EPI Issue 18 by Logan Plaster

Refugees prepare for European winter Improving your NGO’s needs assessments Interview: Dr. Saleh Fares on EM in the U.A.E Virtual reality gives training a new dimension EMERGENCY PHYSICIANS INTERNATIONAL

ISSUE 18

. WINTER 2016 . WWW.EPIJOURNAL.COM

NO SAFE ZONE Recent fighting in Yemen has left only 5 out of 25 hospitals operational, with a weary skelaton crew of medical staff left to take care of the city’s sick and wounded. One physician speaks about practicing medicine under fire. page 8

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EPI X TELEMEDICINE A special 3-part insert on the future of digital healthcare

“[At the hospital], we are constantly exposed to mortar fire, artillery fire, and sniper attacks. So far, 15 of the medical staff have been wounded.” dr. ahmad domainy

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EDITOR’S DESK

Next Up: Cape Town

recently returned home from a tiring but very enjoyable series of international emergency medicine meetings held in Boston at the ACEP 2015 Conference. Each day of the conference was taken up from early morning to evening with back-to-back international organization and committee meetings. I was very pleased by the camaraderie, cooperation, and collaboration between the different organizations that met at ACEP 2015. Each organization is in the hands of very capable leaders, and the prospects for continued productive collaborations are very high. One specific item from the meeting to publicize is that the speaker list is being finalized for the 2016 ICEM conference in Cape Town, South Africa, so if you have any late speaker requests, contact Dr. Melanie Stander at melaniestander@sun.ac.za. In addition, IFEM will be holding elections for all of its officers in April 2016, so if you are interested in becoming an IFEM officer, obtain the sponsorship of your national emergency medicine organization and have them send in your nomination (see IFEM’s web site for nomination instructions). Hope to see you all in Cape Town! On a more sober note, the recent mass casualty atrocities that have occurred in different countries remind us of the importance of emergency medicine in national health care systems. France’s prompt and efficient response to the casualties in Paris redemonstrated the value of pre-planning and practicing emergency response to a mass casualty event. Unfortunately, it appears that we are going to have to deal with more of these events in the near future. If your healthcare system does not have a detailed and well practiced system for dealing with mass casualties from terrorist events then you should quickly put this in place, and conduct practice drills to help make sure the planning is effective. On a side note, we should stop referring to the perpetrators of these outrages as “masterminds” but refer to them as the “barbaric criminals” which they are. Emergency medicine is at the forefront of dealing with the trauma that results from terrorist atrocities. As such, we have a unique vantage point from which to understand the carnage that is wrought. As physicians I encourage you to speak out against these crimes and join multinational efforts to fight terrorism worldwide.

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

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

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

ICEM 2016 // Cape Town, South Africa April 18-21, 2016 www.icem2016.org

European Society for Trauma & Emergency Surgery Congress 2016 // Vienna, Austria April 24-26, 2016 www.estesonline.org

JANUARY 2016 International Conference in Emergency Medicine and Public Health – Qatar // Doha, Qatar January 14-18, 2016 www.hamad.qa

The EMS Conference 2016 // London, UK January 21, 2016 www.healthcareconferencesuk.co.uk

FEBRUARY 2016 American Academy of Emergency Medicine (AAEM) Scientific Assembly // Las Vegas, Nevada, US February 17-21, 2016 www.aaem.org/aaem16

JUNE 2016 EMCORE Melbourne 2016 // Melbourne, Australia June 4-5, 2016 www.theemcore.com

17th International Conference on Emergency Medicine // Mexico City

IN THIS ISSUE www.epijournal.com

03 | Editor’s Desk

Field Reports 6 | Bhutan 8 | Yemen

Departments 10 | News and Perspectives Refugees continue to flow into the E.U. as winter quickly approaches.

12 | NGOs

June 5-9, 2016 www.smme.org.mx

A needs assessment analysis can sharpen volunteer health care delivery.

18th International Conference on Emergency Medicine // Seoul, South Korea

14 | Interview

June 12-15, 2016 Hosted by The Korean Society of Emergency Medicine (KSEM)

19th International Conference on Emergency Medicine // Buenos Aires, Argentina

Dr. Saleh Fares discusses the work of ESEM, and EM in the U.A.E.

EPI x Telemedicine 18 | Telepharmacy Telepharmacy slowly finds its footing, particularly in hospital environments.

June 16-19, 2016

19 | FutureRx

Rocky Mountain Winter Conference On Emergency Medicine 2016 // Steamboat Springs, Colorado, US

OCTOBER 2016

Will automation and innovation eliminate pharmacy errors?

February 20-24, 2016 www.rockymtncme.com

EuSEM 2016 // Vienna, Austria

What does “real telemedicine” look like for medical professionals?

MARCH 2016

October 1-5, 2016 www.eusem.org

22 | The Healthy Circle

Updates in Emergency Medicine 2016 // London, UK March 10-11, 2016 http://bit.ly/1WfsjHQ

APRIL 2016 The 12th Emirates Critical Care Conference // Dubai, United Arab Emirates April 7-9, 2016 www.eccc-dubai.com

American College of Emergency Physicians Scientific Assembly 2016 (ACEP 2016) // Las Vegas, Nevada, US October 15-18, 2016 www.acep.org/sa

20 | Google Docs

Keeping providers, patients, and other key players e-connected for optimal care.

24 | Tech: Virtual Care “Augmented medicine” takes training and practice into the next dimension.

Reports 27 | Parachute Packers

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

One doctor learned the value of his supporting staff—by doing their jobs.

30 | Off the Clock A lawyer devises a model Good Samaritan law for your own country.

34 | Grand Rounds Peter Cameron: new clinical guidelines must first be supported by rigorous scrutiny.

Emirates Society of Emergency Medicine Scientiﬁc Conference

Abu Dhabi, UAE

r Registe Now!

2015

6 - 10 December 2015 | Jumeirah Etihad Towers Abu Dhabi, UAE

Join us for the second edition of Emirates Society of Emergency Medicine Scientiﬁc Conference (ESEM) and have the opportunity to engage in a more structured learning and working experience led by experienced clinicians from various ﬁelds of emergency medicine.

Featured Tracks in the Scientiﬁc Program • • • • • • • • • • • • • • • •

Target Your Therapy Women in Emergency Medicine Sport Medicine Dilemmas in Pediatric Emergencies Emergency Medicine Nursing Fulcrum in EM Cardiovascular Emergencies Respiratory Emergencies ED Administration Literature Update in EM Toxins Commonly Seen in ED (Toxicology) Technology in ED International Emergency Medicine Pre - Hospital Care Simulation Infectious Disease Seen in ED

Earn up to

30 CME hours Accredited by College of Medicine and Health Sciences

www.esemconference.ae

Keynote Speakers Ian G. Stiell, MD, MSc, FRCPC

Amal Mattu, MD, FAAEM, FACEP

Professor of Emergency Medicine Vice Chair, Department of Emergency Medicine University of Maryland School of Medicine United States of America

Professor, Department of Emergency Medicine, University of Ottawa, Distinguished Professor and University Health Research Chair, University of Ottawa Senior Scientist, Ottawa Hospital Research Institute Canada

Cecil James Holliman, M.D., F.A.C.E.P., F.I.F.E.M.

Nadeem Qureshi MD, FAAP.FCCM Associate Professor Pediatrics School of Medicine, St Louis University Attending Pediatric Emergency Medicine Cardinal Glennon Children's Hospital St. Louis, Missouri United States of America

President, The International Federation of Emergency Medicine (IFEM) Professor of Emergency Medicine, M. S. Hershey Medical Center, Professor of Public Health Sciences, Penn State University United States of America

Gregory Ciottone, MD, FACEP

Director, BIDMC Fellowship in Disaster Medicine Associate Professor of Emergency Medicine, Harvard Medical School - Boston Director, Disaster Preparedness Program, Harvard Humanitarian Initiative - Cambridge United States of America

#ESEM2015

Organised by

Supported by

Platinum Sponsor

Gold Sponsor

Endorsed by

Conference Secretariat: MCI Middle East LLC, UAE, Tel: + 971 4 311 6300, Fax: + 971 4 311 6301 Email: esem@mci-group.com

FIELD REPORT WINTER 2015

BHUTAN IN A BOX A month training emergency personnel at Bhutan’s central hospital proves to an up-closeand-personal look at the mountain nation that has been dubbed “the last Shangri-La”. by kenneth v. iserson, md, mba

lthough I had been warned that the landing at Bhutan’s Paro International Airport was one of the most difficult in the world, I was only semi-prepared for the aerobatic gyrations our aircraft took when maneuvering to line up with the tiny runway. I later learned that pilots only have visual cues as they thread between mountain peaks and then drop to target the small landing strip. Once safely on the ground, my real adventure began—working with and helping to teach “general medical officers” (ie, physicians) who work in the country’s largest emergency department (ED). As I descended the airplane stairs, I came face-to-face with the airport terminal, a traditional Bhutanese building, over which loomed a huge billboard photo of the current king and his predecessors. This was to leave no doubt in anyone’s mind that Bhutan is still a kingdom—the 6

last of the traditional Himalayan kingdoms that is still independent (unlike Sikkim, Assam, and Tibet) and ruled by a king (unlike Nepal). An 18,000 square-mile oval, Bhutan is less than twice the size of Pima County, Arizona, in which I live. Hemmed in by Tibet (China) and Sikkim and Assam (India), it is within spitting distance of Nepal and Bangladesh. In the north lie the Himalayan peaks; the south is tropical and the east is ruggedly rural. No one seems to be certain how many people live there, although the best estimate is around 734,000 residents, according to the 2015 World Factbook published by the U.S. Central Intelligence Agency. Emerging from the small terminal, I faced a horde of taxi drivers and guides collecting visitors and soliciting business in multiple languages. All the men were dressed in gho, the traditional robes; women wore kira, long skirts with jacket tops. Mistakenly, I thought their dress was for tourists. I soon found that the Bhutanese commonly wear traditional garb, including many of the hospital’s physicians and nurses. Often referred to as the last

Issue 17 18 // Emergency Physicians International

Languages by the numbers

28% Sharchhopka

24% Dzongkha (official)

22% Lhotshamkha

26% Other

~ Physician Density

.26/1000 0.26 physicans per 1,000 population

“Shangri-La,” the fictional Himalayan site in James Hilton’s 1933 novel Lost Horizon, Bhutan is the only country to promote Gross National Happiness (GNH) as official public policy. Open to tourism only since 1974, it has added modern conveniences very gradually; television and the Internet were outlawed until 1999. Today, in the two larger cities, cell phones ring constantly and there is widespread Internet access and cable television in multiple languages. Most foreigners come to trek through the spectacularly diverse landscape and to experience the culture: people in traditional dress and houses built in traditional styles, often adorned with large fertility penis illustrations. Although the country is small, a rudimentary highway system of narrow, winding roads with no guard rails, often stubbornly clinging to steep mountainsides and plagued by frequent landslides during the rainy season, makes travel onerous and somewhat dangerous. My visit to Bhutan had been arranged through Health Volunteers Overseas, an NGO that has been

photo by Göran Höglund (Kartläsarn)

