk of systems becoming unsustainable and collapsing which magnifies the inability to deliver safer care.

Objectives • To define a set of core principles and practices that should form the standard working conditions for all emergency physicians in developed

healthcare systems and what developing systems should aspire to over time.

• To develop basic frameworks for models of practice applying these principles in developed and developing systems using best practices from national organizations.

• To share good practices and make a set of recommendations that can be used by governments and national bodies to create greater EP workforce resilience and sustainability.

Principles and Practices 1. Safety and equality – The EP should work in an environment that facilitates the development of a safe, appropriately and adequately resourced system to meet the needs of the population. It should also be inclusive and care for all pa-

tients and fellow healthcare workers equally.

2. Training – The EP must have received training that is of an appropriate standard to perform his or her duties as described by their relevant specialist organization or credentialing body.

3. Professional development – The EP must have access to regular specific/allocated time and funding for ongoing professional development to maintain their skills and remain up to date.

4. Job planning – Clinical duties for all EPs must be structured and balanced to be able to deliver consistent high quality care and minimize the likelihood of ongoing fatigue.

A formal job plan should be agreed on and regularly reviewed by all

ED specialists. Fatigue is a major stressor in Emergency Medicine and must be minimized by careful balancing of clinical (in normal and unsociable working hours) and non-clinical work.

5. Shift patterns – Shift patterns for EPs must be well structured and must include formal time periods for safe patient handover. Poorly planned shift patterns pose a direct risk to the health of EPs with poor consequences for their patients and staff. Careful shift length sequencing should be employed and especially where night shift burdens apply, shift patterns must be carefully considered.

6. Unsociable hours – The EP will, by the nature of his or her specialty, more often work outside the normal 9am–5pm Monday to Friday stan-

Want to get involved in the creation of future global standards for the practice of emergency medicine?

Join the International Federation for Emergency Medicine (IFEM) at www.ifem.cc

Guidelines

dard working week. In addition, clinical care is invariably practised in an environment of high decision density per hour. This exposes the patient (and the staff in the ED) to greater risk. Well-designed shift patterns must appropriately recognize this vital aspect of emergency care delivery outside normal hours in order to be able to recuperate and recover adequately. It will often be appropriate to remunerate EPs at enhanced rates to encourage recruitment and retention of adequate staff to facilitate sustainable models of emergency care for unsociable hours. Good practice dictates that systems should create schedules that limit the working week to 40 clinical hours per week. Included within that envelope should be adequate time for managerial activity, teaching, clinical governance and research activities as appropriate. Exceeding these good practice guidelines are not sustainable in the long term.

7. Support in fragile systems – Fragile emergency care systems may be compromised by resources at the local and/or governmental level.

These systems will, due to location or other circumstance, require enhanced recruitment and retention strategies due to their fragility and dependency needs. A clear focus on development of a core service, creation of a networked solution to a larger more stable system and enhancements are some of the ways to finding ways to return a failing system to stability. EPs working in systems such as these or those less familiar to them will add risk to themselves and their patients if they are not well prepared. Recruitment and retention strategies must create balance for and mitigate these risks.

8. Appraisal & career planning – The EP must ensure that there is a system for annual appraisal of

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Developing and honing leadership skills are vital at every stage of a career in emergency medicine from the junior trainee through to those working at a national level in the specialty. The EP should actively pursue leadership roles and learn from his or her experiences but must also be actively resourced to optimize their skills and improve their local systems.

performance to support personal development and build a clinical career pathway. The EP should aim to develop career plans in 3–5 year intervals that will allow a steady building of a ‘decades of clinical life’ approach from the EP’s 30s ideally through to their early 60s.

9. Mentorship & support – The recently qualified specialist EP should seek a mentor whom they can trust to help support their development needs for the short and medium term. This will enhance job planning and career development plans.

10. Portfolio and flexible careers – Emergency medicine provides an ideal platform for a range of opportunities that can be built up within an EP’s career portfolio. This portfolio can be linked to flexible careers (due to family needs, disability or episodic illness) or to support varied interests.

11. Wellness & wellbeing – A healthy EP will be best placed to achieve career longevity. Physical or mental illnesses may impose restrictions.

Working in a poorly supported, stressful environment that creates ongoing fatigue will likely lead to career burnout unless robust measures are in place to prevent this. Creating tailored strategies to maintain wellness or wellbeing and embedding them into daily practice

Issue 17 // Emergency Physicians International

are critical to career sustainability.

12. Training the next generation – Vital to any system is the ability of an EP’s job plan to have time and resources set aside for training the next generation. In many ways this can act as a powerful lever to enhance and stimulate career satisfaction for trainers and trainees.

Dedicated time should be allocated for those EPs with specific education roles within their system to facilitate this. Valuing trainees / residents both with well-designed formal teaching programmes as well as maximising the ‘teachable moments’ in the clinical environment are essential ingredients. The added benefits of blending free online and subscription web based EM training materials with formal teaching are essential.

13. Leadership - Developing and honing leadership skills are vital at every stage of a career in emergency medicine from the junior trainee through to those working at a national level in the specialty. The EP should actively pursue leadership roles and learn from his or her experiences but must also be actively resourced to optimize their skills and improve their local systems.

14. Team building - Excellence in team working is at the very heart of continued on page 33

R report

// diy development

Need an Acute Care System? Start Building It. Building a country’s emergency medicine acute care system need no longer be a shot in the dark.

Over 65 countries around the world have developed a functional EM system, and consistent patterns and challenges of development have emerged, providing a clear pathway to any country now that wants to build an EM system. Here’s how to start.

by terry mulligan do, mph

T

he world is on the cusp of a breakthrough in emergency medicine (EM) development.

Until the 1960’s, no country in the world had EM as an official medical specialty or had developed a comprehensive acute care system. Over the next several decades, the rate of national EM specialty development and national acute care systems development progressed steadily. In 2015, there are approximately 65 countries worldwide with EM as an official medical specialty, with 3–5 countries per year adopting EM as a specialty and beginning to develop their own compre-

hensive EM systems.

There are many social, economic, political, and scientific reasons for this progression of EM and acute care systems development, but perhaps the most important reason is that the world of global emergency medicine is learning from its experiences.

Compared to our early experiences in the 1960’s and 1970’s, the world now knows much more about how to build comprehensive EM and acute care systems, on local, national, and regional scales. When emergency physicians, hospitals, universities, or health ministries are seeking solutions for problems with overcrowded emergency rooms, personnel and training shortages in critical care and trauma, and the escalating costs of hospital care (all the normal healthcare problems), they increasingly look to those countries and professional EM societies with established EM and acute care systems, and with histories of collaboration and cooperation. The emerging field of global emergency medicine development has responded to these inquiries and requests, and offers solutions to these common challenges and difficulties that are specific to culture, socioeconomics, and lo-

cal health care needs and abilities. Instead of offering a one-size-fits-all pathway to EM and acute care systems development, the field of global emergency medicine instead suggests the common endpoints of comprehensive EM and acute care systems, and shares successful pathways to reach these endpoints.

