EPI Issue 14

Leader profile: Meet Tanzania’s Hendry Sawe Iraq: Improving healthcare during Arba’een Legal liability for global medical volunteers How to conduct rigorous research in LMICs EMERGENCY PHYSICIANS INTERNATIONAL

ISSUE 14

. FALL 2014 . WWW.EPIJOURNAL.COM

_____ MSF experts provide in-house training in Brussels to MSF staff volunteering for Guinea, Sierra Leone and Liberia. _____

Ebola in the Field

grand rounds – Do post-grad exams really test the soft skills necessary in EM? disaster response – Psychological first aid is critical for both doctors and patients.

Dr. Adam Levine does rounds at Liberia’s largest Ebola clinic. page 20

Emergency Medicine Education Whenever You Want It ANNALS

CARDIOVASCULAR

CLINICAL POLICY

CRITICAL CARE

IMAGES

LECTURES

MOC

MANAGEMENT

PEDIATRICS

PROCEDURES & SKILLS

R/C

STROKE

TRAUMA

ULTRASOUND

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2014-Int

EDITOR’S DESK

A Season of Beginnings

I

t was a big summer for global emergency medicine. We kicked things off with a memorable International Conference on Emergency Medicine (ICEM) in Hong Kong. This 15th ICEM brought together more than 2200 attendees from 66 countries. There were 10 well-attended preconference workshops, 10 simultaneous lecture tracks with 260 speakers presenting over 300 lectures, and over 500 abstract posters. Four of the lecture tracks were presented in Chinese.

Looking forward, all eyes are on ICEM 2016 in Cape Town, followed by ICEM 2018 in Mexico City. Beginning in 2019, this historically biennial conference will move to an annual schedule. Bids to host the 2019 and 2020 ICEMs are currently under consideration, and bids for the 2021 ICEM are currently open. So if your national emergency medicine organization would be interested in organizing and hosting a future ICEM, I’d encourage you to go to IFEM’s web site www.ifem.cc for application instructions.

There’s never been a better time to get involved with global emergency medicine at a strategic level. IFEM committees are experiencing a turn-over in leadership, and I would encourage any interested individuals to sign up for a standing committee in order to gain experience and contribute to the develop of the specialty. There are committees on finance, governance, core curriculum and education, just to name a few. In addition there are task forces to join, from disaster medicine to ultrasound to gender issues. We also may soon be starting a Geriatric Emergency Medicine Special Interest Group. One exciting proposal that has just broken ground is the formation of an International Trainees (“Residents” or “Registrars”) Association under IFEM. So clearly, there is limit to the ways that you can get involved on a global, strategic level.

If your interests are a bit more academic, or university-focused, I’d like to point you towards the work being done by the International Emergency Medicine Fellowship Consortium (IEMFC). I represented IFEM at IEMFC’s annual meeting in August, in New York City, and I can attest that they are doing a superb job of coordinating the programs and efforts of the more than 30 International Emergency Medicine Fellowship Programs now operational. The IEMFC has also developed a web based unified application service for applicants to International Emergency Medicine Fellowship programs, and has developed a close working relationship with the Society for Academic Emergency Medicine (SAEM). Check out their web site (www.iemfellowships.com) for more information.

These are exciting times in the global development of emergency medicine, but we will need many hands, and we’ll need new, innovative leaders to emerge within our midst. Come collaborate with IFEM, for your own professional benefit as well as the benefit of the specialty as a whole. Together we can advance emergency medicine globally! And as always, if you have new ideas for initiatives to help in our common mission, my (virtual) door is always open. Email me at jholliman@cdham.org.

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

Beginning in 2019, ICEM will move to an annual schedule.

Bids to host the 2019 and 2020 ICEMs are currently under consideration, and bids for the 2021 ICEM are currently open. So if your national emergency medicine organization would be interested in organizing and hosting a future ICEM, I’d encourage you to go to IFEM’s web site for application instructions.

Leader profile: Meet Tanzania’s Hendry Sawe Iraq: Improving healthcare during Arba’een Legal liability for global medical volunteers How to conduct rigorous research in LMICs EMERGENCY PHYSICIANS INTERNATIONAL

ISSUE 14

. FALL 2014 . WWW.EPIJOURNAL.COM

_____ MSF experts provide in-house training in Brussels to MSF staff volunteering for Guinea, Sierra Leone and Liberia. _____

Ebola in the Field

grand rounds – Do post-grad exams really test the soft skills necessary in EM?

Dr. Adam Levine does rounds at Liberia’s largest Ebola clinic. page 20

disaster response – Psychological first aid is critical for both doctors and patients.

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

www.epijournal.com

3

LETTER FROM THE PUBLISHER

The Kids Are Alright

W

hen I attended the International Conference on Emergency Medicine (ICEM) in June, I had the opportunity to sit in on a number of IFEM executive meetings. Time and again I would smile as I looked around each conference table and saw the same wise, familiar faces from recent conferences . . . if not from the meeting 30 minutes prior. IFEM can feel a bit like a family, and at these meetings you can feel good knowing that the founding fathers of global EM are still at the helm.

But then I began to wonder. What will happen when these men and women retire?

Who will take their places leading the next critical phase of emergency medicine development? As that question began to gnaw at me I looked around the Hong Kong Convention Center and couldn’t help but feel that there was a noticeable lack of young blood. I had to wonder: which young physicians were being mentored to lead?

This issue we take a look at a few of these new faces. In Europe, Pieter Jan and Riccardo Leto started a Young Physician Section within the European Society for Emergency Medicine. The group – for those under 35 – has thrown educational events, but resources and mentorship from outside the section are limited. EPI supports what the section is doing and would like to see it expanded and replicated in other societies.

Young EPs are making their mark outside of Europe as well. In Tanzania, 33-yearold Hendry Sawe has become the president of the Emergency Medicine Association of Tanzania (read our profile on page 16). In South Africa, 32-year-old Bhakti Hansoti recently conducted a Fogarty-funded project to test a pediatric triage system in Cape Town (more on page 13). In Liberia, Adam Levine is serving with the International Medical Corps at the world’s largest Ebola clinic (report on page 20).