A man reads scriptures at Paro dzong (photo by Nagarjun Kandukuru)

active in Bhutan for years. Based at the Jigme Dorji Wangchuck National Referral Hospital (JDWNR) in the capital, Thimphu, my month-long volunteer position was to work, teach, and consult with the physicians in their busy ED. In that position, I received a grand tour of the entire Bhutanese population. Since this was the country’s only tertiary care and teaching hospital, all patients referred from other regions of the country automatically came first to the ED. Thus, in the large, boxlike ED, we saw patients from every part of the country—from the highest reaches of the Himalayas to the jungles bordering India. The Next Generation One of the benefits of this month was the opportunity to work with an amazing group of nine EDbased general medical officers and a bevy of industrious nurses. Most of these physicians had recently graduated from medical schools in Sri Lanka, India, and Cuba, among others (at that time, Bhutan had no medical school of its own), and most were doing an internship/social service year while they awaited a government-sponsored residency position in another country (Bhutan currently has no residency programs). After selecting students for medi-

cal school on a merit-based system, the government then pays for their education and requires them to work for the government on their return. Officials can send these tyros anywhere in the country, including extremely remote areas. Their working environment could be a Basic Health Unit, a District Hospital, or one of the country’s four larger hospitals. Work Languages One of the amazing things about working in Bhutan is that, while the hospital’s work language is officially English, all the physicians and most of the nurses speak at least four languages: English, Dzonga (the language most common in Thimphu), Tibetan, and Nepali. Many also speak at least one other language— often one from Eastern Bhutan. Although there are at least 13 languages in this tiny country, the ED personnel could approach a patient or family member and immediately identify a coworker who also spoke that language. That was the case with a Buddhist nun from a remote region who presented after a grand mal seizure. Since not more than 100 people spoke her language, we had to await one of the staff internists, who also spoke that language. Cultural Experience My big plunge into the local cul-

ture was purchasing and attempting to wear a gho. My Western roommate helped me put it on, but, as I walked to work, all the children I passed stared and giggled. Upon arriving at the ED, the nurses quickly hustled me into their break room and re-draped my robes. As they explained, expert assistance is essential, since the gho must be draped exactly right or you get the reaction I did. If it is draped correctly, you receive smiles, nods and compliments. While I found the belt almost suffocating, the front flap formed the biggest pocket in the world. It’s so big that cameras, wallets, and keys disappeared in the huge space. And, if you’re wondering what you wear underneath, it’s the same as the Scotsmen. In the summer months, Bhutanese men wear little or nothing (being a prudish Westerner, I wore shorts); in the winter, they often wear long underwear. During my few free weekend days, I was able to appreciate some of Bhutan’s amazing sites. There was almost no place where pointing a camera wouldn’t result in great pictures. Truthfully, though, it took quite a bit of effort to get up to the Taktsang Pahphug monastery, also known as Tiger’s Nest—one of the most awesome sights in the world. Even so, the lasting images I carry with me stem mainly from working alongside the wonderful Bhutanese doctors, nurses, technicians and students—and very interesting patients.

Dr. Iserson is the author of “The Global Healthcare Volunteers’ Handbook: What You Need to Know Before You Go” (2014); www. galenpress.com, and “Improvised Medicine: Providing Care in Extreme Environments” (2013), McGraw-Hill

www.epijournal.com

FIELD REPORT

(L) Smuggling oxygen cylinder on foot past the blockade on the city. (R) Dr. Ahmad holds a shell that landed in the hospital

WINTER 2015

YEMEN: EMERGENCY CARE UNDER FIRE In Taiz, an epicenter of the destruction in Yemen’s civil war, a recent medical graduate is among the skeleton crew providing care at Al-Thawra Hospital. In this active war zone, there are severe shortages of medical supplies and electricity—but no shortage of patients. interview with

dr. ahmad domainy

civil war suddenly broke out in Yemen, in March 2015. A group known as the Houthis, allied to the military units loyal to the former president, swept across the country causing the current president (elected after the Arab Spring) to flee. In 8

response, a coalition led by Saudi Arabia began an aerial bombing effort. Intense battles have since occurred in residential areas of many major cities as ground forces loyal to the current president, Southern Separatists, along with other armed political and extremist groups, and Coalition ground forces all try to take control of the cities infiltrated by the Houthis and their allies. In addition to an appalling number of civilian casualties and deaths (including many women and children), the infrastructure has become nonfunctional (electricity services, fuel services, garbage services, water and food delivery). Many have fled their homes and face a daily struggle to survive by finding food, water, and shelter in the face of scarcities, massive inflation, and lack of jobs and salaries. Unfortunately, medical services have not been spared, either. This

Issue 17 18 // Emergency Physicians International

Taiz By the Numbers

20 out of 25 Hospitals closed in Taiz

1 out of 8 Mother & child healthcare facilities closed in Taiz

$42-$70 Price for 20 litres of fuel on the black market

month, the International Committee of the Red Cross insisted that deliberate attacks on healthcare facilities must stop. Hospitals are continually under shelling, bombing, and sniper attacks. Patients and staff have been injured and facilities have been damaged. Many hospitals have closed and those that continue to operate do so under extreme shortages of staff and supplies, as well as daily personal danger. Dr. Ahmad Domainy, a recent medical school graduate, continues to work at Al-Thawra Hospital in the center of Taiz, the most severely affected city in Yemen. Taiz city has a population of approximately 1 million people, and Al-Thawra serves patients from the entire governorate, which has a population of about 3 million people. Of the approximately 25 hospitals in the city, only five remain somewhat functional. Approximately 600,000 people have fled their homes, becoming “internally displaced persons.” “At the beginning of the war, most of the medical and administrative staff left the hospital,” said Domainy. “Our staff decreased from 350 to 150. Due to the dangers of traveling, most of us were forced to live in the hospital itself.

If all of us left, who would care for these patients? “Because of my posting about war crimes on Facebook, I am afraid to return to my home as I am certain that my name and photo are in the hands of the militias running the checkpoints. I fear I will be abducted or killed. “[At the hospital], we are constantly exposed to mortar fire, artillery fire, and sniper attacks. So far, 15 of the medical staff have been wounded. One of our paramedics was shot in the head and killed while trying to rescue the injured in his ambulance. Our intensive care unit was shelled and totally destroyed. The shelling took the life of one of our nurses. “For seven months now we have not received any salaries. There has

been no money to purchase medications for the patients, and there has been no money for lab test solutions. We have been able to find some charitable individuals who have helped with the some of the costs. But because of the siege on the city and country there is an extreme shortage of medications and IV solutions. The blockade has even prevented oxygen tanks from entering the city. At great risk we have found ways to smuggle in oxygen and medications through the blockade away from the eyes of the invaders. “There has been very limited electricity and not enough diesel to fuel the main hospital generator. We use several small generators to

power the x-ray machine, OR, and lab. In spite of this, we have been able to offer some care to an average of 50 wounded patients a day. During recent months, the arrival of the rainy season in conjunction with the buildup of garbage in the city, has brought on a dengue fever epidemic. We had been accepting over 100 cases a day of dengue fever and malaria. So we decided to open a special unit to treat Dengue Fever and, with the help of some charitable individuals, we have been able to treat many patients free of charge when we could find the supplies to do so. “Those of us who have stayed to work believe it is our holy duty to do so. If all of us left, who would care for these patients? We need training, supplies and medical charities to help us out. You may not know who we are. But please know that in this spot in the world there are people who just want to live but are dying because of the work of the enemies of life.”

(L) Dr. Ahmad stands on a burned out tank in Taiz in a lull in the fighting. (R) A roundabout near the hospital.

www.epijournal.com

News & Perspectives

Syrian refugees camp in tents on the Slovenian border with Croatia (R) while in Greece they wait en masse for humanitarian assistance (L).

Winter is Coming Autumn turns to a winter that few of Europe’s beleagured asylum seekers have ever experienced. Dr. Keith Raymond gives a front-line physician’s perspective from Vienna.

ienna is the city where East meets West, a city where spies have secret rendezvous in coffee houses. It is a city of intrigue, romance and fine music. The Westbahnhof (the western train station) has become a staging site for asylum seekers. In the small town of Nickelsdorf at the east Austrian border, 4,000 to 10,000 refugees enter daily from Hungary. In the Salzburg Banhof near the western border, the underground parking garage has been turned into a transient camp, housing three thousand refugees daily awaiting trains to Germany. Summer has given way to Autumn, and the bloom is off the rose. Despite the EU taking swift action on behalf of the asylum seekers, frustration is growing amongst them. Old prejudices between Afghans and Syrians have led to brawls in refugee camps in Hamburg. Some 370 Albanians and Pakistanis clashed in a shelter in the German region of Hessen after a dispute over distribution of food. German nationals burned a Sport Hall in Wertheim that was being prepared to receive more refugees. A small village in Bavaria that had a hundred people, mostly retired, has seen its population swell by a thousand refugees, that are now sheltered 10

Issue 18 // Emergency Physicians International

in an old military Kaserne (base). As a result, German authorities are slowly applying the brakes to refugees entering from Austria. To put things in perspective, Austria has a population of about nine million, similar to New York City. Germany has a population of about 81 million, and in this year alone six hundred thousand refugees have arrived from Africa and the Middle East. The inevitable build up along the border has slowly increased tempers. Meanwhile ‘Gut menschen’ (do-gooder Church volunteers) are performing charitable deeds, everything from distributing backpacks with socks and coats to organizing soccer games. The weather is beautiful when it is not raining or cold. Medically, I have seen a huge upsurge in allergic rhinitis and atopic dermatitis, primarily due to exposure to allergens these folks have never previously encountered. Here, the antihistamines must be prescribed, as Claritin and Zyrtec are not over the counter. Additionally, dental problems are coming to light, as some of the refugees have never seen a dentist in their life. I saw one man whose teeth were almost entirely rotted out, and in need of removal. Sadly, dentures were not covered. On top of this, dietary restrictions and changes amongst the refugees point to future nutritional deficiencies, particularly in the children. Still there is optimism for the most part. This may change as winter sets in. The nut trees and berry bushes have been exceedingly generous this autumn. The bees have stored rich honey. Both are indicators of heavy snow and a long winter. A winter that few if any of the asylum seekers have experienced before. To date, the EU has not mandated medical screening exams for asylum seekers. This may change as endemics arise in the camps. The language barrier remains stark. Recently, I reviewed a patient’s medications and found she had been taking vaginal tablets orally.

Ocular Irrigation: As Easy as 1-2-3 1

She was embarrassed when I noted and clarified her treatment. Still, this happens even when there is not a language barrier. Pressured practices and the inability of the patient to read instructions not in Arabic contributed. Fortunately, she suffered no ill effects. I sense a growing sense of expectation – sometimes entitlement – from the refugees. Back in Afghanistan, Syria, Nigeria, Iran, and other countries, these citizens were not offered the same privileges from their governments. Housing, food, and funds were not volunteered. In Austria, asylum seekers are given 45 Euros a month, while in Germany that figure is triple. But these funds come from limited resources, and as a result Austria is considering the possibility of taxing incarcerated prisoners. While it may not offset the short fall, it provides an indication of the times. The Hungarians have recently closed their Croatian and Serbian borders, so the tide of asylum seekers are shifting toward Slovenia, after which they will travel north into Austria, and the city of Linz will become the next staging site, with Spielberg on the Slovenia border being the choke point. While my wife and I were vacationing in Italy, traveling by rail, many Americans traveling along with us, voiced their frustration that they had been diverted to Linz, as the Salzburg rail station had been closed to all but asylum seekers. I merely shrugged and shook my head. Clearly the misperception that a vacation trumps asylum was fixed in their minds. Perhaps such luxuries will be indulged in the future, perhaps not.