This approach works because of the relative homogeneity of acute care systems around the world. At first glance, the respective EM/acute care systems of three or four countries look very different and distinct. However, after being exposed to 30, 40, or 50 countries’ EM systems, they start to look more similar and alike, despite small differences in language, culture, socioeconomic status, or health care system. Patterns in EM system development begin to emerge, and it becomes apparent that other countries’ experiences and histories in national EM development can be used as templates or road-maps for other emerging EM systems. For example, when sifting through each country’s specific set of challenges and difficulties surrounding EM development, it becomes obvious that approximately 70%–80% of their difficulties are nearly www.epijournal.com

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R report

// diy development A country’s emergency medicine acute care system is a collection of subsystems within subsystems, resembling Russian nesting dolls.

have emerged. In general, the many hundreds of seemingly unrelated difficulties and challenges appear to fall into a relatively small number of major categories, each of which is connected to and embedded inside the other categories. Roughly speaking, it has been proposed that there are eight major systems that should be completed in order to build a comprehensive acute care system. They can be visualized as an interconnected set of systems and subsystems (similar to a collection of embedded Russian dolls), and are outlined here: i) D iscrete patient care systems—Hospitals, clinics, community clinics, etc.

identical across different countries and societies. Therefore, global EM development experiences have shown that—rather than “reinventing the wheel”—each country only needs to reinvent and discover the answers to about 20% of their own countryspecific EM development challenges, and they can look outside their borders for ideas and assistance for the majority of their challenges. Only a small minority of EM systems development problems are completely country-specific.

Building a comprehensive EM and acute care system requires far more than training emergency care providers; it requires a multifaceted, multi-professional, multidisciplinary collection of systems-within-systems: patient care systems, education and academic systems, administration and management systems, economic and finance systems, legislative and health policy agendas, and public health and national policy agendas. Each of these systems and subsystems have their own timeline, professionals, nomenclature, and financing and governance, yet each must be developed simultaneously (if possible) and interlinked as much as possible in order for a comprehensive EM and acute care system to emerge.

The ultimate goal of EM systems development is to provide the highest quality, safest, most efficacious and cost-effective emergency care to every person—yet each

country goes about this development curve slightly differently. Historically, the development project curve for acute care systems usually starts after a handful of interested care givers work to establish patient care systems and training programs, often resulting in the recognition of EM as an official medical specialty (or its equivalent) in that country. Following the establishment of training programs, steps need to be taken to influence and secure financial support for EM care and EM providers. For example, legislative support to ensure nationwide access, and equality and efficacy of emergency care; and public health and policy support to establish and ensure EM as a national priority of national health care systems and agendas.

How to connect all these unconnected systems? Unlike natural, organic systems that grow and flourish under their own impetus and power, EM systems development has to be influenced, coaxed, and sometimes dragged kicking and screaming through these upper echelons of development—often against considerable political, economic, and systemic resistance. Someone has to build it, and, put simply, that’s really what development is.

Over the past 15–20 years of collective experience of EM systems development in approximately 65+ countries around the world, certain patterns of EM development

ii) E ducation systems—Specialty training for physicians, nurses, EMTs, dispatchers, midwives, community health workers, etc. iii) A dministration and management systems—How do you run an ED? How does it fit into your hospital system?

How does your system run 50 EDs? iv) E conomic and finance systems—How does a person pay for their emergency care? How does the hospital pay providers and prepare for emergency care?

How does the national health care system and/or insurance system pay for emergency care, if at all? v) L egislative agenda—Legislation is involved in patient care, education, administration and management (especially larger scale management), and financing/ funding. Examples include EMTALA (in the United States), Prudent Layperson’s Rules, Acute Health Care as a Human Right, etc. vi) H ealth policy agenda—How to get emergency care on the health policy radar screen of national Ministers of Health? Of Ministers of Economics?

For example, is health care defined in a country as a human right (political)? If so, is the government required to fund health care (legislative) and thereby

fund acute/emergency care? vii) Public health agenda—The need for emergency care is ultimately an indicator of a country’s overall dedication to public health. As Rudolph Virchow said, “Medicine is a social science and politics is nothing else but medicine on a large scale. Medicine as a social science, as the science of human beings, has the obligation to point out problems and to attempt their theoretical solution; the politician, the practical anthropologist, must find the means for their actual solution.” Emergency care is a subset of the larger system of public health. Globally, improvements in longevity and quality of life came from public health measures. The emergency physician (EP) working in the ED is contributing their own share to public health; EPs take care of the people who often have no other option for care. Dr. Lewis Goldfrank, an EP, has said, “Every patient who presents to the emergency department represents a failure of the public health system.” Improvements in public health are reflected in a population’s use of the ED, and good emergency care contributes to public health. As the front door to the health care system, EDs are vital for providing first-hand disease surveillance, recognition, treatment and disposition, and the ripples of good emergency care are felt all across the hospital system, the economic system, and the public health system. viii) I dentifying and solving local variations—While most challenges and solutions to newly developing EM systems can be found outside that country, embedded in the history and experiences of the dozens of other countries on similar EM development curves, there are nevertheless local challenges that apply only to one or a few countries. Examples include religious or cultural necessities, region-specific epidemiologic or demographic needs, or locally-defined cultural or socioeconomic issues. It falls to each country to

The next step in global EM development may likely prove revolutionary, wherein countries who choose to adopt cheaper and more effective ways to deliver emergency care will influence EM care even in developed systems.

examine and develop local solutions to these local problems, which, again, usually only constitute a small minority of EM developmental issues.

Discussion These eight categories function as discrete spheres but are necessarily interlinked and connected. The linkage between these discrete yet connected spheres constitutes the entire system. An action or a behavior affecting variables in one sphere is felt, responded to, and compensated for by the rest of the system. The entire system starts to look like an interconnected living organism—each variable is connected to nearly all of the other variables, and small change in one sphere is felt throughout the whole system. When the system is built to strengthen itself and to push forward its own development, we see rapid progression along the EM development curve, and the eventual establishment of a comprehensive system. That’s the goal to keep in mind when starting to build projects in each of these eight categories.

I envision these categories hierarchically, like a set of nested Russian dolls. Step 1 is the innermost doll, with each subsequent subsystem fitting outside the inner subsystems. Each subsystem—care systems, education systems, administration, economics, legislation, public health, health policy—

needs to be built individually but with the connections to the other subsystems in mind. None of the individual subsystems can be done overnight and each has its own particular time frame for development, examples of which can be found by looking to other countries’ EM development experiences. Whereas EP training and specialty recognition can be done in 3–5 years, for example, economic and legislative agendas may take 5–10 years, and policy agendas can take 5–15 years, depending on local challenges and priorities. Nevertheless, these EM developmental projects must be undertaken and they can be achieved. In the words of Bill Gates, “We always overestimate the change that will occur in the next two years and underestimate the change that will occur in the next ten. Don’t let yourself be lulled into inaction.”

The field of emergency medicine is approaching 50 years old. The field of global EM development is leaving a top-down, proscriptive model wherein the influence of a few countries is offered and filtered down into the rest of the world. Instead, we are now entering a hybrid model wherein EM developments in the rest of the world are filtering back and influencing the so-called founding countries. The next step in global EM development may likely prove revolutionary, wherein countries who choose to adopt cheaper and more effective ways to deliver emergency care will influence EM care even in developed systems.

It’s an exciting time to be involved in global emergency medicine development.