Even younger – but no less vital to the future of EM – are the folks behind the newly minted International Student Association of Emergency Medicine. To truly change the trajectory of emergency care, exposure to emergency medicine needs to happen as early in medical school as possible. And the global EM community needs to be active enough in medical education to guide this exposure (more on ISAEM on page 8).

Global emergency medicine counts numerous sages among its leadership. But for IFEM to help take global emergency medicine to a new level, a new generation will need to be welcomed to the table, and then actively mentored.

Logan Plaster Publisher

on the web

LOG ON TO EPIJOURNAL.COM, THE FIRST GLOBAL EMERGENCY MEDICINE NETWORK • Join more than 2000 registered members from more than 90 countries • Create a professional profile for networking and communicating internationally

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Fall 2014 // Emergency Physicians International

editorial director C. JAMES HOLLIMAN, MD publisher LOGAN PLASTER logan@epijournal.com On Twitter @EPIJournal executive editors PETER CAMERON, MD TERRY MULLIGAN, DO, MPH LEE WALLIS, MD PROF. V. ANANTHARAMAN editors LONNIE STOLTZFOOS GREGORY KING DR. RASHMI SHARMA regional corespondents CONRAD BUCKLE, MD MARCIO RODRIGUES, MD CARLOS RISSA, MD KATRIN HRUSKA, MD SUBROTO DAS, MD MOHAMED AL-ASFOOR, MD JIRAPORN SRI-ON, MD editorial advisors ARIF ALPER CEVIK, MD ANITA BHAVNANI, MD KATE DOUGLASS, MD HAYWOOD HALL, MD CHAK-WAH KAM, MD GREG LARKIN, MD PROF. DONGPILL LEE SAM-BEOM LEE, MD ALBERTO MACHADO, MD JORGE OTERO, MD advertising JAINE ACKLEY The Walchli Tauber Group, Inc. jaine.ackley@wt-group.com 001-443-512-8899 ext. 104

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

You read it at EuSEM...

Now get it at home EMERGENCY PHYSICIANS INTERNATIONAL

Simple ED design tweaks on a budget

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

Design: The Value of In-House Imaging

The eight building blocks of austere medicine

Pan-Asian Council Promotes New Research

Why EDs in Hong Kong Are So Understaffed

Karachi: Prepping the ED for the next blast

Design: The Future of Psych EDs

How Important is Training Standardization?

Surfing doctors put new spin on training

Cameron: Less Turf War, More Collaboration

ISSUE 13

. SUMMER 2014 . WWW.EPIJOURNAL.COM

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

EMERGENCY PHYSICIANS INTERNATIONAL

Typhoon Haiyan Special Report Empowered community health workers form the backbone of disaster relief efforts.

Two Filipino physicians share lessons learned following the typhoon disaster response

ISSUE 12

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SPRING 2014

. WWW.EPIJOURNAL.COM

India’s MVA Problem: Bystander Apathy EMERGENCY PHYSICIANS INTERNATIONAL

ISSUE 11

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

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

.

FALL 2013

. WWW.EPIJOURNAL.COM

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

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

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

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

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

– now available – PRINT SUBSCRIPTIONS GLOBAL SHIPPING INCLUDED EXECUTIVE EDITORS: JIM HOLLIMAN, PETER CAMERON, LEE WALLIS, TERRY MULLIGAN & V. ANANTHARAMAN SCAN THE QR CODE WITH YOUR SMARTPHONE

OR GO TO EPIJOURNAL. BIGCARTEL.COM

EVENT CALENDAR 10/14–11/15 THE COMPREHENSIVE GUIDE TO GLOBAL EM CONFERENCES

DECEMBER Emirates Society of Emergency Medicine Scientific Conference 2014 // Dubai, United Arab Emirates

IN THIS ISSUE www.epijournal.com

December 5-9, 2014 www.esem2014.com Contact: pco@esem2014.com

03 | Editor’s Letter

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

Field Reports

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

04 | Publisher’s Letter

8 | Dispatches 10 | Poland

OCTOBER

MARCH

Pan-Pacific Emergency Medicine Congress 2014 // Daejon, South Korea

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

Departments

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

Keeping research rigorous in resourcelimited settings

October 13-15, 2014 www.2014pemc.org Contact: secretariat@2014pemc.org

11 | Rwanda

13 | Research

NOVEMBER

APRIL

16 | Profile

African Conference on Emergency Medicine (AfCEM) 2014 // Addis Ababa, Ethiopia

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

18 | Austere Medicine

November 4-6, 2014 www.afcem2014.com Contact: www.afcem2014.com/contact-us.html

EMCON 2014 (16th Conference for the Society of Emergency Medicine India) // Mumbai, India November 6-9, 2014 www.emcon2014mumbai.com Contact: vamahospitality@hotmail.com

4th Eurasian Conference on Emergency Medicine // Belek, Turkey November 12-16, 2014 www.eacem2014.org Contact: secretariat@eacem2014.org

5th World Congress on Emergency Medicine // Guadalajara, Mexico November 19-22, 2014 www.urgenciasmexico.org Contact: cgr@att.net.mx

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

SEPTEMBER UK College of Emergency Medicine Scientific Conference // Manchester, United Kingdom September 28-30, 2015 www.collemergencymed.ac.uk

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

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

Tanzania’s Hendry Sawe brings fresh energy to African EM leadership Five tips every emergency physician should know about emergencies at the shore

Reports 20 | Ebola Dr. Adam Levine takes EPI inside the high-risk zone in Liberia’s largest Ebola clinic.

22 | Journal Scan Tranexamic acid for traumatic bleeds.

What does the literature say?

24 | Mass Gatherings Iraq: Can the massive Arba’een pilgrimage rise to a new health standard amidst terrorist chaos?

27 | Disaster Response Psychological first aid: As essential for care-Givers as for their patients

29 | Global Volunteers Understanding the legal liability of participating in healthcare volunteer work. Plus, 10 tips for global volunteers,

by Dr. Ken Iserson.

34 | Grand Rounds

LIST YOUR NEXT INTERNATIONAL EVENT FOR FREE ON THE EPI NETWORK – WWW.EPIJOURNAL.COM/EVENTS 6

Fall 2014 // Emergency Physicians International

Clinical postgrad examinations try to ensure that matriculating physicians are ready for the world of emergency medicine.