Patient enters, eyes inflamed.

Attach to I.V. set, start flow, then insert the Morgan Lens. In less than 20 seconds, irrigation is underway and your hands are free to help elsewhere.

THE MORGAN LENS. SAVING EYES. KEEPING HANDS FREE. • The only “hands-free” method for ocular irrigation—frees staff • Effectively removes chemicals or non-embedded foreign bodies • 100% of fluid treats the injury • Eliminates blinking reflex—no pooling • Patient rests comfortably with eyes closed • Patient may be transported without stopping irrigation Fast, comfortable, and effective—there’s a reason 95% of the hospitals in the USA use the Morgan Lens.

NGOs

Assessing Needs: Are You Asking the Right Questions? A healthcare project in Tijuana highlighted the need for NGOs to begin with an accurate and thorough needs assessment. Only then can an emergency medicine team enter into a local context in a helpful and lasting way. by mary cheffers, md; todd

schneberk, md; craig torres-ness, md; ariel bowman, md

Issue 18 // Emergency Physicians International

he delivery of medical care in developing countries by volunteers should always face the “Volunteers challenge of being honest with conducting the itself. The goal is to provide a population with resources it normally cansurvey expressed not access, but too often there is a lack of how it enriched rigor in the allocation of said resources and a lack of reassessment through outcome meatheir interaction surements. This is an all-too familiar scenarwith patients, io—both on a local and a global level. Owas it created an ing perhaps to the good intentions always at the forefront of these projects, it is often opportunity to easy to deliver redundant, unneeded services speak to the or to misappropriate funds and resources. A recent example of this can be found in patients about post-civil war Rwanda, when several NGOs their lives and their were found to be delivering superfluous services with no quality measurements or asdifficulties.” sessments of their respective benefit to the communities they served. The Rwandan government ultimately established regulatory standards for NGOs to ensure their efforts were more suited to the needs of the people. Recently, in southern California, we had the opportunity to work with a local NGO that makes frequent trips to the border city of Tijuana, Mexico in order to deliver primary and urgent care in several low-income neighborhoods, including slum areas. The population served by this NGO has evolved over the course of the past decade, the neighborhoods have improved, and the healthcare system in Mexico has also expanded public health coverage. While the initial need of these populations was patent at the inception of this NGO, a brief inquiry revealed that they had not organized a needs assessment to evaluate and adjust their interventions in response to the

Below, volunteer healthcare workers in a triage tent in Tijuana prepare for the day to begin.

A Model for Establishing a Needs Assessment to Improve Volunteer Medical Care Establish the goal of the needs assessment. Our goal was to characterize the demographics, socioeconomic status, public health status, and health care access of people living in the zones served by a free clinic in order to help identify needed interventions and guide resource allotment by the clinicâ&#x20AC;&#x2122;s management.

changes around them. We built a volunteer team of pre-health students to perform a needs assessment and demographic survey of all the patients seen at these clinics. This has given new energy within the group to adapt to the current needs of this community, and likely changes will include expanding to new neighborhoods and seeking new interventions with lasting effects, such as lead testing in children, and addressing barriers to the primary care system. From this initial survey will also follow several more assessments to better evaluate subsets of the population that come to the clinic. Volunteers conducting the survey expressed how it enriched their interaction with patients, as it created an opportunity to speak to the patients about their lives and their difficulties. The patients themselves enthusiastically engaged the survey, because it gave them a chance to express their gratitude for the services provided. This collaboration was a good reminder of how medical providers can be of use to these local organizations, which often have resources but may lack information or knowledge on how to apply them most effectively and efficiently. In our case, it has been a rewarding experience for both the members of this local organization and the emergency physicians involved. We believe that this type of partnership between community organizations and international emergency medicine endeavors is a great model for the future. This model can lead not only to effective change abroad but reduces redundant, parallel, and at times competing work. FURTHER READING: In the Aftermath of Genocide: The U.S. Role in Rwanda By Robert E. Gribbin iUniverse Publishing 2005.

Create targeted questions for the needs assessment. Questions were either created de novo or copied from publicly available household surveys, and adapted to fit the setting and limitations of our interview setting. Collect the data. Bilingual volunteers interviewed all willing clinic patients during all hours the clinic was open. One person per household was interviewed, and our goal was to conduct the survey in 10 minutes. Analyze the data. The surveys from the various sites were analyzed and compared to extract the information we were interested in. Use the data to create a focused a secondary survey. The secondary survey should focus on a health need in the population identified on the previous survey e.g. diarrheal disease, which can be targeted with an intervention in the subsequent step. The goal should be to demonstrate the foundation for an implementation.

www.epijournal.com

Interview

EPI: How has the Emirates Society of Emergency Medicine (ESEM) changed since its inception?

Dr. Saleh Fares on EM in the United Arab Emirates As President of the young Emirates Society of Emergency Medicine (ESEM), Dr. Saleh Fares and his fellow society members have worked closely with each other to tighten training and clinical practice protocols, and advocate broader recognition and support for EM from both the people and the government of the United Arab Emirates. We talked with Dr. Fares about the recent and upcoming projects of the ESEM society, and his hopes for EM in the UAE and the broader Middle Eastern region. interview by lonnie stoltzfoos

DR. SALEH FARES: When we started ESEM, in August 2012, our hope was to gather the emergency medicine (EM) community in the United Arab Emirates to work together and develop the infrastructure of EM in the country. Those efforts actually went quite a long way. We managed to attract many emergency physicians (EPs), EM residents, and medical students, and that broad range of support from our members really boosted and empowered the society and enabled us to achieve many completed projects and successes. We offer opportunities for EM trainees and residents to become involved with our activities as volunteers or as speakers, depending on their level, which many have found to be very exciting and rewarding. So the key was to bring everyone in the field together, and ESEM has served as a good medium for that. In the past, many of us EPs in the UAE were a fragmented group, for lack of a better term, but now it seems everyone knows each other on a first name basis. We gather very frequently for various activities and meetings, scientific activities, and to contribute to the future of EM in the UAE. ESEM was recently awarded the privilege of hosting the International Conference on Emergency Medicine (ICEM) in Dubai in 2021, which is a big achievement for a young society just over 3 years old. We also hosted an IFEM symposium in Abu Dhabi in June 2015. Over the past 3 years I think we’ve been one of the most—perhaps the most—active EM society in the Middle East, and that’s brought a lot of good attention to us.

EPI: How do you think ESEM members and activities have influenced performance metrics of Emirati EM practice and outcomes thus far? FARES: ESEM has helped reshape the UAE’s perspective of EM as a whole, although that’s a subjective evaluation. A way to do that is by devising and sharing and discussing clinical practice guidelines, which results in more scientific activities, which then inform and hopefully improve processes, which then improve clinical outcomes. It’d be difficult for me to cite figures, because one of the weaknesses here in the region is

Issue 18 // Emergency Physicians International

In all the aspects of EM we are focusing on now, from pre-hospital care to boosting the academic level to establishing a really robust emergency response system, being abroad allows me to benchmark our accomplishments to an international level. Our vision of EM in the UAE is a tailored vision. It’s not a cut and paste version of an existing system—it’s a mixture of European, North American and Middle Eastern EM models.

good data—but we are working on that. We believe that, based on our collaborative efforts, we will be seeing favorable outcomes in the UAE, and hopefully the region, at least in terms of decreased mortality and morbidity in many of the emergency diseases, such as trauma, acute coronary syndrome, and so forth. We now have a STEMI network in Abu Dhabi and Dubai, for a start, and ESEM played a strong role in bringing that about, which I believe is bringing much improved outcomes and decreasing the door-to-balloon times in the region. We are preparing for a big campaign on first-aid training. The UAE doesn’t have a responder protection law, more commonly known as a Good Samaritan law, and that presents a big disincentive to the community for intervening in the field when there’s a first-aid need. So we are hoping to train the community and to encourage them to participate and not shy away from such important interventions. This will truly save many lives! We are also working on establishing a role in the credentialing process for emergency physicians. ESEM will hopefully be able to guide the accreditation, and the evaluation and the credentialing process, for EPs in the UAE. We do frequently make recommendations for staffing, equipment, and so forth. ESEM members also contribute to medical protocols. For example, we recently published an ultrasound credentialing curriculum, which was supported by IFEM and was the first such ultrasound document to be published on the IFEM website.

Formal EM and EM subspecialty training is moving forward strongly in the UAE. we currently have 5 EM residency programs across the country. Although we have subspecialists and experts in toxicology, intensive care, emergency ultrasound, disaster medicine, and prehospital care, for example, we have yet to formalize EM subspecialty training and fellowships within the country. But that’s on the horizon.

EPI: You received medical training in Europe, completed your EM residency and EM board in Canada, and completed a disaster medicine fellowship in the United States. How has your international perspective informed your practice of EM in the Middle East? FARES: I was very fortunate to receive the medical training and exposure that I got. Meeting so many pioneers of the field in the continent where EM started, and exchanging ideas with them, enabled me to envision the future of EM in the UAE, and the work I’m doing now is basically just trying to bring that vision to reality. In all the aspects of EM we are focusing on now, from pre-hospital care to boosting the academic level to establishing a really robust emergency response system, being abroad allows me to benchmark our accomplishments to an international level. Our vision of EM in the UAE is a tailored vision. It’s not a cut and paste version of an existing system—it’s a mixture of European, North American and Middle Eastern EM models. It’s a vision to fit the needs of the UAE, and that’s what’s making it work, in my opinion.

EPI: What are some of the greatest challenges faced by EM in the UAE? And some of the greatest opportunities for growth? FARES: The current challenge, which we are trying to overcome, is the small number of qualified emergency physicians. But at the same time it’s an opportunity, because that’s enabling us to boost and empower residency programs. The other challenge is overcoming the lack of clear understanding of true EM as a science in the region, but that problem is common anywhere

Interview

EM is new. Recognition is growing, however, thanks to the great work of our members. ESEM was recently recognized as the most successful medical society in the UAE, and there’s strong interest among medical students in pursuing EM as a career. So that by itself started as a challenge, but ended up being an opportunity to expand the specialty itself. One other main challenge is the lack of an EM “umbrella” organization; for example, we don’t have a governing EM body. ESEM is trying to cover that gap until a formal organization comes about. With the lack of this organizational body comes a lack of funding, but again, as an EM community, our advocacy is starting to get good recognition now. As for growth opportunities, I think there’s huge need for pre-hospital care here. There’s a lot of potential for expanding and forming a state-of-the art EMS system to serve the country. Given the political heat in the region now, it’s easy to argue that a good emergency medical system, including pre-hospital care and robust emergency care, is a vital part of any healthcare infrastructure investment here. Despite economic fluctuations in the region, healthcare investment is very well positioned in the UAE, and I’m seeing more investment in emergency healthcare now than before. This may not be as applicable to, let’s say, less acute diseases or less acute subspecialties, but in higher acuity EM there’s a still good bit of support from the government and the private sector. Cost effective and innovative emergency care projects can be an attractive opportunity for support and investment. Finally, in addition to pre-hospital care, I also see an opportunity for expanding EM training in our academic facilities. The number of universities and hospitals is increasing in the region, many of which are interested in having EM as one of their priorities.