Thirty years ago, the world didn’t really know how to build EM systems, and, thirty years from now, nearly every country in the world will have begun or finished building EM systems. The window of opportunity for global EM development is wide open right now, and the experiences of the 65+ countries now undertaking EM development are ripe with learning opportunities, both positive and negative, by which EM and acute care systems development can progress country by country, region by region, to the benefit of emergency patients all over the world. www.epijournal.com

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R report

// asia advances

China: Mainland E.M. Takes Strides The emergency department at The University of Hong Kong-Shenzhen Hospital is the first ED in mainland China to meet international standards.

by dr. kin heng constantine au & dr. gary chu

S

henzhen is a major city in the southern Province of Guangdong, located immediately north of the Hong Kong Special Administrative Region, and about 30 kilometers north of Hong Kong itself. The Shenzhen area is China’s first Special Economic Zone—and one of its most successful. It covers 2,050 square kilometers and has a total population of more than 14 million.

The University of Hong Kong-Shenzhen Hospital (HKUSZH) is a proud collaboration between the Shenzhen Municipal Government and the University of Hong Kong (HKU). This project, begun in 2012, aims to reform healthcare in China, as well as bring the best in teaching, training, and research into Shenzhen, all of which meet international standards.

Baseline Challenges Healthcare reform is a huge task with many challenges and obstacles. The Chief of Service, Dr. Gary Chu, arrived at this hospital in September 2012. The second consultant, Dr. Constantine Au, joined in December 2012. At that time, the Acci-

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Issue 17 // Emergency Physicians International

Two emergency medicine consultants from Hong Kong transformed an undeveloped ED, staffed by two nurses, into an internationally-recognized A&E with nearly 30 physicians, 34 nurses, and an average of 350 patients daily—all in less than two years.

dent and Emergency Department (A&E) consisted of only a small resuscitation room. Two nursing staff members had to deal alone with anything from minor allergic reactions to major trauma, including falls from a construction site next to this hospital. Staff slowly joined the department. At that time, the Medical School in Shenzhen was still new and there were no medical graduates from Shenzhen. All doctors and nurses came from different parts of China. They had different training, different exposure, and different ex-

The University of Hong Kong-Shenzhen Hospital first opened its doors for clinical service in July 2012. It aims to reform healthcare in China, as well as bring the best in teaching, training, and research into Shenzhen

pectations.

Most A&Es in China categorize patients according to specialty. For example, a woman with abdominal pain may be seen by a gynecologist on call. Emergency generalists are rare in China. As the A&E of HKUSZH aimed to follow the Hong Kong system, it introduced generalist care and triage according to severity.

Abuse of CT scan, ESR, and CRP were common. Despite ordering Troponin I for chest pain patients, doctors would order CK-MB as well. However, they seldom ordered h’stix or ECG for indicated patients.

Indicated drug use was different from that of Hong Kong. The law required skin tests for the use of penicillin, tetanus vaccine, and antiserum for snake bite. As a result, cephalosporin became the first choice of many doctors. Abuse of ribavirin was common. Intravenous drip was commonly prescribed to A&E patients in China.

In China, patients keep the A&E records after discharge, and hospitals seldom keep copies. As a result, A&E doctors do not record much on these records, to avoid complaint or litigation.

What Did We Do? The A&E of HKUSZH aims to promote evidence-based medicine in order to reduce unnecessary investigations, use of antivirals, and use of IV drugs. Its goal is to become an icon of emergency medicine in China.

We also wanted to inform and educate the public of the concept of A&E HKUSZH, and to manage public expectations. Signage and pamphlets were arranged, and interviews were conducted with local media outlets.

On-site training The next step was to offer in-house training and supervision to A&E staff.

Doctors and nurses from the A&E departments of Queen Elizabeth Hospital, Alice Ho Miu Ling Nethersole Hospital, United Christian Hospital, Caritas Medical

Centre, North Lantau Hospital, and volunteers of the Hong Kong St. John Ambulance Brigade, Hong Kong Red Cross, and other organizations, were invited to Shenzhen to offer in-house training. The training topics included triage systems, resuscitation, infection control, and communication skills. The first Basic Life Support (BLS) and Advanced Cardiac Life

Since holding workshops to enhance the communication skills of the staff, the recent complaint rate has ranged from 0.00% to 0.17% per month.

Support (ACLS) of the American Heart Association were conducted in November 2012, in Shenzhen. The first few doctors and nurses of the department joined these courses. When a new target was set, the choice given to the staff was either to achieve it or to leave the department. An audit team, headed by Dr. Innu Li, was put in place to monitor performance and adherence to department protocols.

Dr. Gary Chu and Dr. Constantine Au personally supervised doctors in handling pediatric patients for two months.

Each doctor in the department had to undergo pediatric rotation for at least one month. Dr. Robert Yuen, a retired pediatric consultant of Hong Kong, conducted monthly training for doctors and nurses between 2013 and 2014. Rotations to ENT and gynecology were arranged.

Each doctor and each nurse had to attend the Airway Workshop. Afterward, doctors had to finish a two-week attachment at the Operating Theatre, and nurses had to finish a three-day attachment. Dr. Tak-Lun Poon, a part-time orthopedic specialist of HKUSZH, started to conduct

regular training in trauma, basic surgical skills, and orthopedic skills in mid-2013.

Hands-on bedside ultrasound training— rarely practiced by A&E doctors in China—was conducted regularly.

As English is the international language of Western Medicine, English classes were arranged to teach the staff daily English, with separate classes for medical English.

The A&E department is prone to all sorts of complaints, originating from both patients and intra-staff conflict. To enhance the communication skills of the staff, communication workshops began in September 2014. Country and Barrick, a head-hunting company in Hong Kong, conducted the first two workshops. The recent complaint rate has ranged from 0.00% to 0.17% per month.

Off-Site Training In order to raise training exposure, doctors and nurses were sent to training centers in Hong Kong and elsewhere. Clinical observations and visits were conducted at the A&E departments of Queen Elizabeth Hospital, United Christian Hospital, Caritas Medical Centre, and Alice Ho Miu Ling Nethersole Hospital.

With the exception of the first few doctors and nurses who joined the department, all doctors and nurses were sent to the Caritas Medical Centre-Resuscitation Training Centre (CMC-RTC) in Hong Kong to receive further training in BLS, ACLS, and to take the Trauma Course of CMC-RTC. This collaboration began in May 2013. About one-third completed the Pediatric Advanced Life Support (PALS) as well.

The ambulance crew attached to the A&E of HKUSZH received training from the Hong Kong St. John Ambulance Brigade (HKSJB). The instructors of HKSJB came to HKUSZH and conducted some lectures and skill stations in January 2014.

Each crewmember was then sent to Hong Kong and had a three-day attachment with HKSJB. www.epijournal.com

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The Hong Kong Poison Information Centre (HKPIC) offered much support to our training program. Two doctors completed the Diploma Course in Clinical Toxicology in 2015. Since mid-2013, many doctors and nurses have taken the Certificate Course in Clinical Toxicology.

Infection control was a hot topic after SARS. Starting in 2013, four doctors went to the University of Hong Kong to take the two-year Certificate of Infectious Disease course, and three nurses took the twoyear Infection Control Course. The worldfamous Prof. KY Yuen conducted both courses. They completed their courses in July 2015, and another batch will start in November 2015. All staff now wear surgical masks when approaching any patients—another rare practice in China.