But can written exams assess the soft skills necessary to practicing EPs?

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DISPATCHES READER-SUBMITTED UPDATES FROM THE FOUR CORNERS

Global Trends in EM Med School Education Developing EM Starts With Medical School Interest Groups

by Larshan Perinpam & Anh-Nhi Thi Huynh

E

mergency medicine is a constantly evolving and progressive area of medicine but as yet is still not established as an independent specialty in many countries (Denmark, Germany, Brazil to name a few). One of the foundations for the increasing interest in EM is situated in Emergency Medicine Interest Groups (EMIG) amongst medical schools worldwide. By offering medical students lectures, workshops and courses in EM, these groups ignite an interest in this new speciality. The interest for EM that is cultivated in medical school plays a significant role in the making of future EM physicians. It is essential, therefore, for the field of emergency medicine to cultivate and encourage these medical school opportunities.

Despite the importance of EMIGs, no international organization was founded that connects all EMIGs around the world in a unified attempt to develop EM. That led a small group of us to found the International Student Association of Emergency Medicine (ISAEM). We are optimistic about the potential advantages that can arise following the establishment of such an international organization. These include enhancing the awareness and developing the interest of EM amongst medical students; exchanging ideas and information in a more streamlined manner, to create an optimal platform from which to host various educational and promotional events about EM and the coming together of many medical students allowing the forging

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Fall 2014 // Emergency Physicians International

of collaborations and friendships. Furthermore, medical students would be able to connect with other institutions and medical students though exchange programs across international borders and thereby expand their horizons by learning about different cultures within EM and wider society. This would form an experience that would not only embellish their knowledge about EM but also add to their growing experiences as continually developing health professionals, which would inevitably allow them to contribute to the evolution of EM in their own country. These experiences could provide an essential basis from which to push for the establishment of EM as an independent specialty with its own specialty-training program.

We believe there are limitless possibilities for what an international organization connecting all EMIGs in the world can achieve. We are also optimistic that EM will develop further as a specialty worldwide. These represent only a portion of the reasons why we founded ISAEM. Anh-Nhi Thi Hunyh and Larshan Perinpam co-founded ISAEM on the 15th of October 2013. Larshan Perinpam, a medical student from Aarhus University, Denmark and a Research Trainee at both the department of EM at the Mayo Clinic and the Research Center for Emergency Medicine at Aarhus University Hospital, Denmark was elected as the first President of ISAEM. AnhNhi Thi Huynh, a medical student from the University of Southern Denmark and former President of the national student organization for Emergency Medicine in Denmark was elected as the first Vice-president for external affairs of ISAEM. When ISAEM was founded there were no guarantees it would last. Today we are delighted that ISAEM is thriving. ISAEM is currently in the process of liaising with a number of EMIGs that represents a number of different countries. Slowly but surely,

ISAEM will increase the number of EMIGs that it engages to represent more than 10,000 medical students interested in EM worldwide within a year.

Today ISAEM is working closely with a number of international EM societies and organizations. European Society for Emergency Medicine (EuSEM) has been a tremendous helper to us since the conception of ISAEM and today ISAEM is endorsed and recommended by Swedish Society for Emergency Medicine (SWESEM); Danish Society for Emergency Medicine (DASEM); EMRA (based in the United States); AAEM/RSA (based in the United States); European Society for Emergency Medicine (EUSEM) and Professor Colin Graham, Editor-in-Chief of the European Journal of Emergency Medicine, based in Hong Kong.

Among many other projects, ISAEM is currently working on an international exchange program for medical students worldwide to experience EM, and it is our aim that by the summer of 2015, we will be able to send the first medical student abroad to experience EM in another country. In many countries, EM still has a long way to go, but we are confident ISAEM’s relationship with EMIGs throughout the world will be a critical factor in the establishment of EM as an independent specialty. ISAEM will strive to help and further develop EMIGs around the world together with its respective societies and thereby develop EM internationally. Indeed, we believe that “alone we can go fast but together we will go far.”

Learn more about the International Student Association of Emergency Medicine (ISAEM) at www.isaem.net

Q. How could medical school education – specifically exposure to emergency medicine – be improved in your country? ______________________

01 AUSTRALIA Link medical student rotations to physically seeing, clerking and presenting patients to emergency / inpatient physicians.

--------------Get junior emergency medicine doctors to talk to students to tell them what it’s like (e.g. career advice).

--------------I think, in view of all the other pressures on medical education that our students exposure is about right. The only caveat is that a small proportion do a rural GP attachment as an alternative. There is no opportunity for them to do both. ______________________

02 AUSTRIA The current Teutonic system utilizes Trauma Surgeons exclusively. Introducing Emergency Medicine would be a major paradigm shift. If so, the Notarzt would be moved from the ambulance to the Shock Room, which is currently controlled by an Anesthesiologist. Another paradigm shift. Stay tuned.

Keith Raymond, MD ______________________

03 BELGIUM More elaborate topics about EM during the normal curriculum.

Ankur Verma ______________________

04 CROATIA More case presentation in education, more practical skills (reanimation, ventilation, venepunction).

Neven Škaro ______________________

05 DENMARK We need emergency phycians teaching emergency medicine at university, together with the the other specialists.

Today only specialists in specialties

like surgery teach emergency aspects of surgery, anaesthesiologists teach airway management and so on.

Dan Brun Petersen, MD ______________________

06 ESTONIA We need longer practical training.

Currently there is only one seminar for resuscitation. ______________________

07 FRANCE We need mandatory First-Aid classes with average population and nationwide exam questions specifically on emergency medicine. We also need to start five-year training for residents.

Nathalie Flacke, MD ______________________

08 IRAQ We suggested that medical college should add in the currecula for 4th -6th years of medical students level, theory and practical EM subjects. Only two of 19 medical college did. In Iraq we started since 2012 to train all newly graduated doctors in emergency training courses prior to being approved as employees and working in hospital.

The certificate of passing such courses is obligatory for new doctors. The training course range from 10-15 days.