EPI: What is the typical spread of patients who present to the ED in the UAE, in terms of cardiac, trauma, and other presentations? FARES: It depends. Across the country, EM has his-

Issue 18 // Emergency Physicians International

torically been used for primary care due to the lack of official primary care in the system. For some time (and this is changing), the majority of cases we’d see in the ED were low acuity—upper respiratory infections, gastroenteritis, etc., and other common complaints, with the minority of cases being high acuity. This is changing now for two or three main reasons, one of which is the increase of primary care access, and the second reason is the improved understanding of emergency medicine and emergency departments. People realize now that there’s no point in waiting in an emergency department for hours if they could get the same treatment somewhere else. Finally, ESEM, as well as the government, are discouraging use of the ED for unnecessary complaints.

EPI: Who are other regional leaders in EM whose work you admire? FARES: There are many. But I would mention Dr. Ahmed Wazzan, the President of the Saudi Society of Emergency Medicine. He is very active and very humble and also very keen to improve EM in a huge kingdom. Saudi Arabia is a very big country, and the society has been doing a great job with his leadership. The second person I would mention is Junaid Razzak. Dr. Razzak did a great job in Pakistan. Despite the limited resources and the security situation there, he managed to get a great emergency system in Pakistan, but specifically in Karachi, a very busy, heavily condensed city.

EPI: What are the next steps for ESEM? FARES: The next step for ESEM is to continue growing. We’re supportive of, and eager to collaborate with, regional and international societies. We firmly believe that emergency medicine has no borders and we should all work together. The unique mission of EM is to save lives in what are usually grave or adverse circumstances, and EM is truly a fundamental need in any healthcare sector. So we are eager to participate in many more projects to continue this work and I’m blessed to have a strong team to work with in achieving our goals.

EMERGENCY PHYSICIANS INTERNATIONAL X TELEMEDICINE MAGAZINE

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pharmacy

Rx for change

Next Up for Telepharmacy Telepharmacy is only beginning to scratch the surface of its full potential as a tool for improving patient care and optimizing the pharmacy workforce. by brian roberts

While telepharmacy has a long history – Australia’s Royal Flying Doctor Service used a radio consultation to verify the administration of medications to a remote patient in 1942 – it wasn’t utilized in the United States until the 2000s. In the last fifteen years, healthcare has seen two broad applications of telepharmacy, hospitalbased and community-based, each carrying unique challenges and opportunities. Hospital Telepharmacy Structured from early successful teleradiology models, the hospital application of telepharmacy involves remote verification from a licensed clinical pharmacist for a prescription ordered by a healthcare provider. As automated dispensing cabinets become increasingly common in U.S. hospitals, facilities need this 24/7 verification to ensure nurses are dispensing medications that are safe for the patient, rather than overriding medications at the cabinet and discovering a problem when it’s too late. In rural areas, 18

recommended 24/7 coverage is often unavailable as trained clinical pharmacists may be attracted to larger urban centers. Telepharmacy allows these hospitals to outsource to a third-party company or “share” a pharmacist between sites, decreasing the cost for the facility and providing tele-monitoring for other facilities. Telepharmacy also enables hospitals to better manage their staffing levels during natural ebbs and flows in pharmacy workflow. For instance, following a morning medication pass, the pharmacy may receive a spike in the number of prescription requests to be filled. Rather than staffing for this level, hospitals are able to maintain a mean-level of pharmacists, filling in when needed with remote services. As electronic health records become mainstream, telepharmacists also have the ability to interface directly into hospital health information systems or patient records, ensuring they have the most accurate information possible before making any medication decision. Telepharmacy enables hospitals of all sizes to better use their on-site pharmacists for patient care activities. The role of the pharmacist continues to evolve to that of a care provider, and the ability to receive reimbursement for direct patient care provided by a hospital pharmacist grows. Whether it be discharge counseling or medication reconciliation, numerous studies show that on-site pharmacists can be better utilized on hospital floors rather than remaining in the pharmacy to verify medication orders. Community Telepharmacy Following the recession of 2007-2008 the number of independent pharmacies in rural areas decreased, leaving patients in rural areas without many services including medication counseling. In conjunction with Medicare reimbursement changes, community pharmacists weren’t able to maintain their practices despite the increasing role for pharmacists as care providers. In 2001, North Dakota became the first

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continued on page 20

workforce impact

Will the rise in telepharmacy reduce our need for pharmacists?

urprisingly, and perhaps counterintuitively, telepharmacy doesn’t reduce a need for pharmacists, but allows for a reallocation of labor. Rather than spending a shift verifying medication orders or filling prescriptions, the on-site pharmacists are able to be more involved in other clinical activities, which will in turn improve patient outcomes, reduce readmissions, and improve hospital clinical activity and profits. The ASHP practice model actually favors bifurcating order entry and verification from clinical services and working with care teams. While there is the potential for rural hospitals to reduce their labor costs by staffing to a mean level, rather than consistently staffing for peak order times, telepharmacy also provides clinical pharmacist coverage to facilities that may have had periods of no coverage before due to cost restraints. Because a telepharmacist can generally cost a hospital less than staffing for a fulltime employee due to the ability to have labor sharing between facilities, it makes 24/7 pharmacist coverage more attainable. This is a very important service for hospitals that have recently implemented CPOE (Computer Physician Order Entry) and need real time verification. By providing this additional coverage, telepharmacy may actually be adding staffing when there was previously no pharmacist covering that shift. Given that 24/7 coverage is a recommendation of the Joint Commission, anything that makes this a more attainable goal for hospital pharmacies is a step in the right direction.

Tomorrow’s Pharmacy Today

KitCheck

Three game-changing pharmacy innovations are reducing error and lowering costs by michael levin-epstein

GoToPills What percentage of medications prescribed in the United States are taken off-label? The answer might shock you. After attorney Tamera Venzke spoke to a client who had suffered serious kidney complications after taking a drug approved only for migraines, she decided to take action. With her physician partner Jim Brantner, she founded GoToPills, which provides a free app for consumers to check drugs they’ve been prescribed for FDA-approved uses. And it offers physicians and pharmacists a comprehensive suite of tools — including off-label alerts, off-label informed consents, and FDA-approved list functions — to make sure they’ve made the right prescribing decision and GotoPillsRx, which tailors medications for each patient. GoToPills is easily integrated into electronic health and e-prescribing systems, according to Venzke. The company was selected by Walgreens to be part of their healthcare app portfolio, she notes, and other affiliations are on the horizon: “GoToPills is in discussion with NASA to be part of the medication program for astronauts and is in discussion with a chain of hospitals for implementation of the prescribing tools,” Venzke tells Telemedicine Magazine. “The health and lawsuit risks associated with off-label drugs are substantial,” Venzke asserts. “Since 2009, more than 14 billion dollars have been paid in off-label drugs settlements and that number is growing.”

ScriptPro Are you ready to have your prescriptions filled by robots? With ScriptPro’s Compact Robotic System (CRS), currently on permanent display in Cleveland, Ohio, at the HIMSS Innovation Center — part of the Global Center for Health Innovation — you can see the robotic future in telepharmacy. The CRS display features a touchscreen kiosk that enables visitors to fill and dispense a sample prescription through the robot. This showcases, according to company officials, the “efficiency, safety, and accuracy” of ScriptPro systems as they are utilized in retail and ambulatory pharmacy operations. Behind the scenes—and less evident to Innovation Center visitors—are ScriptPro’s strategic planning and financial management services designed to help health systems succeed in a dynamic and financially challenging environment. The Global Center for Health Innovation functions as a permanent demonstration and testing site open year round to show how interoperable technologies improve the quality and efficiency of care for patients and communities.

One evening KitCheck founder Kevin MacDonald was having dinner with a hospital pharmacist who had just spent two days manually checking pharmacy kits for proper medications and expiration dates. With his background in cloud software and RFID, McDonald was confident this mundane task could be automated. What he found out was that not only could automation reduce labor time by about 90%, but it could also eliminate human error. “In just about three years, more than 200 hospitals have adopted KitCheck, which has resulted in an average savings of 71%-96% in labor cost while simultaneously improving kit stocking accuracy by virtually 100%,” says Chief Marketing Officer Bret Kinsella. Kinsella believes that the benefits of KitCheck will make it an industry standard and expects AnesthesiaCheck, the company’s other product, to take off as well for use in the OR. We’re entering a new era of data-driven pharmacy, says Kinsella. “Clinical pharmacy decisions are already being made using data analytics,” Kinsella says. “KitCheck’s solutions are the first to provide medication tracking and operational data, which will enable optimized processes, real-time visibility and better decision making.” Legislators are considering measures to require medication tracking from manufacturers to distributors to the hospital, Kinsella adds. That will be implemented over the next five years to provide a robust view of medication through the hospital supply chain, perhaps similar to the Food Safety Modernization Act now regulates the food chain. “Within a decade, we will know the trail from manufacture to patient use for every medication,” he says, “and companies like KitCheck will provide data to support that visibility and also automate handling processes along the path.” www.epijournal.com

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geriatrics

TELEPHARMACY continued from page 12

state to allow retail pharmacies to operate without requiring a licensed pharmacist to be physically present. Instead, a pharmacy technician staffs the facility, with a fully licensed pharmacist available remotely to answer any questions and verify medication orders. In this simple way, many retail pharmacies can share the services of one centrally located pharmacist. This system was implemented in the U.S. Navy in 2010 as the largest telepharmacy implementation at that point. A supervising pharmacist offsite can view original prescriptions, offer video consultations, and remotely distribute medications (which are visually verified with another camera on-site) to patients onboard the ships. Future Applications Telepharmacy is growing, but the available technology is still underutilized. While the proof points for patient safety are well developed, the industry is now becoming more nuanced, exploring potential benefits of telepharmacy from an operational standpoint. Recent legislation has been promising, as it redefines the role of the pharmacist as a car provider, particularly in rural areas, allowing these providers to receive Medicare reimbursements for telepharmacy. Telepharmacy is in its infancy, but it’s an idea whose time has come. Whether that means integrating remote pharmacists into patient bedside consultations, or offering home-consults for patients in extremely rural areas, the options are broad, with many more applications yet to be explored.

caveat emptor

Dr. Google and the Dark Side of Telemedicine Telemedicine offers great advances in care delivery, but providers need to be savvy to the pitfalls, such as non evidencebased apps and patients misrepresenting themselves online. A little “buyer beware” will go a long way. by jodi lyons

“All the dollars in healthcare have multiple zeros behind them, that’s just how it works. The average revenue per user in Facebook is $4. For eBay it’s $89 dollars, for Amazon it’s $109 dollars. For Medicare it’s $1,200.” - Abhas Gupta, partner, Mohr Davidow Ventures 20