Three doctors and two nurses attended the Winfocus Congress, in Hong Kong, in November 2013. They then assisted with in-house training efforts.

Dr. Wei-fu Qiu was the first doctor to attend the Advanced Trauma Life Support (ATLS) of the Queen Mary Hospital, in January 2014. To date, nine of our doctors have passed the examination. The target is to have all doctors trained. In May 2014, three nurses completed the Advanced Trauma Care for Nurses (ATCN), and another three completed the course in May 2015.

Our doctors and nurses have attended many overseas training courses, as well, in-

cluding the Toxicology Course in Macao, the Toxicology Course in Kaula Lumpar, Malaysia, and the Asian Conference on Emergency Medicine in Tokyo.

In China, “grandfather practice” tends to overrule evidence-based practice. The A&E of HKUSZH is determined to introduce evidence-based practice to China.

A group of our doctors and nurses attended the 12th Asia Pacific EvidenceBased Medicine & Nursing Workshop and Conference, in Singapore, in February 2014. Together with the audit team, they saw some successes. For example, the use of IV drugs has been reduced; fewer than ten IV drugs were ordered for ~300 daily patients. The prescription rate of ribavirin has dropped from 300 prescriptions monthly to zero. Abuse of ESR, CRP, CKMB was stopped. Gastric lavage has only been used three times since our operation; instead, the A&E follows the international standard and uses activated charcoal. At the time of writing, a group of doctors and nurses are taking the Evidence-Based Medicine/Nursing and Literature Appraisal Workshop organized by the Hong Kong College of Emergency Medicine.

To further promote bedside ultrasound, we formed a collaboration with the Australian Institute of Ultrasound (AIU). In October 2014, the first batch of three doctors and two nurses went to AIU in Gold Coast, Australia to learn ultrasound in emergency medicine. The team visited the

MILESTONES

2012

July: A&E opens with limited clinical services September: Chief of Service, Dr. Gary Chu, arrives November: A&E clinical staff and EMS staff begin receiving advanced training in triage systems, resuscitation, infection control, and communication skills December: Consultant, Dr. Constantine Au, arrives

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The official opening of the A&E Department at HKUSZH, on June 16, 2014, which coincided with the GEM 2014 meeting.

GEM, which will be held this year on November 24–26, aims to bring the EM practice of China to the international level, with a focus on bedside ultrasound, systemic trauma care, modern toxicology, sports medicine and EM as a specialty in general medicine. Community first-aid is another focus.

A&E of the Gold Coast Hospital, as well.

Several months later, tutors from AIU came to Shenzhen to teach. Additional courses are scheduled in 2015.

In order to prepare the AED for possible CBRN attack, five doctors and five nurses attended Advanced Hazmat Life Support (AHLS) at the Alice Ho Miu Ling Nethersole Hospital, in Hong Kong, in January 2015. A decontamination chamber is currently under construction at HKUSZH. Milestones The A&E HKUSZH started her test run in May 2013, with partial services, which were extended to 24 hours a day in September 2013. Unlike other A&E

2013

January: Drs. Chu and Au oversee pediatric rotations for A&E doctors May: The A&E HKUSZH starts its test run, with partial services June: Regular training begins in trauma, basic surgical and orthopedic skills, and bedside ultrasound training September: The A&E HKUSZH extends its services to 24/7 December: Ambulance service is extended to 24/7

Pictured (from left to right) • Dr. Constantine Au, Consultant, AED, HKUSZH; Dr. Paul Ho, President of Hong Kong College of Emergency Medicine; Mr. Terence Ng, Assistant Chief Ambulance Officer Hong Kong Fire Services Department; Prof. Maaret Castren, President European Resuscitation Council; Prof. Judith Tintinalli, Professor and Chair Emeritus, Department of Emergency Medicine, University of North Carolina at Chapel Hill; Prof. Peter Cameron, Past President of IFEM; Prof. Gautam Bodiwala, Past President of IFEM; Prof.

Grace Tang, HCE, HKUSZH; Ms. Yihuan Wu, Vice Mayor of Shenzhen; Dr. Gary Chu, Chief of Service AED, HKUSZHDr. Che-Hung Leong, Chairman of the Hong Kong University Council; Ms. Jing Zhou, Nursing Officer, AED, HKUSZH

departments in China, patients are prioritized according to their clinical needs, instead of by specialty. The Hong Kong A&E triage system is implemented right from the beginning. As all of the A&E doctors and nurses have formal BLS and ACLS training, the A&E department is responsible for emergency crash calls throughout the hospital, including all the wards and non-clinical areas. A resuscitation record template has been designed to improve and standardize the documentation. These records will be audited by the A&E department to ensure that our hospital maintains its standards, and for CQI. Incidents involving mass casualties and fatalities require strong multidisciplinary collaborations. Thus, in preparing for di-

2014

sasters and outbreaks such as Ebola, we are also working closely with other clinical departments and government departments to conduct drills and set up protocols.

As there were only two full time consultants at the beginning of service, telemedicine was practised. A department WeChat group was set up for 24/7 monitoring and supervision. Working groups have their own WeChat groups, as well.

Other milestones include beginning limited ambulance service in mid-December 2013, which later extended to 24 hours a day. Unmatched Type O Blood was first transfused at the A&E in March 2014, another practice that is seldom conducted in China.

March: Unmatched Type O Blood first transfused at the A&E; Critical Incident Support Team assembled to fight workplace violence in the A&E June: The official opening of the A&E HKUSZH, after finally acquiring most of the basic elements of an A&E August: Emergency ward is opened, with seven beds

Anti-Violence Training To fight against workplace violence— a serious problem in this locality—the Critical Incident Support Team (CIST) assembled in March 2014. Dr. Shaolong Leng, who holds a medical degree as well as a law degree, leads the CIST. Zero tolerance is the motto. All A&E staff received a personal alarm. The CIST prepared educational materials and a training program on this important issue, and all AED staff, regardless of rank, must complete the Workplace Violence Course. This course aims to minimize incidence, avoid harm, and facilitate police reports. The course was well received and is now extended to staff of other departments. The CIST offers 24/7

2015

January: 24/7 phone consultation becomes available to the A&E doctors and nurses March: The Council Meeting of HK College of Emergency Medicine approves the accreditation of the A&E HKUSZH April: The Hong Kong Academy of Medicine officially endorses accreditation approval July: Four doctors and three nurses from A&E HKUSZH complete two-year infectious disease courses September: American Heart Association approves A&E HKUSZH as a recognized training center www.epijournal.com

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support against workplace violence, and it has produced a video to educate the public on this issue.

Grand Opening The official opening was celebrated on June 16, 2014, when the A&E department had finally acquired most of the basic elements of an A&E. We were honored to have Prof. Peter Cameron, Prof.

Gautam Bodiwala, Prof. Judith Tintinalli, and Prof. Maaret Castren as our keynote speakers, plus over 50 guest speakers from five continents. The opening coincided with the 2014 Global Emergency Medicine (GEM) meeting, which was granted the National CME of China, as well as CME from most colleges of the Hong Kong Academy of Medicine. Media coverage lasted for two weeks.

The emergency ward opened in August 2014. It started with seven beds, and the ultimate goal is to have 30 beds.