Shakir Katea, MD ______________________

09 ITALY We need mandatory rotations in the ED during the first 2 years of curriculum of every specialty.

Dr. Roberto Cosentini ______________________

10 MEXICO We need to have a course of emergency medicine the same way they have cardiology pulmonary Dr. Roberto Maxwell

--------------We need better cooperation between different schools and institutions.

Dr. Jorge Loria ______________________

11 THE NETHERLANDS We would benefit from lectures by emergency physicians in the university curriculum.

David DuBois ______________________

12 NEW ZEALAND We should have a required one month rotation through ED, CPR & ALS courses.

David DuBois ______________________

13 NICARAGUA One way we could improve would be lectures through videoconferences and procedures about it.

Dr. Carolina Ulloa ______________________

14 PHILIPPINES I think increasing residency programs and slots would increase exposure to it. I’ve never met an EM physician during medical school and we’re in a top 5 school and state funded. I’ve only learned about the handful of EM residencies when I went to the capital city, and applying to another specialty.

Now I’m an applicant for EM. Loreen Cadiz ______________________

15 ROMANIA We need national emergency medicine education because these kinds of specific courses are only six weeks long, in few medical schools only.

Daniela Mitrofan

______________________

15 SWEDEN A better tutorial system would be beneficial.

--------------We need a national curriculum that would have to be endorsed by all medical universities (we are actually working on that within the Swedish association for emergency medicine, but the universities are independent and don’t have to use our guidelines). And we are not enough emergency physicians in Sweden yet to provide good education to all medial students. ______________________

16 TURKEY In our country all the university faculty of medicine haven’t got emergency medicine deparment yet. I think it is so important that having a special deparment for emergency medicine in university hospital. Otherwise, doctors who have not particular education about emergency medicine, especially general surgery specialist or internal diseases specialist, perform in emergency service.

Dr. Derya Abuska --------------Continue to expand classes taught by EM docs to medical students.

Dr. John Fowler ______________________

17 UNITED KINGDOM We need the re-structuring of curriculum (which is happening now to some extent) to reflect the shift in acute care in the UK (i.e. increasing caseload to the emergency department). This needs to take into account that history and examination is more focused, and that we deal more with clinical presentations, rather than deal in symptoms.

Dr. Deepankar Datta ______________________

18 USA We need to ensure a wide spectrum of ED experiences, not just busy academic Level I truama centers. U.S. EM is mostly practiced in smaller community ED (30-50K visits/yr) Brad Goldman, MD www.epijournal.com

9

FIELD REPORT OCTOBER 2014

t Ambulances arrive at an emergency department near downtown Wroclaw

POLAND Poland’s significant emergency medicine problems stem from a lack of funding and a lack of regulations regarding staffing and training. by dariusz timler, md, phd

E

mergency medicine in Poland started in 1999 when the specialization was introduced for the first time and successfully completed by about 800 doctors. Still, a considerable shortage of such emergency specialists can be observed. It is estimated that still 2,500 emergency doctors are needed in Poland.

In Poland today there are a total of 255 EDs that are operating. They have varied bandwidth and offer medical services of varied quality. This may result from the fact that the standards imposed by law refer only to the equipment while there is no precise law on employment. The fact that other medical specialists are allowed in the system may affect the quality of services, which is not satisfactory in all cases.

10

There are a few reasons why this specialization is not frequently chosen by medical graduates. First of all, the obvious lack of possibility of starting their own medical practice and having benefits makes it economically less attractive. Working in emergency medicine also involves being constantly exposed to high stress levels and requires a lot of physical strength. Those who eventually decide on this medical speciality have no opportunity to gain further degrees as it is not regulated by law. The fact that currently in Poland there are no medical journals specialized in rescue medicine with an impact factor makes pursuing an academic career path very difficult.

Another motivation for not choosing this specialization and making an extra effort to study in this new field is the legal situation in Poland which, unlike other European countries, allows different medical specialists to be in the emergency care system. This was done as a solution to a staffing problem, but the result in the end has been a lowering of quality.

Standards imposed by law refer only to the equipment in the ED while the role of highly qualified staff is rather

Fall 2014 // Emergency Physicians International

77.5 Life expectancy in Poland (ranked 46th worldwide)

81 Average life expectancy in Western Europe (highest is 87.2 in Monaco)

underestimated. Poland needs more precise laws on required staffing.

It can be assumed that the employment of specialists in emergency medicine exclusively, including nurses, should become the priority. What should be done in the first place is to encourage the future doctors to decide on this specialization by making it more prestigious. This can be achieved by facilitating the research and the publication in the field with the support of both the international and national medical environment as well as relevant institutions. The Polish researchers whose determination has enabled them to contribute to the scientific achievements in the discussed area up to now deserve much more support. At present, most of the expenses related to the publication of scientific research in Poland are covered from private funds.

While underdeveloped institutional assistance does not work sufficiently, the key role of reputable EuSEM board to improve the present situation cannot be ignored.

Another issue is training itself. The current model only fulfills the requirement of continuous training. It does not state or define the number of obligatory courses within the framework of retraining, not to mention the skills and knowledge to be possessed. Only the carefully planned schedule of training with high standards of teaching can improve the quality of gained experience for future doctors and paramedics. Much financial support – far more than is currently available – is needed.

Especially, in relation with multicentric international research, development of which is limited as grant acquisition is extremely difficult.

All in all, the development of emergency medicine in Poland is very slow now. The pressure of the environment has not been effective so far and the national registry for acute critical illness, injury, syncope, CPR, etc... does not exist. Undoubtedly, such records would help you to create an objective image of emergency medicine today and con-

RWANDA

t Clinical University Hospital in Poznan

Educational advances must be paired with administrative solutions that support consistent, accountable care-giving.

tribute to the development of scientific research, which consequently would improve the quality of health care in our country.

Research projects for CPR (pre- hospital and hospital) as well as for syncope, acute critical illness injuries conducted in most of the resorts in Poland would be of high importance.

What has to be realized in the view of increasing the quality of emergency service in Poland is the poor knowledge of English among paramedics which discourages them from participating in courses organized at the international level. Additionally, the high cost of such training gradually leads to the phenomenon of foreclosure when Polish emergency specialists are left behind the world scientific discussion and cannot benefit from the corresponding achievements. One solution to this problem would be to find a way to lower the charges – at least in the case of the participants conducting relevant research.