Issue 18 // Emergency Physicians International

As the telemedicine market opens up, patients will be exposed to even more unverified, unhelpful information than they already are. Many of you have had patients show up to your offices with “evidence” printed off of some random website and demanding a particular “medical” treatment. “Dr. Internet” is a popular physician who never went to medical school and doesn’t know the patient, yet dispenses “notquite-but-awfully-close-to-medical” advice. Whether it’s coconut oil for Alzheimer’s Disease or krill oil for cancer, patients are sure to get upset when you tell them that their requested treatment is quackery. Patients therefore are forced into an odd dichotomy – a balance between buyer beware and buyer have faith. “Buyer have faith” – credat emptor – is a term that describes the scenario in which the buyer should ethically be able to trust the advice and expertise of the “seller” – in this case, the person providing medical information

Percentage of employees who used a telemedicine offering this past year as part of employee wellness programs

or care. To quote an old commercial, “an educated consumer is our best customer.” This challenge is only going to get worse as the telemedicine market opens up and web-based applications “replace” humanto-human interaction between medical professionals and patients. The art and science of medicine can be supported by, but not replaced by, an algorithm. It is important to preserve the instinct, training, education, experience, and compassion that medical professionals bring to the table so that the diagnosis and treatment plan don’t take place in a vacuum. The analysis of data is only one part of the equation. Products based on symptom checkers and the like present a particular challenge. Think of how many diseases or adverse reactions to medications manifest themselves in “flu-like symptoms.” Another challenge is mimicking symptoms: is it a GI bleed or a side effect of bismuth sulfide? How are patients to know if they have a serious problem or not? How do they know who or what to trust? Consumer education is vital as is a clear means of differentiating between reliable sources and quacks. Most professionals understand the difference between scientifically validated information with peer review and the information found in a chat room where no one has any medical expertise. Many consumers don’t know the difference. It also is important to differentiate between “real” telemedicine and “there’s an app for that” faux telemedicine. The telemedicine industry needs to thoroughly educate the consumer base so that the distinction between legitimate telemedicine practices and quacks are more easily identifiable. This is vital for patient protection

It is important to differentiate between “real” telemedicine and “there’s an app for that” faux telemedicine. – buyer beware. The second side of the equation is “seller beware.” Medical professionals face a particular challenge if they don’t have a preexisting, face-to-face relationship with the patients before embarking on a telemedicine relationship. That is the “danger” of relying on patient self-reported symptoms and allergies. While similar challenges exist when enrolling a new patient even in a traditional office visit, the online-only world raises the stakes. There is limited data on the patient, and that data often is patient self-reported. How is the practitioner supposed to know if or how much the patient is cognitively impaired? A drug user/abuser? Confused? Misunderstanding the questions or situation? Doctor-shopping? Lonely and just needing someone to talk to? A hypochondriac? It is often easier to “see” these challenges face-to-face. Particularly in the world of geriatrics, it is important in both face to face and telemedicine interactions to perform some sort

Droning On: Improving Access in Rwanda In the landlocked, hilly East African nation of Rwanda, the delivery of necessary medical supplies to remote areas has been a tortuous, if not impossible task. That may all change next year when Rwanda serves as a testing ground for a proposed cargo drone route that

of cognitive and mood screening that identifies executive functioning and decisional capacity, not just a test of short-term memory. This allows the medical professionals a chance to decide whether or not to trust the patient’s self-reporting, to know if the patient truly is able to understand the medical recommendations, to identify whether or not the patient is capable of adhering to the recommendations, and to decide whether or not to treat the patient. There are evidence-based, scientifically validated cognitive assessment and mood screening tools that can be administered in 15 minutes or less in-person, online, or over the phone even over asynchronous care. Using them protects both the patient and the medical professional. Short-term memory retention only tells a small part of the story and tests like the MMSE don’t give enough guidance to the practitioner. Additionally, as the population ages, it becomes even more important to understand the psychosocial and practical implications of the medical interaction. If the medical practitioner calls in a prescription, does s/he know if the patient is able to get the medication and take it properly? Does the practitioner need to know or have they done their job just by calling in the prescription? Is there a need for follow up? Who arranges the follow up? The expanding world of telemedicine and web-based medical advice creates many opportunities to expand access to medical care, especially to those who are not wellserved by “traditional” means. Yet, just as patients need to beware of bad information on the Internet, medical professionals need to beware of bad information from the patients. Buyer and seller, beware!

would deliver medical supplies to hard-toreach villages. The proposal, put forth by the British architecture firm Foster + Partners along with the Swiss Federal Institute of Technology and its Afrotech initiative, calls for unmanned drones with a wingspan of 10 feet to carry deliveries weighing up to 22 lbs. www.epijournal.com

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valencia

the internet of medical things

Is Telemed Connectivity “A QualcommSized Problem”? The founder and leader of Qualcomm Life, Qualcomm’s healthcare subsidiary, Rick Valencia directs product, technology and M&A strategy in the wireless health market. With more than 25 years of experience in rapidgrowth, technologyenabled businesses – not to mention his involvement with organizations like the World Economic Forum and Rock Health, Valencia has a voice that is helping shape the telemedicine market. Telemedicine editorial director Bill Gordon caught up with him to find out where he sees the market heading.

TelemedMag: What is your vision for mHealth/telemedicine in the future?

TelemedMag: Who are the Qualcomm Life partners you are most excited about and why?

rick valencia:

valencia:

Qualcomm Life’s vision has always been a world with access to health care anytime, anywhere, and we have been working to establish and support new care models to make this vision a reality. Health care has historically been very siloed and has revolved around episodic care being delivered in traditional settings – like a hospital or doctor’s office. With the pervasiveness of mobile and connectivity solutions, we see care shifting from episodic to continuous, and being delivered whenever and wherever the patient needs it. Powering this shift is what we call the Internet of Medical Things – a digital ecosystem of medical data, devices and sensors that are all interconnected, and that eventually play an important role in a patient’s care journey. Qualcomm Life’s focus and investment will be a catalyst in the Internet of Medical Things, ultimately enabling intelligent care everywhere.

Issue 18 // Emergency Physicians International

We have a robust ecosystem of more than 2,000 member companies spanning the health care spectrum, including medical device manufacturers, pharmaceutical organizations, health care providers, application developers and more. Just this week we announced that Qualcomm Life acquired Capsule Technologie, a leading global provider of medical device integration and clinical data management solutions with more than 1,930 hospital clients in 38 countries. By combining Qualcomm Life’s wireless expertise and ecosystem of connected medical devices outside of the hospital with Capsule’s leadership for connecting medical devices, EMR’s and IT systems across the hospital enterprise, we are creating one of the world’s largest open, medical device ecosystems to deliver intelligent care everywhere. Some recent examples of the great work being done within our ecosystem include

our collaboration with Northern Arizona Healthcare, who is leveraging Qualcomm Life’s 2net™ platform as well as HealthyCircles™ to enable an improved remote monitoring solution that expands and enhances the care of cardiac patients, pulmonary patients and those needing postoperative care. This model has been especially effective for remote patients in rural areas of Arizona who have limited access to electricity and running water. Earlier this year, we also announced a collaboration with Walgreens. By powering connectivity for their Balance Rewards mobile application, Qualcomm Life allows members to sync select mHealth devices directly to their Balance Rewards account, earning points, which ultimately turn into cash, to reward and incentivize healthy behaviors. TelemedMag: In your opinion, what is the biggest roadblock to wider spread success and/or adoption in the mHealth/telemedicine world? valencia:

There are two significant roadblocks that continually come up: data security and scalability. Overcoming the many challenges that are inherent in healthcare systems around the world requires unprecedented wireless expertise, borderless connections, a global, secure infrastructure, and an open ecosystem approach. Fortunately, making connected health care a reality is a Qualcomm-sized problem. TelemedMag: What are the future technologies in development that will change the game? valencia:

The Internet of Medical Things is here – and changing people’s lives as we speak. In powering and shaping new digital relationships with traditional and nontraditional partners and patients, we are creating a secure connected fabric that will enable devices and sensors in and around the consumer to connect directly to data and to each other. This data liquidity and accessibility will unlock value by enabling

We are creating a secure connected fabric that will enable devices and sensors in and around the consumer to connect directly to data and to each other. This data liquidity and accessibility will unlock value by enabling systems and companies to securely connect, share, and develop breakthrough intelligence and care efficiencies. systems and companies to securely connect, share, and develop breakthrough intelligence and care efficiencies. This is changing the way consumers receive and act on personal health information, care for themselves, engage providers, and interact with technology. TelemedMag: Any final observations about the telemedicine market? valencia:

With the recent chronic care management (CCM) reimbursement codes and the hospital readmissions penalization, providers are finally being incentivized to keep patients healthier and out of acute care settings. This is a major shift from what has historically been an industry based on a feefor-service model to a fee-for-value or outcomes based reimbursement model. With these changes well underway, telemedicine and mobile health will be critical in keeping at-risk patient populations out of acute care and ambulatory settings through remote monitoring programs.

Qualcomm’s Village Boasting a diverse healthcare ecosystem composed of medical devices, platforms, and applications, you’d be forgiven for asking, “what exactly does Qualcomm Life do?” With an overarching aim as broad as it is ambitious – to make the healthcare system accessible – Qualcomm Life centers heavily around its cloud-based 2net platform. This platform provides digital data acquisition, transmission, and storage of patient records in order to facilitate a seamless mobile connection between physicians, pharmacist, and the patient. Qualcomm Life calls this ‘The Healthy Circle’ and hopes that by connecting the key players in healthcare they can help educate and guide recovery for the patient while keeping providers informed and keeping costs contained. -Taja Whitted

www.epijournal.com

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virtual reality

HOLODECK MEDICINE: How Immersive Technology Is Changing the Doctor’s Point Of View by Scott Jung

ne of the hottest trends in the computer industry is augmented and virtual reality, a computing environment which partially or completely skews reality with computer-generated imagery. Somewhat like a primitive version of Star Trek’s “holodeck”, this technology allows a user an escape from real life with immersive sound, lifelike visuals, and interactive, gesturebased interaction. While virtual reality is finding itself increasingly in the next generation of video games, both augmented reality, in which images and information is superimposed over real-world images, and virtual reality, in which one’s entire field of view is completely computer-generated, is also being trialed in the healthcare industry, namely medical education. While an experienced doctor is still absolutely essential, “augmented medicine” and other new technologies are allowing them to extend their talents even further and learn even more about the human body and disease. For patients, this could mean reduced costs and better outcomes for surgical procedures and treatments. Here’s our list of notable technologies that you might someday see in a medical school or doctor’s office near you. 24

Issue 18 // Emergency Physicians International

Smartglass Learning Ever since the launch of Google Glass in 2013, the tech industry has eagerly speculated about how each field of medicine would embrace it. In August 2013, a surgeon at the Ohio State University Medical Center wore Google Glass during an ACL repair as medical students watched the live-stream on laptops in another area, and since then, a number of doctors have started using Google Glass to stream and record their surgical procedures for educational purposes. Google Glass was officially discontinued in its current form in early 2015, but some are still hopeful that smartglasses might still be the next revolution in surgery technology. One company, Pristine, has developed a program called EyeSight to stream and record live video and photos from the smartglass user’s point of view. This content

Smartglasses by inSight Augmented Medicine

can be shared with a colleague with a simple voice command. Another company, inSight Augmented Medicine, has developed a similar app called Telepresence that can transmit the smartglass user’s point of view to a remote user’s tablet. The tablet user can annotate the video or picture with their finger, and the video feed with annotations, drawings, and text is transmitted back to the smartglasses and seen through its display. Both EyeSight and Telepresence were developed for multiple smartglass platforms, so Google Glass is not required.