In January 2015, Dr. Fei-lung Lau, the Founding Director of HKPIC, Dr. Man-li Tse, the Consultant of HKPIC and Dr. Yiu-Cheung Chan the Associate Consultant of HKPIC joined the A&E of HKUSZH as part-time consultants. The aim is raise the training and service of clinical toxicology to international standards.

Liquid activated charcoal was first used in an intoxicated patient in April 2015. This is not a common decontamination method in China. With their help, a Clinical Toxicology Team was formed, and, as of January 2015, 24/7 phone consultation is available to the A&E doctors and nurses.

International Accreditation The Accreditation Team of the Hong Kong College of Emergency Medicine (HKCEM) visited the A&E department of HKUSZH in December 2014. The findings were favorable. The Council Meeting of HKCEM approved the accreditation in March 2015. On April 9, 2015, the Hong Kong Academy of Medicine officially endorsed this approval. The A&E of HKUSZH is the first training center of HKCEM that lies outside Hong Kong.

HKUSZH is undergoing the accredita28

tion of the Australian Council of Healthcare Standards (ACHS). The A&E is responsible for hospital-wide CPR training, resuscitation audit, and admission flow CQI project. The preliminary comments have been favorable.

Community Outreach and Relations Serving the local community is always our priority. We have conducted a First Aid Promotion Program, visited many schools to promote CPR, and conducted health talks and health checks at a local eldercare center. We formed a Community First Aid Teaching Team, led by two registered nurses, Ms. Meng Yao and Ms. Rong-xiang Shi. This team was given portable CPR mannequins and Automated External Defibrillator trainers, and the team regularly conducts classes with ~20 local participants.

In 2015, we launched the Safe School Shenzhen Project to spread the concept of community first aid to the students of Shenzhen. An Official WeChat Site was set up in May 2015 for the promotion of Emergency Medicine and First Aid to the community. Dr. Innu Li headed this Public Relation Team.

In January 2014, the department hosted the first Sports First Aid Foundation Course in China, in cooperation with the Asian Football-Rugby Union. HKUSZH A&E doctors and nurses have provided standby medical care for international rugby leagues in China, local tennis matches, as well as the Youth Olympics of 2014.

Our main working partner in bringing an international standard of EM to the whole of China is the China Candlelight Education Fund of Hong Kong. This foundation has built over 450 schools in rural China in the past 20 years. Since 2014, it decided to branch out into medical education. Our first joint project began in October 2014, in which instructors of CPR and infectious diseases were sent to rural hospitals in Guangdong Province.

This exchange was well received, and the visits are conducted each season. This exchange program will be extended to the

Issue 17 // Emergency Physicians International

Guizhou province in southwest China beginning September 2015.

To date, the daily patient load ranges from 250–450, with weekend surges. Half of these patients are children. In addition to the two full-time and three part-time Consultants from Hong Kong, there are 26 local doctors. Dr. Wei Han, Dr. Huaming Pan, and Dr. Yanli Wang are the Associate Consultants, while the rest are residents. There are 34 nurses, headed by Ms. Jing Zhou. Mr. Xuanji Huang, Ms. Jiangyue Liu, and Ms. Mina Tao are the three Advanced Practice Nurses and the rest are registered nurses.

Future Development In addition to improving our current services and projects, we have a long wishlist. The A&E department will expand the number of beds in the emergency ward.

An E-ICU will be opened within two years. Dr. Wei-fu Qiu and his team started the Trauma Registry in January 2015, and we will use those data to improve trauma management.

The Clinical Toxicology Team aims to offer consultations to all clinical departments of HKUSZH within two years.

With the help of the three Clinical Toxicologists from Hong Kong, the hope is that the A&E of HKUSZH will become a branch of the HKPIC. In terms of training in the future, HKUSZH has applied to become an International Training Centre (ITC) of the American Heart Association. The A&E department will manage this ITC. Simulation courses in resuscitation, trauma care, and ultrasound will be developed. We shall develop more research projects and submit more publications. More efforts will be spent on promotion of evidence-based medicine and evidence-based nursing.

In terms of community service, we shall increase the number of CPR/AED classes, and will conduct more training exchanges with hospitals in China and Asia.

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Low-Fidelity ED Design Solutions Just because a hospital lacks reliable electricity, adequate staff numbers or fancy machines doesn’t mean it can’t take advantage of high design. Enter “frugal innovation”.

by manuel hernandez, md, mba

T

alk to anyone who designs healthcare environments about what needs to be included in a new emergency department (ED), and you will hear very strong opinions about what constitutes the “best” in ED design. Many in the industry have advanced recommendations for all-private treatment station models, in-house imaging, ceiling-mounted equipment booms, observation units, and utilization of new technologies. While these recommendations can result in successful solutions, they assume access to a number of resources that facilities in the developed world take for granted. Hospitals in many parts of the world are questioning how to design

and operate an ED when reliable access to electricity, clean running water, wired or wireless high bandwidth telecommunications, medical gasses, and even capital for design and construction, is limited. In many cases, conventional solutions, such as large photovoltaic farms, wind generators, and drilling deep wells are not only impractical but cost-prohibitive as well.

Enter low-fidelity design. Enter frugal innovation.

Notions of low-fidelity design and frugal innovation are front of mind in many parts of the world. In an article penned in Harvard Business Review, the authors contend that many organizations are turning to frugal innovation in response to overengineered and costly products, as well as the reduced availability of a number of natural resources including water, minerals and wood.1 However, healthcare solutions cannot simply be about doing more with less; rather, it is the necessity of creating affordable, quality, reliable, and sustainable solutions that help advance performance.

How exactly does a hospital in a low-resource environment design an ED that can function even when the power supply fails?

The answer rests in leveraging what is available in abundance, determining what can function without other prerequisites, and identifying what does require significant financial resources to build, own, operate, or repair.

Rethinking Patient Access and Communications In many parts of the world the

Keeping Cool: The roof overhang protects the south facade from direct sunlight during the hottest part of the day. Air is brought in from low windows while operable clerestory windows and openings in the ceiling allow warm air to escape. Basic fans in the plenum facilitate air movement.

technology revolution has leapfrogged hardwired voice and data communications in favor of wireless technologies. In 2013, the China Internet Network Information Center reported that 79% of citizens in rural China relied on mobile phones to access the Internet.2 In 2014, mobile phone ownership rates were at 83% in Ghana, 82% in Kenya, 73% in Tanzania, and 65% in Uganda.3 In parts of Latin American and the Caribbean, mobile phone penetration has exceeded 100%, based on the number of phones per resident.4 Understanding this, healthcare innovators have been exploring how wireless communication technologies can support virtual patient access. The ED is well-positioned to take full advantage of these emerging technologies.

“Do I really need to go to the ED?” Redefining patient access for emergency care can be as simple as rethinking who does and does not need to seek emergent, in-person care. Phone calls, mobile technologies www.epijournal.com

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with clinical capabilities, and real-time “virtual” appointments can all help assess patients’ need for emergent care well before they arrive in the ED. Early studies using telephone consultation for non-serious emergency ambulance service patients in the UK has demonstrated that decision support in conjunction with telephone consultation can be a safe way to provide support to lower-acuity patients requesting ambulance service.5 Designers in India have been focusing on helping patients identify when it is time to seek in-person medical care through technologies such as LifePhonePlus, a mobile device that allows anyone with a mobile phone connection to obtain an electrocardiogram, evaluate blood glucose levels, and communicate with clinical specialists, avoiding unnecessary travel.