The division of funding for hospital and pre-hospital emergencies caused an uneven development of these two sectors, leaving one developed at the other’s expense. The initial enthusiasm for EDs apparently was replaced with the attitude of disapproval due to the wrong estimation that they are unprofitable for the hospital. As a result, directors of hospitals are discouraged from investing in EDs. And this only hinders future graduates from seeing emergency medicine as a viable career.

The realization of the problem is not enough. For several years the Ministry of Health and National Healthcare System (NHS) has not been able to cope with these emergency medicine problems. What Poland needs are clear standards. The already existing resuscitation recommendations and guidelines in Poland need to also include regulations concerning the number of physicians and other staff working at the EDs. This in turn would raise the standard of treatment provided by emergency doctors as well as the safety of patients.

It has been the pattern of the NHS to promote scheduled (elective) services while underfunding other sectors like emergency medicine. As a result, Poland’s 14 trauma centres are at risk of being closed. The situation has gotten so dire that one of the directors was about to resign from his Trauma Center Hospital regardless of a large financial support from the European Union, because the funds were for equipment only.

The time is now for Polish emergency physicians and lawmakers to recognize the critical role of emergency care, and invest not only in equipment, but in personnel and academic research.

Dr. Timler is the head of the emergency department of Copernicus Memorial Hospital in Lodz, Poland. He is also an adjunct at the Medical University of Lodz, Poland and a member of the board of the Polish Society of Emergency Medicine.

RWANDAN HEALTHCARE

BY THE NUMBERS Doctors 1 per 15,428 inhabitants Nurses 1 per 1200 inhabitants Infant Mortality 48.6 per 1000 Under 5 Mortality 72.3 per 1000 Maternal Mortality 487 per 100,000 Source: Rwanda Ministry of Health

by joseph novik, md

I

n the last year of emergency medicine (EM) training, most residents “pre-attend,” over part of an emergency department (ED) under relaxed supervision. Almost exactly five years since my last pre-attending shift, I find myself in Rwanda working in the Kigali University Teaching Hospital Accident and Emergency Department doing the exact opposite; pretending to be a resident. It’s a much harder act.

I start my day seeing a woman in her 30s who was been dyspneic for two weeks. She tells me (through an interpreter) that her chest hurts and she can’t catch her breath. She looks air-starved and her extremities feel cool, though she is not hypotensive. I go through the rest of her history and physical exam, documenting in the paper chart and tracking sheet I designed last night as I go. I share my management plans with the nurse and update a white board we have been piloting. The nurse tells me which orders are unfeasible so I develop a more resource-appropriate plan. We do an ECG together and struggle to adhere the suction-cup style electrodes to her chest. I can trace sinus tachycardia, otherwise nothing specific. Radiology is jammed with patients, and there is not yet a workable system in place to acquire an emergent chest X-ray. An old Siemens ultrasound machine from the nearby ICU becomes available, so I drag it to the patient’s bedside, hoping I can get a look at her heart before the next power outage. It switches on and I see

www.epijournal.com

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FIELD REPORT RWANDA, CONT’D an echocardiogram with all the classic signs of pulmonary embolism. I change my treatment plan again to account for the findings and write prescriptions for enoxaprin, a chest xray, and blood work and give them to the family. The process from initial screening to prescribing medication to the patient takes me just under an hour. I’m happy to make a diagnosis but on a practical note, I need to work through the system much faster. I note the logistics that caused me trouble and will share them, as I do every week, with the emergency interdisciplinary committee – a team of Rwandan and American EM practitioners through which all problems in the ED are addressed. These shifts bring me intimately close to the interface of patient need, the limitations of the ED, and the collective creativity we employ to stretch those limits. We are detailoriented now, preparing for the launch of Rwanda’s first program in Emergency Medicine.

The case for emergency medicine development in Rwanda is strong. Nation wide, communicable disease-contribute to the majority of life lost (77%) followed by non-communicable disease (14%), and injuries (7%). In larger cities like Kigali and Butare, it is estimated that trauma has an even greater impact on death and disability1. With few exceptions, EDs are largely absent from most district hospitals. In referral centers where EDs may exist, general practitioners and nurses with no EM training struggle to care for a hyperacute patient population. Of course, training alone is insufficient. Working at the University teaching hospital in Kigali is a constant reminder of challenges we face to provide patient care in the absence of dependable workflow solutions, diagnostics, and the general predictability of both human and physical resources. Educational advances in Rwandan EM must be paired with administrative solutions that support consistent, accountable, and reliable care-giving.

12

The Rwanda Ministry of Health (MoH) has been addressing the gaps in emergency medicine and other specialties largely through the Human Resources for Health (HRH) initiative, a consortium of 19 US universities.

The HRH program, launched in July 2012, is designed to accelerate growth in quality and quantity of specialized health care providers by coupling foreign and local health care workers in areas of education, administration, and direct patient care. Schools of medicine dentistry, nursing, public health, and management are all involved.

HRH-Rwanda, funded by USAID and Global Fund, is the largest single nation effort of its kind, providing almost 100 full-time physicians working collaboratively across teaching institutions in Rwanda in a variety of critical disciplines. Emergency medicine is a unique branch of this program in that no program or Rwandan EM faculty yet exist, but development of a formal residency program is under the HRH mandate and supported by the MoH and Rwandan Faculty of Medicine Over the past year, US and Rwandan EM stakeholders have harnessed this opportunity to strengthen the foundation for emergency medicine.

A four-year residency curriculum was

Fall 2014 // Emergency Physicians International

5 Dense housing stock in Kigali makes emergency response extremely difficult.

developed and is moving through approval stages. The University Teaching Hospital in Kigali was selected as the primary training location and in partnership with the HRH hospital management team and Columbia University’s sidHARTe (Systems Improvements at District Hospital and Regional training in Emergency care) program, workflow and physical infrastructure system improvement initiatives have been ongoing. Successes over the last year include adaptation and implementation of the South African Triage System, a resuscitation team, a whiteboard patient tracking system, dedicated rooms for patient isolation and procedures, enhanced availability of critical emergency equipment, among others enhancements to patient care and the training environment. We have enjoyed support across specialties and continue to work together to solve interdisciplinary challenges like trauma management and overcrowding. The HRH program also provides financial support for basic equipment needs such as point-of-care blood lab testing, ultrasound machines, monitors, and other critical equipment, which is expected to arrive in the coming months.