Augmented reality can be used to make anatomy education an immersive experience. (Pictured: the Microsoft HoloLens.)

Microsoft Kinect One gadget that could prove beneficial during surgery may already be sitting next to your TV. Microsoft’s Kinect motion-sensing camera has already shown itself to be a useful tool to help surgeons view and manipulate medical images. Within the sterile field, surgeons are usually unable to operate a mouse, keyboard, or even a touch screen with their hands. The Kinect makes viewing and manipulating images and patient data as simple as waving their arms. Moreover, the camera in the Kinect is sensitive enough even to detect subtle changes in a patient’s skin color. An additional Kinect device could theoretically be aimed at the patient being operated on to monitor a user’s heart rate or track radiation exposure from x-rays or CT scans.

Immersive Surgical Navigation & Planning Brain surgery has always been a risky undertaking. Not only because the brain is the control center for the entire body, but also because it contains a dense network of blood vessels and anatomical features that are unique for every person and extremely delicate to navigate. One company, Surgical Theater, took inspiration from flight simulation technology and developed a platform which integrates CT and MRI scans and traditional x-rays to create a highly detailed three-dimensional model of the part of the brain being operated on. These models can be manipulated and used for planning the best entry/ incision point, the best path around the patient’s vasculature and the minimum amount of skull bone

needed to be removed to facilitate faster healing. Recently, Surgical Theater received approval in the EU to incorporate virtual reality headsets for enhanced navigation and planning. Once the procedure is planned, the details can be imported into another Surgical Theater program which allows the surgeon to see the 3D model and plan in real time from inside the operating room.

-----Tablet-Based Augmented Reality Tablet computers have transformed the computing industry because of their portability and ever-increasing processing power. Fraunhofer MEVIS research center in Germany has harnessed the power of the tablet computer and developed www.epijournal.com

epi x telemedicine tech

virtual reality

an augmented reality app to assist with liver cancer surgery. CT scans are used to create a model of the liver and its cancerous site to assist with preoperative planning. However, instead ofbeing sent to a stationary computer monitor, the model is sent to a tablet computer. As a result, a surgeon can superimpose the exact locations of important blood vessels and anatomical features during a procedure when the tablet is held over the patient’s actual liver. The liver can be filmed with the built-in camera, and the tablet can be operated as normal with touch gestures. This technology helps ensure that the surgeon doesn’t make any unnecessary cuts, can make adjustments quickly and flexibly, and completely remove the cancer.

-----Oculus Rift Goes Way Beyond Gaming Like the Kinect, the Oculus Rift is another gaming device that is dabbling in the medical technology industry. The Oculus Rift is a virtual reality headset that displays a fully immersive 3D experience that makes you feel like you are actually in the middle of an environment. Motion sensors detect when you move your head and change your perspective accordingly. Now owned by Facebook, Oculus Rift is still looking for its niche in gaming and consumer media, but it’s already been 26

used as an immersive medical learning tool. Last July, a surgeon in France wore a GoPro Dual Hero camera system on his head as he performed a total hip replacement surgery. The cameras created a stereoscopic 3D video that could be viewed through the Oculus Rift. Moreover, the sensors in the Oculus Rift allowed the viewer to move his or her head and focus on different aspects of the procedure, such as the surgical site or the assistants. The team behind the surgery hopes that doctors anywhere in the world would someday be able to observe a surgical procedure by simply donning an Oculus Rift. They believe that the headset can be a revolutionary learning tool for both new and experienced surgeons.

Issue 18 // Emergency Physicians International

Doctors aren’t the only ones that have all the fun when it comes to Oculus Rift, however. They’re also being evaluated in patients as a form of virtual reality therapy (VRT). Dr. Albert “Skip” Rizzo of the University of Southern California’s Institute for Creative Technologies has developed an Oculus Rift version of the Virtual Iraq/Afghanistan PTSD Exposure Therapy System that he created in 2005 to help treat war veterans suffering from PTSD. The system uses virtual reality to recreate combat situations to help alleviate fearful associations linked to traumatic memories and has been shown to significantly reduce PTSD symptoms. According to Rizzo, the lower price point of the Oculus Rift will make it much more affordable for clinics and allow for research to expand to other areas of mental health.

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// parachute packers Dr. Idrose making coffee for department staff—his first task on his day working as a hospital attendant.

“Having simple but tasteful coffee served in the pantry are little things in my department to keep our staff motivated, or to at least demonstrate that we care about our staff. That morning I stirred a jug and it passed as ‘alright’ among the morning staff.”

Emergency Medicine ‘In Their Shoes’ After working as a doctor for almost 15 years in Kuala Lampur – eight as an emergency physician – I decided that I needed a better understanding of the work being performed by our support staff. So I embarked on a two day exercise of working in the role of each member of my team, from the assistant medical officer to the staff nurse. The lessons I learned walking in their shoes were both humbling and profound.

by dr. alzamani mohammad idrose

doctor does not work alone. This is especially true at the emergency department (ED), where a good team is needed to ensure all aspects of patients’ care are met. Apart from doctors, the backbone of the team is primarily made up of assistant medical officers (AMOs), nurses, and hospital attendants. Behind every service that a doctor renders to each patient, a lot of work is done behind the scenes by these groups of people. For example, before a doctor sees a patient for consultation at the ED, patients are “triaged” by the triage officer—who is either an AMO or a nurse. Apart from triaging, AMOs and SNs also perform a wide range of jobs for patient care from setting up intravenous lines to resuscitation of criticallyill patients and the subsequent care. During resuscitation, a doctor, among other things, may order certain drugs to be prepared or given by an SN and even directs AMO or other staff to take turns doing the chest compression or other procedures. On the other hand, hospital attendants may play a role in assisting doctors—sending specimens to the lab, cleaning and sterilizing equipment, or pushing patients on wheelchairs or trolleys to the wards after

admission has been decided by doctors. Permission to Assume Duties of Others I had been working as a doctor for almost 15 years, and eight of those years as an emergency physician. During these years, I had only observed and given remarks regarding the duties of these support staff, but never in my past had I performed their duties myself. I asked my Head of Department at Hospital Kuala Lumpur, Professor Dato’ Sri Dr. Abu Hassan Asaari Abdullah to allow me to perform their duties at my department, and had my roster as specialist rearranged. The reason I wanted to do this was to understand their work by experience. I received permission to do so over a period of two days, so I informed the supervisors and got their uniforms on loan to wear during my new duties. In the Hospital Attendant’s Shoes After receiving permission to “walk in their shoes,” I went ahead and started performing various duties of a hospital attendant in my department. I started off by making coffee in the pantry for staff. Having simple but tasteful coffee served in the pantry are little things in my department www.epijournal.com

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to keep our staff motivated, or to at least demonstrate that we care about our staff. My coffee may not be as good as the experienced ones, like Kak Noraini Hasan, who was legendary with the excellent way she turned government-supplied coffee into tasty “San Francisco Coffee-like coffees” with refreshing aromas. But that morning I stirred a jug and it passed as “alright” among the morning staff. Perhaps the secret ingredient is the passion and sincerity in making one. I then moved on to the resuscitation area and started to clean used resuscitation equipment. With Pakcik Rashid (who had been with us for almost 30 years), we cleaned used oxygen masks, tubings, and nebulizer containers. Together we scrubbed them hard and washed with soap and sponge before rinsing each one of them thoroughly. As I worked with him, I witnessed the passion in him in ensuring that each used equipment was cleaned and restored to good as new. The equipment was subsequently autoclaved, sterilized, and repacked to be kept in hygienic condition for use on other patients. It was sheer hard work, as each one was scrubbed rigorously under running water and cleaning solution in the form of Chlorhexidine 1%. This he has performed with no loss in thoroughness for the last 30 years, and I immediately realized what a gem we had in our attendants. All I knew before this was just ordering the equipment when I needed it. I never had the slightest thought of who cleaned up after me and who packed things up for me. We owe it to them in ensuring that our equipment is clean, and that new patients using them do not get infected. After completing the cleaning task, I joined the consultation room to assist doctors. My medical officer could not help but smile looking at his specialist taking orders from him. But in that green uniform, I was an attendant taking his every order diligently in full character and seriously asking him to give me order as his willing and ready staff. I assisted him in calling patients in or sending investigation specimens to the lab. Intermittently, I would send patients re28

Performing triage is not an easy task. I found that, in many situations, the AMOs had more experience and expertise than a young doctor. They not only used all their senses but at times developed a sixth sense whereby their gut feeling made them decide that certain patients were not well and deserved to be in a critical category.

quiring admission to the wards. A few staff in the ward recognized me in my attendant uniform and they could not help wondering what I was doing by assuming a different role. When asked, I just smiled and continued with my work. I had to get my job done right without unnecessary distractions. In experiencing their work sending patients up to the wards, I realized that our hospital attendants are important ambassadors for our hospital. The way they handle and communicate with our patients on the way to the ward would influence patients’ perception of our hospital. The attendants have an opportunity to create a good impression of hospital services if they can provide comfort to patients as they are wheeled to the wards. In the Assistant Medical Officer’s Shoes Now finished with my work as an attendant, I continued work as an AMO. Among others, my job was to handle patients at the triage counter where every patient was assessed and vital signs taken before category of severity is determined. Patients are categorized as critical (red), semi-critical (yellow), and non-critical (green). Critical pa-

Issue 17 // Emergency Physicians International

tients would be sent to the “red zone” and these patients have a “zero minutes” waiting time. Semi-critical and non-critical category patients were sent to yellow and green zones with a waiting time of at least 15 and 90 minutes, respectively. Performing triage is not an easy task. I found that, in many situations, the AMOs had more experience and expertise than a young doctor. They not only used all their senses but at times developed a sixth sense whereby, for a reason that cannot be explained, their gut feeling made them decide that certain patients were not well and deserved to be in a critical category. I also had to deal with patients with poor manners and arrogant behavior. Nevertheless, my AMOs demonstrated patience and respectful communication. Some patients were demanding, but the triage officers used their skills in explaining to patients the current situation and the reason why some of them had to wait a bit longer than the rest when we were inundated by an overwhelming flow of patients. The AMOs’ role at the triage counter is most challenging, especially because one has to muster a lot of patience. They had to deal with demanding and rude patients and relatives and still, under management’s orders, remain calm and collected. They even smiled in the face of adversity. There were episodes in the past where the AMOs were assaulted by dissatisfied relatives. One even broke the front glass with a chair. It takes, at times, superhuman qualities to handle patients and relatives at the front counter, but the AMOs do all the challenging triage and communication for us while we concentrate on treating patients within protected walls. Apart from triaging, I went on to handling patients at the resuscitation zone, transfer and transport of patients, doing wound stitching, assisting doctors and specialists in resuscitation, and handling equipment, oxygen, and ventilators. They are the expert in all equipment used in our department. This experience provided me with insight into their work challenges. Indeed, without their contribution, our work at the ED would be crippled. They made sure all

high by any international standard. They were indeed the backbone of our department. I understood better their work after this short stint.