Using Bluetooth or WiFi technologies, the LifePhonePlus device collects information, transmits it to the user’s mobile phone, and then on to a health provider. The provider can then transmit medical advice back to the user’s mobile phone or instruct the user to seek medical care as soon as possible.6 Does that laceration really require a visit to the ED? A study assessing the efficacy and patient acceptability of using mobile phone images of acute wounds to transmit information to a remote physician for diagnosis and treatment demonstrated strong patient acceptance for the approach with few concerns regarding privacy and 30

security.7 The advantages to this approach are clear: in remote and resource-limited environments, leveraging tele-technologies can reduce unnecessary ED visits with concomitant reductions in overall cost of care delivery, as well as patient inconvenience stemming from excessive travel distances and diagnostic delays.

Recent research has turned to assessing the feasibility and efficacy of patient-initiated internet-based urgent care visits via Skype®. One such study looked at 16 different chief complaints, each with a list of “red flag” symptoms warranting an immediate in-person clinical evaluation. The study demonstrated that none of the patients using the online encounter approach required referral to an ED.8 Other studies have demonstrated the effectiveness of leveraging telemedicine to manage chronic diseases such as diabetes, hypertension, and hyperlipidemia.9 The time is not far off when we will use these technologies for things like ED post-discharge follow-up and remoteED management of chronic disease decompensation for conditions such as congestive heart failure and asthma or chronic obstructive pulmonary disease.

In many parts of the world, the infrastructure for remote monitoring and follow-up already exists. For example, a study of children presenting to an ED in resource-limited western Kenya showed that 89% had access to a mobile phone, and, in 84% of those instances, successful

Issue 17 // Emergency Physicians International

WINTER WARMTH: A lower sun angle allows direct sunlight and heat gain deep into the patient room. Baseboard units provide radiant heat, while fans bring in tempered fresh air and circulate it throughout the building.

post-discharge follow-up was made using the mobile phone.10 Leveraging Technology for Emergency Medical Decision Making, Care Delivery and Diagnostics In many clinical environments, significant monies are spent during the design process to acquire expensive technologies to support patient care and diagnostics.

This is done sometimes at the expense of investments in facilities, human capital, or other equipment and technologies that would yield a higher return on investment.

At the same time, the use of lower-cost technologies in supporting care delivery and diagnostics may not be fully realized.

How can we perform lab studies without a lab analyzer? Prick finger, apply blood to a device with a paper filter, view results on bottom side of device, digitize results, send

The HemoSpec employs a spectrophotometric method that reduces the per-test cost of anemia diagnosis to under $0.01 by using chromatography paper as the only disposable. The HemoSpec method is accurate to within 2 g dL(-1) for 95% of blood samples essayed.

images to technician via telemedicine, and incinerate hazardous waste. Micropatterned devices currently exist that can assess aspartate aminotransferase (AST), alkaline phosphatase (ALP), alanine transaminase (ALT), lactate dehydrogenase (LDH) or total bilirubin levels.11 Similar devices exist for assessing hemoglobin levels. Hemospec is a portable device that can assess hemoglobin levels to within 2 g/dL. Using inexpensive chromatography paper costing less than $0.01USD per test, the portable technology, currently in testing, can deliver fast, reliable diagnostic information.12 Even when whole blood for laboratory analysis is required, low-fidelity innovation can play a role. In many resource-limited environments, technologies as simple as a blood centrifuge are limited in availability.

In others parts of the world, the equipment is available but the power to operate it is either absent or unreliable. Seeking a solution that will provide reliable capabilities in these environments, a team of undergraduate students developed a hand-powered centrifuge designed from a “salad-spinner,� hair combs and a round plastic container, all assembled using hot glue. Using a reader card adjusted to the outputs of the hand-powered centrifuge, the technology provides packed cell volume measurements that correlate with conventional centrifuges.13 What if I need to take the care to the patient? Backpacks housing mobile technologies are another novel solution appropriate

for highly remote clinical environments. A number of different configurations of backpacks have been used in South America and Africa to bring diagnostic and management resources to resource-limited settings. The backpacks, some of which are powered by battery packs affixed with solar panels, allow providers to address conditions ranging from hypertension to diabetes, anemia and malaria, and can include technologies such as glucometers, urinalysis strips, and first aid supplies.14 We really want to incorporate ultrasound in the ED, but can we afford it? With ultrasound taking on a greater role in ED care, finding low-cost, low energy solutions can help further advance this vital technology.

Portable, hand-held ultrasound technologies are already in use today. Clinical users in resource-constrained environments have found these technologies to be valuable in practical clinical application.15-17 Portable ultrasound solutions provide battery-powered scanning capabilities at a fraction of the cost of a traditional ultrasound unit.

Delivering Care When Electricity or Access to Clean Running Water is Unreliable No electricity? No problem. A team from Rice University in the US has developed a technology that uses nanoparticles to convert solar energy directly into steam, operating with efficiency levels that allow even ice-cold water to be used in the

process.18 The technology facilitates sanitation and water purification and can be employed easily in remote locations and developing countries. The space requirements for the technology are limited compared to traditional photovoltaics, which can be cost-prohibitive and require acres of solar panels. Students at Rice University have already used this technology to develop steam-powered autoclaves for sterilization of medical and dental instruments in clinics lacking electricity.

In Nigeria, a physician struggling to operate a medical clinic with unreliable electricity supply has been designing innovative solutions to respond to the unreliability of the power grid, and the high cost of purchasing fuel to operate electrical generators. Among his design solutions are blood centrifuges operated by bicycle pedal-powered ingenuity, bicycle pedal-powered surgical suction pumps, and a boiler fueled by corncobs that feeds steam to homemade autoclaves.19 In parts of the world without reliable electricity supply, these design innovations have the ability to support more advanced diagnostics and management in the ED. An added benefit of these self-designed technologies is the ability to make repairs when malfunctions occur without having to rely on expensive and often delayed replacement parts.

In situations where access to clean water is limited, portable solutions exist that can use any available water to produce sterile www.epijournal.com

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water for injection, sterile purified water, and water for dialysis. These devices can provide an alternative to the transport and storage of packaged sterile water in remote locations.20 Delivering Supplies to Difficultto-Access Locations For some EDs in highly remote or isolated locations, replenishing needed supplies and medications can prove daunting.

Flirtey Inc. has developed experimental unmanned aircraft technologies—drones— that facilitate deliveries of medications and other supplies and equipment to remote locations. The technology, currently in the testing phase, can accelerate delivery of necessary care. Several companies, including Google and Deutsche Post DHL AG, are testing similar unmanned aircraft technologies around the globe.21,22

for telemedicine consultation, storage of portable devices and supplies, and ample locations for wired or photovoltaic charging of battery-operated devices is essential. The ED of tomorrow will be as much about virtual care and consultation as it is about inperson interactions today. New EDs should be planning for the eventuality of the unmanned aircraft deliveries. We must give careful consideration to how low-fidelity

Making Room in the ED for New Innovations How does all this inform the design of a new ED in a remote or resource-limited environment? Planning an ED in such an environment requires exploration of available resources, known limitations, and lowcost, low-fidelity solutions that respond to the conditions of the physical environment.