Emergency medicine training will initially take two forms. With sidHARTe’s leadership, a two-year, parttime EM post-graduate diploma program will begin this September to address the immediate need for district hospital practitioners with basic skills in EM and critical care. A proportion of graduates from this cadre will then matriculate into a three-year, full-time emergency medicine Masters in Medicine (M-Med) residency program designed and facilitated by HRH-EM faculty.

Coinciding with the HRH initiative is the reorganization of Rwanda’s national university structure. Thanks in part to support from the current Dean of Medicine and leaders of other CONTINUED ON PAGE 33

Research

Keeping Research Rigorous in ResourceLimited Settings A South African study of triage methodologies sheds light on the challenge of applying goldstandard research standards on low-resource health systems by bhakti hansoti, md

I

n South Africa, most primary healthcare clinics see well and sick children but have no formal triage system. Children are seen and treated by nursing staff on a first come, first served basis. This delays identification and referral of critically ill children who need to be sent immediately to a hospital for specialized care. In Cape Town these same clinics see over half of all critically ill children who first present for care. A formal assessment (formal triage) at the point of entry is generally not feasible

and results in critically ill children often waiting several hours prior to their first encounter with a healthcare professional.

As anyone who has implemented a successful triage system knows, this problem is as deadly as it is preventable.

So I applied for a two-year Fogarty fellowship through the NIH that was aimed at developing an intervention to prioritize critically ill children in primary healthcare clinics in Cape Town.

We created the Sick Children Require Emergency Evaluation Now (SCREEN)

approach as a potential solution to this problem. It is so straightforward that lay employees can be trained to use it in two hours. The tool consists of seven questions – delivered in the parent’s language – to detect danger signs. The questioner asks, for example, if the child is sick, under two months old, unable to eat or drink, or is vomiting everything. Those familiar with the WHO Integrated Management of Childhood Illnesses (IMCI) may recognize some of these questions as the IMCI danger signs.

Preliminary data evaluating the impact of SCREEN has been extremely promising with the result that the City of Cape Town has decided to adopt the screening tool in all of its 120 clinics.

Intuitively, persons reading this article will agree that this is a straightforward feasible approach to the clinical problem that exists. But a bigger question remains: Can we prove that it works? And where is the evidence? Prior to implementing SCREEN, the last 10 months have been spent on researching tool development, reliability and validity. This article is my story as I tried to complete these tasks in the most through and rigorous way possible.

In Cape Town, primary health clinics see over half of all critically ill children, yet formal triage at the point of entry is generally not feasible. This results in critically ill children often waiting several hours prior to their first encounter with a healthcare professional.

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The hierarchical model of evidence dictates that the most stringent evidence category is a double blind randomized control trial. However we must question if this research gold standard is even implementable when evaluating an acute care intervention in low resource settings. If not, then what strategic alternatives are available to the clinical researcher, and how does one navigate the continuing battle between scientific rigor and methodological feasibility?

In an ideal research study, the principal investigator would have access to every one of the 120 clinics and have an indepth knowledge and value within the system to conduct research in any of the sites as desired. Cluster randomization would be the methodology of choice. In addition there would be an abundance of research funding and support staff, to flawlessly execute the methodology regardless of local constraints. In reality, the foreign researcher beyond resource limitation is left with yet another challenge. To conduct research well, there needs to be community buy-in and the engagement of key stakeholders early in the process. To ensure the success of this project from as early as the conceptual design phase I engaged with the City of Cape Town. This was made easier by having mentors and colleagues who were already well acquainted with the local health system leadership. Sub district managers and healthcare executives soon become decision makers driving the implementation of this research. Random 14

allocation will often not be in keeping with needs of the local clinical environment. The benefit of forgoing this methodological need, may have allowed me to secure investment and ownership from the local community into the project and thus the successful dissemination and implementation of SCREEN long term.

For the purposes of studying a screening/triage tool, reliability evaluations are defined as evaluations of triage tools against other evaluations, either by the individual themselves at a later time (intra-rater), another health care professional (inter-rater), or a triage tool expert (expert opinion). Validity is defined as evaluation of outcomes for triaged patients (admission, ICU stay, death, resource utilization, requirement of intervention etc.) by triage category.

To measure the reliability of a screening tool one requires a reference or “gold� standard against which to measure the tool. In this case we were required to find the definitional gold standard for identifying a critically ill child. The use of IMCI is ubiquitous in low and middle-income countries (LMICs), and thus it seems natural to use this as our operational gold standard. However, IMCI is not a triage tool, even though a component of this program identifies children that are severely ill to facilitate transport to a higher level of care. In addition by using a locally understood gold standard we ensured a better understanding of the reliability studies locally.

Summer 2014 // Emergency Physicians International

The feasibility of data collection can be a huge stumbling block, especially in busy overwhelmed clinics with few diagnostic tools. One could consider performing the reliability study in an emergency department or intensive care unit where adequate equipment and personnel are more readily available. However, conducting a reliability study in a nonrepresentative clinical environment will lead to biases in performance measures such as positive and negative predictive value. By conducting the research in the clinics where it will be implemented there was increase confidence and excitement by healthcare professionals on the ground. In addition merely conducting the reliability studies allowed us to identify some of the barriers and concerns we would need to overcome during implementation.

Substantially more research is available on the validity of triage tools in LMICs. Some have even used mortality as an outcome measure. However, most of these studies were performed in tertiary care centres. In pre-hospital environments most residents lack a permanent address, meaning clinical follow up is impossible. Due to the cost or complexity of obtaining definite outcome measures, surrogate markers such as waiting times and expert opinions are often utilized. A process mapping study was conducted showing that SCREEN implementation significant reduced waiting times not only for critically ill children but also for all children (well and unwell) that

A process mapping study was conducted showing that SCREEN implementation significant reduced waiting times not only for critically ill children but also for all children (well and unwell) that presented to the clinic.