Clockwise from left: Dr. Idrose washing equipment as a hospital attendant; taking orders from a doctor as a hospital attendant; and working as a triage officer in the ED.

equipment was in order, all ventilators were charged, patients attended to in time, and medications served accordingly at the procedure room. In the Staff Nurse Shoes After working as a hospital attendant and an AMO, the last thing I had left to do was to work as a nurse. So I borrowed a male nurse uniform and reported for duty to my matron. I joined the morning round with my boss. I got asked questions about head trauma and had to answer as a nurse. Everybody referred to me as Nurse Alza, which

was my nickname, for the day. Among my duties then were getting patients’ vital signs, getting the electrocardiogram for an asthmatic patient who just had gas given (nebulizer), transferring patients to wards, charting patient’s observation, preparing drugs and equipment, preparing sedatives, ensuring each cubicle was clean and that patients’ blankets covered them properly, and that the bed sheet was clean and kempt. As I worked, a psychiatric patient who had stabbed herself was suddenly brought in by our ambulance with the knife in-situ, and I prepared the donut stabilizer and did urine toxicology test. Fortunately, the patient was stable, as she had narrowly missed her large vessel in the tummy, which would have been fatal for her. The only extra thing I did as a nurse on that day was performing ultrasound to assess abdominal injury (which a number of our nurses and AMOs could do), as it was too critical to waste time. The patient survived, thankfully, and was brought to operation theatre in good time. (The surgeon who came was puzzled as to why I was in a nurse uniform.) I appreciate the work of my nurses very much. Many of them did not even have time to have breakfast, as the volume of patients at our department was very

The Parachute Packer As I completed all my chores in the shoes of hospital attendant, AMO, and nurse, I gained a real understanding and perspective of their roles in my department. I believed this experience would arm me with real grassroots information on their function and improve my decision making and planning in my role as a specialist. While “walking in their shoes,” I was also reminded of the story of the parachute packer: There was a seasoned parachute jumper in the air force. He had jumped for hundreds of times in his career and landed safely each time. As he was about to retire, the office threw a farewell party. As the party ended, a stranger came to him to say hello. ‘Do I know you from somewhere?’ he asked. The stranger said, ‘I am your parachute packer. You probably never saw me, as I worked silently in the store room. But I made sure that each parachute I packed was faultless and would open perfectly every time it was used. I am glad your parachutes had no problems and worked every time. All the best for you, Sir.’ The man then left the parachute jumper, who began to think. He had never thought about the people who spent countless hours quietly making sure that he would be able to land safely and go home to his family and continue to make a living. He just realized that he never even said thank you to this man during the whole of his lifetime. As he realized this, he went back to the parachute packer and thanked him, although it was late in his career. Who are your parachute packers? In my department, I now know who they are. Among others, my attendants, AMOs, and my nurses are my parachute packers. I resumed my duties as a doctor subsequent to these job changes with a renewed understanding and clear perspective of my parachute packers, and in appreciating them as my team members. www.epijournal.com

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The Good Samaritan in Law and Practice A study of international protection for emergency responders

by tiffany lee, ma, jd, rmp

ood Samaritan laws are designed to encourage helping behavior in people who witness an emergency situation. Typically, Good Samaritan laws do this by protecting the person who responds from legal consequences if there is a negative outcome despite the responderâ&#x20AC;&#x2122;s best efforts. That individual is then able to assist in good faith without the fear of legal action. There are two types of laws that are typically described as Good Samaritan laws: (1) laws which protect a voluntary responder when they provide assistance to an emergency victim in good faith and without any anticipation of a reward or compensation (primarily seen in the 30

United States), and (2) laws that require anyone witnessing an emergency situation to assist the victim(s) in whatever way they are competent and able to do so, as long as it would not put them at risk as well (primarily seen in Europe and Australia). Many of these laws also contain provisions to protect responders from a civil suit or criminal charges when they act because of a legally compelled duty, and act in an appropriate manner. Good Samaritan laws (also known as responder protection laws) vary greatly in the level and type of protections they provide, as well as the persons and situations they will protect. Such variations are heavily influenced by countriesâ&#x20AC;&#x2122; cultural and legal contexts. This paper examines existing laws of this type, and provides recommendations for best practices in implementing effective responder protection laws that strike a balance between encouraging bystanders to provide rapid assistance to victims of emergencies and the need to leave adequate legal remedies to protect victims who are injured by an abusive or neglectful responder. The Need to Protect Responders In the United States, most people who

Issue 18 // Emergency Physicians International

give assistance in an emergency assume that they have some form of legal protection if they act in good faith. In most countries where this protection is lacking, many people also know that they do not have any protection, resulting in potentially tragic consequences. The most recent and shocking example of this is the series of cases in China, beginning with the Peng Yu case in Nanjing, in 2007. In this case, an elderly woman fell when exiting a city bus. Peng Yu, who had exited the bus just before the woman, assisted her and helped her to the hospital. Later, the woman and her family sued Peng Yu, alleging that he had caused the fall.1 There was no evidence that Peng Yu had in fact caused the fall, but the judge reasoned that Peng Yu would not have assisted the woman unless he was at fault in the accident. This case established a presumption that, lacking clear evidence to the contrary, a rescuer could be held at fault in any accident in which they offered assistance. This ruling led to a series of cases in which injured individuals sued those coming to their aid, alleging that the rescuer had caused the injury. The injured person usually won in court, unless there was clear proof that the rescuer was not involved in causing the injury, usually in the form of witness statements

or video evidence. These cases caused bystanders to fear getting involved when someone was injured or in danger, because they knew how easily they could be held liable for the injury. This led to one instance in 2009 where a man who had fallen and was injured shouted to the crowd, “It is not anybody’s fault. I fell by myself ” in an attempt to prompt someone to assist him.2 After a series of highly publicized accidents in which injured people, including a young child, were left to die without assistance, Shenzhen province implemented China’s first Good Samaritan law in 2013. This law protects those who help an injured person from civil liability for their actions, unless they clearly commit a major fault in their actions. In addition, the law removes the presumption that a rescuer is liable for the injury, and places the burden of proof on the injured party who wants to sue a rescuer for the original injury.3 This law is still very new, and its effects are not yet known. The hope, of course, is that this law will relieve the fears of potential responders and encourage them to help the injured and prevent unnecessary death and disability. Characteristics of Existing Laws Existing Good Samaritan laws share some similarities in both coverage and intent, but there are notable differences. In the United States, each of the 50 states has its own law. Some of these state laws are single, standalone Good Samaritan laws, where all types of medical professionals as well as bystanders are given protection for a range of good faith rescue and assistance behaviors. In other states, the Good Samaritan laws are a compilation of related laws, with each law protecting one particular profession or class of individuals. The type of behavior typically protected in Good Samaritan Laws in the United States is reasonable behavior, or behavior that, at most, could be considered ordinary negligence.4 Gross negligence, actions taken in bad faith, reckless behavior, and intentional injury are specifically excluded in most of the existing Good Samaritan laws.5 The activities covered by current Good

Samaritan statutes in the United States range from a very narrow and specific list of first aid skills6 to very general classes of activities.7 Some US states only protect assistance that is given at the scene of an accident8 or at the scene of an emergency.9 A minority of states provide protection for assistance given during transit to the hospital.10 In New South Wales, the Civil Liability Act 2002 gives very broad protection to any person who acts as a Good Samaritan out of goodwill and without an expectation of compensation. The law protects

There are also variations in the location where protected care can be given. Many existing laws protect only that care which is given at the scene of the accident or emergency. This could complicate protection for a Good Samaritan if a victim is able to escape or move away from the scene of the emergency, yet still requires essential medical assistance. those providing both medical and nonmedical assistance during an emergency to a person who is injured or at risk of becoming injured.11 The law in Western Australia is similar.12 In Canada, Prince Edward Island provides broad protection to voluntary responders.13 The law grants protection to those who assist an injured or ill person because of an emergency or accident, regardless of whether the assistance is rendered at the scene of the accident or elsewhere. Responders must act without expectation of compensation and are not covered if their behavior is grossly negligent. The law in Nova Scotia is similar and includes protection for those who donate or distribute food in an emergency, as long as the donor or distributer believed the food to be fit for

human consumption at the time of donation or distribution.14 ANALYSIS Protected Individuals Existing laws in the United States are not consistent in who is protected by the Good Samaritan law. Two classes of potentially protected persons emerge from the existing laws: medical professionals, and all members of society. Each potentially protected group offers something different to the victim of an accident or serious illness. Medical professionals, of course, can often provide the ill or injured with a higher level of care than the untrained bystander. Medical professionals are a small group, however, and finding one at the scene of every emergency is unlikely. Bystanders, although having either no training or only a little training, may still be able to assist in some way. A bystander may be able to help control severe bleeding, pull an accident victim from a burning car, or use an automated external defibrillator. These actions are potentially lifesaving, or may at least serve to bridge a gap between an accident and the arrival of trained personnel. The issue of who should be provided with legal protection is particularly significant in those areas of the world where emergency medical systems are not fully developed. In these areas, bystander assistance may be the only help given to an ill or injured person before the victim arrives at the hospital. Refusing protection to the untrained or lesser trained bystander would discourage these people from providing assistance and may greatly reduce the chance of a victim receiving lifesaving care. Protected Actions and Locations Protection can be offered for a variety of emergency situations and for different actions taken in response to those emergency situations. There are three commonly protected scenarios: sudden life or limb threatening emergencies such as accidents, falls, and natural disasters; illnesses not caused by an accident, or another external emergency situation, such as a heart attack; and www.epijournal.com

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transportation to a higher level of medical care after either an accident or sudden illness. Three types of actions are usually considered for protection in response to one or more of these above scenarios: strictly medical assistance in response to emergent medical needs; non-medical assistance to an emergency scenario, such as pulling a drowning person out of a lake; and providing transportation or transportation assistance. There are also variations in the location where protected care can be given. Many existing laws protect only that care which is given at the scene of the accident or emergency. This could complicate protection for a Good Samaritan if a victim is able to escape or move away from the scene of the emergency, yet still requires essential medical assistance. This is especially true in those areas where definitive medical care is hard to find. A victim may need to travel significant distances to reach the needed care, and might need ongoing support from lay responders to survive the trip. The Nature of the Protection The protection currently offered to responders in the United States is protection from civil suit by the person assisted, and this is the approach China is trying as well. In the European countries that attach responder protection laws to their duty-toact laws, compensation is also occasionally available to responders who are injured while assisting in an emergency. Lay responders in some developing countries may face an additional difficulty: involvement in the criminal justice system, which could include detention for questioning and being forced to travel repeatedly to testify about the incident. Also, people transporting sick or injured people to the hospital may be required to pay the hospital admission fees, and may face detention or civil suit by the hospital if they do not. In these countries, some protection within the criminal justice system is essential, and will need to include a number of considerations. Perhaps most critical is the need to protect the responder from being arrested and charged by the criminal justice system 32

based only on the fact that the responder assisted the victim. Also, in addition to detention by the authorities, it is necessary to restrict the ability of hospitals to detain voluntary rescuers who bring ill or injured people to the hospital. A strong responder protection law should also restrict hospitals from holding rescuers liable for the cost of the injured partyâ&#x20AC;&#x2122;s hospital admission or later medical careâ&#x20AC;&#x201D;either at the time of the actual emergency or through later legal action. The other problem that may keep bystanders from assisting victims of an emergency incident is not personal criminal liability but the substantial inconvenience of being deeply involved in the investigation of the incident. While it is reasonable for a bystander to be asked to provide a statement if they observed an accident or a crime, it discourages helping behaviors if the criminal justice system can force voluntary rescuers to repeatedly testify in person in court, especially when it requires a great deal of uncompensated travel. The fear of time consuming court appearances and significant expenses could deter an otherwise willing rescuer from assisting a person in distress. Proposal for a Model Law From the above analysis, it is possible to develop a model Good Samaritan Law to protect voluntary responders rendering aid in an emergency. This paper presents the model law as a set of guidelines rather than a specific text to ensure that countries with diverse legal systems can individually adapt the guidelines to fit the needs of their legislative processes. To ensure that bystanders will feel comfortable to render aid, it is essential that Good Samaritan laws be as straightforward as possible to avoid confusing potential rescuers and thus deterring them from offering assistance. Generally, this will require a broad range of activities and individuals to be protected. The guidelines that follow reflect the ideal of an easily understood law. To have the greatest effectiveness, a Good Samaritan law must protect both medical professionals and bystanders. Pro-