Simple design solutions can support better environments of care. Naturallyventilated architecture can be designed to respond to both warm and cool environments. Well-placed windows and skylights can afford natural lighting and cross-ventilation. Water collection and storage devices can hold rainwater run-off for medical and non-medical use, while shaded courtyards can pull natural light deeper into a building while providing shaded areas for patients and staff, and cooler air to support internal building ventilation. Each of these solutions can be enacted without electricity and without access to running water.

In conjunction with these facility-based solutions, the remote or resource-limited ED needs to support the burgeoning use of wireless, mobile, and unmanned technologies that support improved access, diagnostics, and medical decision-making. Spaces 32

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1. Radjou N, Prabhu J. 4 CEOs who are making frugal innovation work. Harvard Business Review. 11/28/14. Information accessed at https://hbr. org/2014/11/4-ceos-who-aremaking-frugal-innovation-work on 8/1/15.

2. China Internet Network Information Center. The 33th report on the development of internet in China.

Information accessed at http://www1.cnnic.cn/IDR/ ReportDownloads/201404/ U020140417607531610855. pdf on 7/24/15.

3. Pew Research Center. Cell phones in Africa: communication lifeline. 4/15/15. Information accessed at http://pewrsr. ch/1PN5qIA on 7/28/15.

4. World Bank. Latin America has more phones than people.

World Bank Data Viz. Information accessed at http:// worldbank.tumblr.com/ post/48769713827/latin-america-has-more-mobile-phonesthan-people on 7/28/15.

5. Dale J, Williams S, Foster T, et al. Safety of telephone consultation for “non-serious” emergency ambulance service patients. Qual Saf Health Care. 2004;13:363-373.

6. Tan P. Frugal innovation brings healthcare to rural India. iQ by Intel. Information accessed at http://iq.intel. com/frugal-innovation-bringshealthcare-rural-india/ on 7/24/15.

7. Sikka N, Carlin KN, Pines J, Pirri M, Strauss R, Rahimi F. The use of mobile phones for acute wound care: attitudes and opinions of emergency department patients. J Health Commun. 2012;17 Suppl 1:37-42.

8. Brunett PH, DiPiero A, Flores C, et al. Use of a voice and video internet technology

design solutions and frugal innovation can and will prove transformative for patients and providers alike.

Disclaimer: The author of this article has no financial or academic interest in any of the products or technologies presented and the contents of this article should not be considered endorsement.

as an alternative to in-person urgent care clinic visits. J Telemed Telecare. 2015 Jun;21(4):219-26.

9. Shea S, Weinstock RS, Teresi JA, et al; IDEATel Consortium. A randomized trial comparing telemedicine case management with usual care in older, ethnically diverse, medically underserved patients with diabetes mellitus: 5 year results of the IDEATel study. J Am Med Inform Assoc. 2009 Jul-Aug;16(4):446-56.

10. House DR, Cheptinga P, Rusyniak DE. Availability of mobile phones for discharge follow-up of pediatric emergency department patients in western Kenya. PeerJ. 2015 Mar 10;3:e790.

11. Vella SJ, Beattie P, Cademartiri R, et al. Measuring markers of liver function using a micropatterned paper device designed for blood from a fingerstick. Analytical Chemistry.

2012 84 (6), 2883-2891.

12. Rice 360o Institute for Global Health. Hemospec.

Information accessed at http:// rice360.rice.edu/Resources/ Documents/HemoSpec.final. pdf on 7/24/15.

13. Brown J, Theis L, Kerr L, et al. A hand-powered, portable, low-cost centrifuge for diagnosing anemia in low-resource settings. Am J Trop Med Hyg. 2011 Aug 1;85(2):327–332.

14. Rice 360o Institute for Global Health. Diagnosticlab-in-a-backpack in Ecuador.

Information accessed at http:// www.rice360.rice.edu/labinabackpack on 7/24/15.

15. Kimberly HH, Murray A, Mennicke M, et al. Focused maternal ultrasound by midwives in rural Zambia.

Ultrasound Med Biol. 2010 Aug;36(8):1267-72.

16. Lesjak MS, Flecknoe-

Brown SC, Sidford JR, et al.

Evaluation of a mobile screening service for abdominal aortic aneurysm in Broken Hill, a remote regional centre in far western NSW. Aust J Rural Health. 2010 Apr;18(2):72-7.

17. Smith ZA, Postma N, Wood D.FAST scanning in the developing world emergency department. S Afr Med J. 2010 Jan 29;100(2):105-8.

18. Press Release, Rice University. Rice unveils superefficient solar-energy technology. Sciencenewsline.com Information accessed at http:// www.sciencenewsline.com/ articles/2012111923460049. html on 7/24/15.

19. Markham D. This rural doctor in Nigeria builds his own hospital equipment. 1/12/14.

Information accessed at http:// www.treehugger.com/gadgets/ rural-nigerian-doctor-buildshis-own-hospital-equipment. html on 7/24/15.

20. Taylor MA, Alambra EF, Anes J, et al. Remote site production of sterile purified water from available surface water.

Prehosp Disaster Med. 2004 Jul-Sep;19(3):266-77.

21. Hackman M, Nicas J. Drone delivers medicine to rural Virginia clinic. The Wall Street Journal. 7/17/15.

Information accessed at http:// www.wsj.com/articles/dronedelivers-medicine-to-ruralvirginia-clinic-1437155114 on 7/24/15.

22. Portnoy J. Drones to deliver medicine to rural Virginia field hospital. The Washington Post. 7/3/15. Information accessed at http://www.washingtonpost.com/local/virginiapolitics/drones-to-delivermedicine-to-rural-virginia-field-

ifem

| guidelines for sustainable e.m. working conditions

continued from page 21

a high performing ED. Good teamwork is central to deliver efficient, effective and compassionate care.

System commissioners and Heads of Departments must invest well in team building and function in order to be progressive and forward thinking. A great team also inspires passion and drives the engine that creates job satisfaction and fulfilment for all the staff in the team.

15. Building career resilience – Each of the factors described above are crucial to helping develop and enhance the concept of career resilience—a complex mixture of psychological and physical wellbeing linked to the satisfaction of a progressive and fulfilling clinical career. These will of course also be influenced substantially by the individual’s personal circumstances and their ambitions in life.

Models of Practice The models and systems of practice of emergency medicine globally at the present time are a complex mixture of specialty development/ maturation, available resources, governmental / state stability, availability of skilled EP providers and geographical constraints amongst many others. Working conditions for the EP will vary considerably depending upon the type of system. For the purposes of classification, three broad categories are described. Each category requires the principles described above to be applied in different ways for the practising EP to work sustainably. a) Developed EM systems—A small number of countries have developed EM systems that have matured over a period of the past 30–40 years and continue to evolve to meet societal needs. Working conditions for EPs in these systems

continue to be challenging due to the unique stressors of where they work. The bibliography describes examples of how individual national Colleges and academic bodies in these systems have created guidance to support EPs within their own systems. b) Evolving EM systems—A larger group of IFEM countries have EM systems that are at an evolutionary stage (both high and middle income countries as defined by the World Bank). The EPs in these countries are working hard to both establish their specialty as well as deliver clinical care in difficult environments. The principles set out above provide guidance for embedding good practices in their basic structures as they evolve and the resourcing required. c) Fragile healthcare systems—An increasing number of EPs provide a range of expertise and services to countries with fragile healthcare systems sometimes at great risk to themselves and their families. In such circumstances development of training and education to local healthcare providers is the main role of the trained EP who will usually be part of a networked and developed academic institution elsewhere. It is particularly important for EPs in these settings to have access to mentorship and support, which can sometimes be provided in a virtual setting during the initial stages of EM development in a particular country or region.