There was also a knock on decrease in left without being seen rates consistently across study sites.

presented to the clinic. There was also a knock on decrease in left without being seen rates consistently across study sites.

However the question as to whether SCREEN has an impact on overall morbidity and mortality within this setting remains unanswered. There is a definitive need to develop a validated set of early outcome measures to feasibly evaluate the impact of acute care interventions.

The story behind the evidence of SCREEN seeks to highlight every researchers plight in low resource settings. Gold standard research requires a controlled environment with unlimited resources, and this is not possible. At the same time we must acknowledge that completing the research in the clinical setting where the intervention will most likely be implemented is not only necessary but also a must. So how do you do this?

Well to begin with you start with the gold standard study design and slowly as you define the resources you don’t have you adjust the methodology to the next most suitable alternative. This requires a thorough needs assessment and significant time learning the system on the ground. Next you seek inspiration, colleagues who have faced these same challenges before you provide ingenious workarounds and solutions in the methods section of their peer review publications. Lastly you change the way you think, about research. By changing the research process paradigm from traditional randomised control trials and intervention-based studies to dissemination and implementation research focused methodologies one can improve the feasibility of clinical research in low resource environments.

As pioneers in this field beyond statistical significance we must focus on clinical relevance and applicability. Clinical researchers in low resource settings are challenged by the complexity of bridging research and practice in to real-world environments. There is a need to conduct research that balances rigor with relevance and employs study designs and methods appropriate for the complex uncontrolled processes confounding the clinical reality.

GO GLOBAL E U R O PE | M I D D LE E AST | ASIA A FR I C A | S O U T H A M E R ICA

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

Dr. Hansoti is an Assistant Professor based at Johns Hopkins University in Baltimore, USA. She received a two-year Fogarty fellowship in 2013 to study emergency care in Cape Town, South African under the mentorship of Dr. Lee A Wallis. Further information about Dr. Hansoti’s work can be found at www.drbhakti. com.

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Profile

Hendry Sawe: Young Leaders Bring Fresh Energy to African EM The 33-year-old president of Tanzania’s national emergency medicine society has become a significant voice in the African Federation for Emergency Medicine. by crystal bae

I

t might sound odd, but in one way we can be thankful for a lack of aviation schools in Tanzania.

Hendry R. Sawe, one of Tanzania’s founding emergency medicine leaders, grew up wanting to fly planes; his backup plan was a career in medicine.

Born in a small town on the slopes of Mount Kilimanjaro, from a family of accountants, Hendry’s dreams of becoming a commercial pilot faded away rapidly because of a lack of licensing schools in Tanzania at that time. This meant that his dream of attending pi16

lot school was thousands of kilometers away from home, the closest school being in South Africa.

Hendry’s passion for medicine started in 1995 when his uncle became very ill. He stayed by his uncle’s side for a month in a regional hospital in Arusha, learning how to change dressings and give injections and befriending doctors. After his uncle passed, the family continued to call on Hendry with any illnesses in the family and he quickly became known as the unofficial “family doctor”. All of this by the age of 16.

Fall 2014 // Emergency Physicians International

Hendry then earned a prestigious academic scholarship, given by the Tanzanian government, to go to medical school at Muhimbili University of Health and Allied Sciences. He graduated in 2008 with the desire to specialize in gynecology. With his newly earned degree, he returned to the same hospital in Arusha to complete his internship training and worked with the same doctor that treated his uncle all those years ago. He finished his internship in 2009, having completed over 250 caesarean sections.

Hendry was well on his way of becoming a specialist in gynaecology in his hometown when he was offered to interview for a position as an emergency medicine physician in Dar es Salam.

He was intrigued by the challenges of emergency medicine and curious to see if it really was like what he saw on television. He took a gamble and abandoned his pursuits in gynaecology for this undeveloped and unknown specialty. After one year as a registrar, Hendry was hooked.

Now in 2014, Hendry is the current president of the Emergency Medicine Association of Tanzania – EMAT, which is the national society of emergency medicine in Tanzania for physi-

When he’s not working a shift at the hospital, Hendry can be found watching or refereeing soccer.

“I am a devoted fan of the Tanzania National team (Taifa Stars) and I also support Arsenal FCUK premier league club.”

Getting Involved: The Emergency Medicine Association of Tanzania (EMAT) has set up a non-for profit fund to support residents pursuing emergency medicine training at Muhimbili University of Health and Allied Sciences (MUHAS). Donate now at www.ematz.org cians, nurses and paramedics. With the creation of EMAT, Hendry and his colleagues continue to work closely with the Government and other stakeholders to make emergency medicine in Tanzania a healthcare priority. There is currently only one full capacity public emergency medicine department in all of Tanzania and no formal public emergency medical services.

Hendry’s work has included training health care providers in district and regional hospitals, providing them with basic and advanced emergency skills to care for the community. This he be-

lieves to be the catalyst for change and development of emergency care. He is also highly involved in research and collaboration with other local organizations, such as the African Federation for Emergency Medicine (AFEM) for which Hendry serves as vice president.

Partnerships like this – as well as with international organizations like the International Federation for Emergency Medicine, are essential in creating a unified effort towards a common goal: building an emergency care system accessible to all Africans, regardless of ability to pay.

Hendry hopes that within the next decade, he can build an emergency care system to prevent mortality from poor access or poor training.

Look for more profiles of African emergency medicine leaders in upcoming issues of EPI. Next up: Dr Sisay Teklu Waji, President of the Ethiopian Society of Emergency Medicine

2015 Annual Meeting May 12-15

San Diego is where you want to be, May 2015. You will hear about the latest discoveries within academic emergency medicine and have a little bit of fun while doing it!

Returning to SAEM is IGNITE, Dodgeball, SonoGames®, Shark Tank, and much more.

Innovations Submission Deadline: November 28 Abstracts Submission Deadline: December 12

Keep up to date with the latest annual meeting news at www.saem.org.

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17

Austere Medicine

5.