Issue 18 // Emergency Physicians International

tection for bystanders should include both those bystanders with formal training in first-aid, and those who have no formal training. This is for two reasons. First, bystanders who have received training may not know if the training they received qualifies under the law, and may be hesitant to help if they think they might be exposed to liability. Second, even untrained or minimally trained bystanders may be able to provide life-saving assistance, either from instinct and goodwill, such as pulling someone from a burning car, or from firstaid information they may have acquired in school, in the media, or heard from others. Medical professionals must be protected as well, but the circumstances can be more limited. Because of their training, doctors, nurses, paramedics, and other health professionals are expected to provide a certain standard of care to the ill or injured as part of their jobs. Their formal patients, if they suspect they have been injured by the negligence of the medical professional, should retain some degree of ability to seek a remedy from the medical professional for that injury. Despite the need to offer some remedy to those who may have been harmed, it is nevertheless essential to provide some degree of protection to encourage medical professionals to provide assistance outside of their daily duties. For example, a Good Samaritan law might not apply protections to a physician while on duty in a hospital, but it would protect that doctor when he is off duty and helps at an accident. The other consideration for the protection of medical professionals is whether medical professionals who are licensed in a different country, state, province, or region should be protected if they respond to an emergency. In normal circumstances, it may seem that the benefits of protecting foreign professionals are minimal. In most countries, there will usually not be a large number of foreign medical professionals visiting at any given time, and the chances of them becoming involved in an emergency response resulting in legal action may be slim to none. While it would be most effective for a Good Samaritan law to protect these foreign professionals anyway, to encourage a response from all

possible rescuers, a provision to protect foreign medical professionals can become a critical issue in a widespread disaster. Especially in smaller countries, or those countries still developing their medical and emergency response systems, a major disaster may result in a substantial influx of foreign-licensed medical professionals. If these professionals, often volunteers, are not offered some degree of protection from liability for their assistance, it may become increasingly difficult to find critical professional resources when they are needed. An effective law must also define clearly what actions will be protected under the Good Samaritan law. Good Samaritan laws are generally thought of as pertaining only to medical assistance, but even then, it can be hard to distinguish where strictly medical assistance begins and ends. In addition, Good Samaritan acts can easily diverge from medical assistance to include such acts as transportation to a hospital or removal from a dangerous situation. Since the line between these acts and the provision of medical assistance can blur easily (if a rescuer moves someone from a dangerous situation to facilitate first-aid, for example), it is important to draw clear lines. To ensure responders feel reasonably protected when they act to save a life in an emergency, it is essential that Good Samaritan laws expand their protections beyond strictly medical assistance. The law must also cover the rescue of persons who are reasonably believed to be in immediate danger, and transportation of the ill or injured person to the hospital. Standard of Care While most voluntary responders will assist a victim as best they can and without deliberately doing harm, any law protecting rescuers must also offer some protection to the victim. Most of the Good Samaritan laws already in existence protect those rescuers who act in good faith, and whose actions are either reasonable or demonstrate—at most—ordinary negligence. These laws typically do not protect responders who act in bad faith, are grossly negligent or reckless, or who willfully disregard the safety and wellbeing of the per-

son they purport to be helping. Reasonable behavior, as it is generally defined, is behavior that a person of similar experience and ability would do, or would consider appropriate to do, in the same situation. This decision must take into account a number of characteristics of the responder, including “physical and mental characteristics, moral qualities and skill. This introduces a subjective element into the test to assess the appropriate standard of care. Thus, the standard of care to apply will vary depending on the level of skill and knowledge possessed by the actor.”15 The standard of reasonable behavior could determine, for instance, if removing a car accident victim from a car was based on a reasonable belief that remaining in the car was dangerous, or if removing the person was an act of negligence or recklessness. The Law Reform Commission’s report on the Civil Liability of Good Samaritans and Responders suggests a number of factors courts should consider in determining if a particular responder’s behavior is reasonable or not. These factors are: the probability of an accident caused by the responder’s behavior, the gravity of the threatened injury, the cost of eliminating the risk, and the social utility of the responder’s conduct.16 The last point is particularly noteworthy; this factor suggests that the determination of reasonableness should consider not only the behavior in that particular scenario but also the overall benefit to society of encouraging the conduct. Negligence comprises those actions that do not rise to the standard of reasonable behavior. For example, negligence is “[w] here it can be shown that the Good Samaritan knew or ought to have known that his or her intervention would injure the stranger…”17 Gross negligence is those actions that are performed out of willful neglect or with reckless disregard for the safety of the victim. The line drawn between ordinary and gross negligence in most Good Samaritan laws offers an appropriate level of protection both to those who may be the victim of a rescuer who acts in an extremely inappropriate manner and to those good-faith responders who

END NOTES 1. He, H. (2013, August 1). Shenzhen introduces Good Samaritan law. Retrieved from South China Morning Post: http://www.scmp. com/news/china/article/1293475/shenzhenintroduces-good-samaritan-law 2. Shinan, L. (2011, January 5). Need to protect our Good Samaritans. Retrieved from China Daily: http://www.chinadaily.com.cn/ opinion/2011-01/05/content_11794724.htm 3. He, H. (2013, August 1). Shenzhen introduces Good Samaritan law. Retrieved from South China Morning Post: http://www.scmp. com/news/china/article/1293475/shenzhenintroduces-good-samaritan-law 4. E.g., Conn Gen Stat Ann § 52-557B (2007) 5. E.g., Ind Code Ann § 34-30-12-1 (b) See also Del Code Ann tit. 16 § 6801(a). 6. E.g., Okla. Stat. tit. 76, 5(a)(2). 7. E.g., Md. Code Ann., Cts. & Jud. Proc. 5-603(a). 8. E.g., 745 Ill Comp Stat 49/1-75. 9. E.g., Utah Code Ann. 78-11-22(1). 10. Wash. Rev. Code § 4.24.300. See also Minn. Stat. 604A.01, subd. 2(b); NJSA 2A:62A-1, 2A:62A-8, 2A:62A-9 (2007). 11. Civil Liability Act 2002 Section 57. 12. Civil Liability Act 2002 Section 5AD. 13. Volunteers Liability Act 1988. 14. Volunteer Services Act (Good Samaritan) 1989. 15. Law Reform Commission. (2009). Civil Liability of Good Samaritans and Volunteers. Dublin: Law Reform Commission. 16. Id. 17. Id.

have made an error in judgment during an emergency response. Likewise, responders can feel comfortable knowing that they are protected if they make a good faith mistake while trying to assist in an emergency, while individuals acting in bad faith will not be able to take advantage of the law to cause deliberate harm to others. An effective Good Samaritan law must be easy to understand, provide protection for both local and foreign medical professionals and bystanders, and cover not just medical assistance but also associated emergency care. In addition, a model law must still provide some legal recourse for those who are injured by those acting in bad faith or with gross negligence. These standards will encourage both professionals and bystanders to confidently provide assistance in emergency situations. www.epijournal.com

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

Pundit-Based Medicine Emergency physicians need to pay less attention to what is trending online, and focus more on practicing good, consistent medicine with evidence-based protocols.

We are now generating more scientific publications than ever before—by an order of magnitude. Emergency medicine (EM) sees itself at the forefront of many of the new treatment paradigms, especially in domains such as trauma, stroke, sepsis, cardiology, and geriatrics, where clinical pathways have all changed rapidly over the last decade

We are constantly bombarded by Twitter, Facebook, Whatsapp, new “authoritative” websites, and a myriad of other social media—all so we can “keep up.” Terms such as FOAMed (Free Online Meducation) are promoted to suggest that we might actually be helped by such avenues. How useful is all this information? If we had neglected the last 10 years of these “scientific advances,” would we have lost any salvageable patients? How do we assess whether any of the constant flow of information is useful? Would it matter if many of the advances were delayed by a few years until adequate assessment of cost and impact were undertaken? Even more importantly, if we had not followed the latest trend, and used our energy to focus instead on standardization of current protocols, would we have had better outcomes? The evidence-based medicine movement from 20 years ago promoted evidence above eminence. It seems that now our colleagues bypass reading the real evidence and go straight to the latest false prophet—usually in 140 characters. Just this year, 10 years of sepsis guidelines promoting “Early Goal Directed Therapy” have been thrown out the window. The ARISE, PROCESS, and PROMISE trials showed that good clinical assessment and management was not helped by the arbitrary application of “goals” for resuscitation. The mandatory use of oxygen for critically ill patients has been shown to be potentially harmful in the AVOID trial, despite the constant mantra to use supranormal oxygen therapy. As yet, large RCTs randomizing liberal vs. limited oxygen therapy have not been undertaken. The mandatory use of cervical collars for trauma patients might also be harmful, especially in the elderly. Again, large-scale RCTs showing safety of restricted use of cervical collars are yet to be undertaken. The massive transfusion ratios in trauma of 1:1:1 for blood/FFP/Platelets may kill non-trauma patients, such as those GI hemorrhage, and haven’t stood up in an RCT in trauma. Yet these protocols have been widely promoted because of strong advocacy on the basis of uncontrolled observational studies.

Issue 18 // Emergency Physicians International

The evidence-based medicine movement from 20 years ago promoted evidence above eminence. It seems that now our colleagues bypass reading the real evidence and go straight to the latest false prophet—usually in 140 characters.

The bottom line is that unless there are multiple RCTs demonstrating a clear advantage, we have to be skeptical of all dogma. Especially dogma that comes in sound bites from random websites and without assessment by academic groups. Should the average emergency trainee/physician listen to the constant chatter online, or wait for definitive statements from appropriately qualified expert groups? It seems to me that there is more risk from constantly changing protocols according to fashion than using the current evidence-based protocols consistently. Dr. Peter Cameron is the immediate past president of the International Federation for Emergency Medicine (IFEM)

Kaleida Health Gates Vascular Institute/SUNY at Buffalo

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Issue 18 // Emergency Physicians International