We hope that in time we can gather examples of how EPs in each of these three broad categories apply the principles set out above to help support each other as well as inspiring others wishing to practice Emergency Medicine.

RECOMMENDATIONS

1

National organisations should review their position in this area, share international best practice and we hope link to the principles as set out in this position statement. For those countries where sustainable working practices for the emergency physician remain a significant challenge, national bodies should create a 5 year ‘roadmap’ of what they wish to achieve.

2

Governments, healthcare commissioners and employers should review the principles set out above and work closely with national Colleges, societies and other academic bodies representing emergency medicine. They should aim to provide the infrastructure and resources to help create resilience and sustainable working practices for the EP workforce in their country using these guidelines.

3

The individual EP must ensure that he or she has a well-structured job plan that has been agreed with their leader. In addition, Heads of Department should review the international and national literature with colleagues in the ED (depending upon the model or type of system that they work in) and ensure that exemplar working practices are described, developed and delivered.

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Grand Rounds PETER CAMERON, MD // IMMEDIATE PAST PRESIDENT OF IFEM

Violence Without Borders From east to west, every emergency department seems to have similar concerns about violence against healthcare workers. No matter where we practice, we need to take a hard look at the factors – both institutional and cultural – that lead to unsafe working conditions.

T

certainly helps. Improving the flow of patients and relatives also assists with frustrations from the public.

An important consideration was video monitoring of all public areas. This was a major improvement that had a definite effect on behavior. Because of privacy concerns, we could not review patient treatment bays. Access to video review of incidents not only resulted in immediate resolution of many incidents but it also had a real time of emergency medicine (EM). Virtually every ED I have worked in deterrent effect. or visited has identified security as a major concern.

Security training was poor and guards were not empowered to As of this writing, I am leaving Qatar to return to Australia, and I restrain individuals without fear of an assault charge (and prison have had the opportunity to reflect on some of the challenging issues sentence) under Qatari law. Therefore, the ability of security to rethat I dealt with in Doha and how much they strict a determined individual with malicious have in common with EM in Australia and intent was (and still is) limited. A great deal the rest of the world. of training and better liaison between seA major area of focus is One of the biggest challenges that I faced curity and clinical staff has helped, but this retraining clinical staff in the first few weeks of arriving in Doha was remains an issue. At minimum, security staff on how to defuse and when one of my doctors was seriously physimust be trained in de-escalation techniques, de-escalate potentially cally assaulted in an unprovoked attack by a how to recognize certain behaviors associated volatile situations. This patient’s relative, resulting in hospital admiswith alcohol and drugs, and how to restrain is probably the most sion. Fortunately, he recovered physically, agitated patients safely. effective intervention that but his mental trauma, and the repercussions A major area of focus was to retrain clinical we undertook in reducing of the assault on the workplace and his colstaff on how to defuse and de-escalate potenthe threat to staff. leagues, was significant. This was not an isotially volatile situations. This is a neglected lated event and certainly not a problem rearea of clinical training, but an obvious interstricted to the ED. As a result of the assault, vention, and probably the most effective inan organization-wide review of security was undertaken, specifically tervention that we undertook in reducing the threat to staff. A confocused on EM and what could be done to mitigate the risk to staff fident, calm, and reassuring staff member, backed up by colleagues, and patients. can defuse most situations. It is important to remember that with In basic terms, there are three groups of attendees that may cause staff turnover, rotations, and so on, this is a continuing challenge. a physical risk to staff in the ED. The first is patients who are psyAll staff have undergone compulsory one-day training, with more chiatrically ill or intoxicated with stimulant/disinhibiting drugs; the advanced training for clinical leaders. second is relatives who are angry/demanding about treatment manPublic awareness of the issue is important but difficult, and it can agement (who may also be intoxicated); and the third is patients or backfire in the sense that the public may take broad based messaging relatives with malicious intent, either to staff or patients—often in the wrong way. To the worst elements of the public it might be seen the setting of war, civil unrest, or gang violence (the third group was as a “challenge” to beat increased security, and to the better behaved not really an issue in Qatar). groups it might be seen as an insult. The messaging must therefore be The approach that we took was to look at the physical structure subtle and targeted. Clearly, the public has to know that certain beof the ED and review entry/exit to key areas with swipe card access havior will not be tolerated in the clinical areas—in much the same and security guards. Limiting relatives and unnecessary movement way that airports require a restrictive approach. Signage and consiswithin the ED was difficult, given the cultural necessity of allowing tent staff behavior with regard to access are important. large families access to seriously ill relatives. In an overcrowded deThe issue of metal detectors, screening of relatives on entry, and so partment with no space for relatives or patients to wait, controlling on was discussed, but the possibility of actually escalating conflict is movement is even more problematic, although getting some control high. The hospital is a community facility and families come there

The problem of emergency department (ED) violence is a worldwide issue, and a systematic approach to mitigating the threat to our colleagues and patients is fundamental to the advancement

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Issue 17 // Emergency Physicians International

I do not believe that we can have a “zero tolerance” approach without making things worse.

for help and compassion. It is not a military or high security area, and families should not be intimidated by high-level security arrangements. For aggressive and agitated patients, it is likely that violence would be increased by such interventions.

Personal distress alarms, staff position monitoring, and other electronic tracking devices have been partially implemented. The physical layout of the current department makes centralized control difficult, but this will become easier with a new facility. An immediate security response across the whole ED is the eventual aim.

With about 100 individual interventions and a corporate approach, security has improved tremendously. There is still much work to do and staff still do not feel totally secure in the ED. In reality there have been no further serious injuries subsequent to this sentinel event.

A continuing issue is low-level verbal abuse and physical intimidation. Much of this is expected with agitated patients who may be intoxicated, psychologically disturbed, or simply frustrated. All staff working in the ED must expect to manage this as part of their work. In addition, they must be formally trained in de-escalation techniques. I do not believe that we can have a “zero tolerance” approach without making things worse. The issue that makes most staff anxious is: what happens when things go wrong and verbal abuse becomes physical abuse? A guaranteed and structured response is necessary to allay staff fears.

The level of violence in EDs varies around the world. Obviously, in war torn countries with civil disruption, violence is common.

There are also many inner city EDs in the US and other countries where drugs and street gangs threaten staff and patients. For most EDs in developed countries, serious physical violence resulting in injury is uncommon, but low level intimidation and verbal abuse is very common. ED staff and patients must turn up to work and feel confident that should a real threat emerge there will be a safe response. Unfortunately, a sentinel event is often required in order for hospitals to take a systematic approach to the issue.

The International Federation for Emergency Medicine is in an ideal position to promote discussion on this topic and to develop best practice models that are sensitive to local context. Accordingly, I am hopeful that this will be a topic for discussion at the 2016 ICEM in Cape Town.

Dr. Peter Cameron is the immediate past president of the International Federation for Emergency Medicine (IFEM)

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