Treating Venomous Stings

Venomous Sea Urchins 1. Scrape off or remove adherent spines 2. Soak the injured body part in hot water (114°F, 45°C)

5 Tips for Managing Coastal Injuries Whether you are a bona fide ‘surfing doctor’ or just an emergency physician visiting the beach, here are a few pieces of core knowledge for medical emergencies on the water. by ingvar berg, md co-founder of the european association of surfing doctors

1. Be Ready for Prehospital Drowning Resuscitation

rologic or pulmonary sequelae. See table 1 on the next page for more. 

The estimate is that worldwide at least 388,000 people drown every year. Surfers are even more susceptible to drowning because of conditions like strong rip currents and big waves, not to mention the risk of being hit by their own board, or sea floor, and thus experiencing head trauma. Head injuries resulting from hitting their own board are common among surfers who don’t wear helmets.

If you are an emergency physician encountering a drowning patient prehospital, you want to be on top of the situation. Studies have shown that the prehospital management of a drowning patient is crucial. If patients reach the emergency department before cardiac arrest, and are treated effectively, nearly all will recover without significant neu-

2. Improvising wound closure techniques

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Since lacerations are the most common surf injury, especially affecting the head and lower extremities, it is good to know a couple of improvised wound closures, for when your beach trek takes you far from a first-aid kit. Here are two suitable wound closure techniques everyone should know.

String and hair tying technique: Scalp lacerations can bleed profusely. One technique to stop the bleeding if now instruments are available is a hair tie. As the name suggests, simply part the hair along the scalp lacaration, twist both sides into individual cords, then tie the opposing strands together tightly.

Duct tape technique: If tape and su-

Fall 2014 // Emergency Physicians International

tures are available, try the following technique described in Auerbach’s Wilderness Medicine. “Cut two strips of adhesive tape 2.5 cm (1 inch) longer than the wound. Fold one-quarter of each strip of tape over lengthwise (sticky to sticky) to create a long nonsticky edge on each piece. Attach one strip of the tape on each side of the wound, 0.6 to 1.3 cm (0.25 to 0.5 inch) from the wound, with the folded (nonsticky) edge toward the wound. Using a needle and thread, sew the folded edges together, cinching them tightly enough to bring the wound edges together properly

3. Improvised Spinal Immobilization Consider a surfboard as your trauma matrass. Transporting a patient with a spinal injury from a beach can be challenging, especially if the patient is unconscious.

4. Bring EPiPENs Epipens with epinephrine can be a lifesaving tool in the wilderness, that is: if you actually bring one!

So get prepared and trained for the (remote) location you have chosen when finding your perfect wave or wilderness environment. You limit yourself to the knowledge and skills you bring with you. Don’t hesitate to get trained by taking a course in surfing medicine, and prepare yourself to explore!

Australian Box Jelly fish (and most other jellyfish) 1. Remove loose tentacles from the skin with fingertips after rinsing with seawater 2. Deactivate the undischarged nematocysts by bathing the sting in vinegar 3. Scrape of any residual tentacle fragments Portuguese Man of War, Blue Bottle, Hawaiian Box 1. Remove loose tentacles from the skin with fingertips after rinsing with seawater 2. Deactivate undischarged nematocysts by soaking body part in hot water (114°F, 45°C 3. Scrape of any residual tentacle fragments

Table 1: Prehospital Management and Classification of Drowning Patients The Asymptomatic Patient

The Patient in Respiratory or Cardiopulmonary Arrest

The Symptomatic Patient

Grade

0

1

2

3

4

5

6

Mortality (%)

0

0

0.6

5.2

19

44

93

Pulmonary Exam

No cough or dyspnea

Normal auscultation with cough

Rales, small amount of foam

Acute pulmonary edema

Acute pulmonary edema

Respiratory Arrest

Cardiopulmonary Arrest

Cardiovascular

Radial pulses

Radial pulses

Radial pulses

Radial pulses

Hypotension

Hypotension

On Scene Management

Release at scene; Education

Rest, rewarm, reassure and release

O2 via nasal cannula; obs. for 6-24 hrs

O2 via NRB ACLS

O2 via NRB ACLS

Hypotension Load and Go

Transport

No

No

Transport or observation

Yes

Rapid

Rapid

En Route Management

Vital Signs

Vital Signs

Possible ETT and manage pressure

ACLS

Hospital

ED or overnight observation

Admission for observation

ICU

ICU

ICU

Courtesy: Justin Sempsrott, MD. Adapted from Szpilman D: Near-drowning and drowning classification: A proposal to stratify mortality based on the analysis of 1,831 cases, Chest 112:660, 1997.

R report

// ebola

Dispatches from Liberia: A Call to Action Amidst an Epidemic of Fear by adam levine, md Scrubs: check. Gum boots: check.

Gloves: check. Tychem suit: check.

Mask: check. Hood: check.

Apron: check. Goggles: check.

Gloves again: check.

“Ready?” I ask the Liberian nurse assisting me. She shakes her head and grabs a small strip of duct tape, covering the space between my hood and goggles where a thin slice of skin was showing. “Now ready,” she replies.

T

he temperature in Monrovia is just over 80, the humidity even higher. I feel the sweat collecting between my skin and suit, pooling in my boots and along the bottom of my goggles as I slowly follow the physician training me into the highrisk zone of the world’s largest Ebola treatment center. It feels far more like scuba diving through a hot spring than beginning morning rounds in a hospital, but that is exactly what we are doing.

A few moments later, I meet my very first patient with Ebola, a young man who had wandered away from his bed during the night and is now lying on the ground near the edge of the high-risk zone. He is tired and confused.

He doesn’t know where he is, or why there are two men in space suits towering over him.

The physician with me calmly reassures him, and together we help lift him to his feet and guide him back to his thin mattress in one of the large white tents serving as an Ebola ward.

He is profoundly weak, and as we walk, I notice that his pants are soaked through with diarrhea, a hallmark of the disease. We lay him down and urge him to drink some water mixed with oral rehydration salts. Then we move on to the next patient. We have sixty more to see on rounds this morning, and already I feel ex20

hausted from the heat.

For decades now, Ebola has been the Hollywood star of diseases, capturing the public’s imagination with its exotic name, high fatality, and the added fear factor that it can cause people to bleed from odd places. Until recently, though, if you had asked any global health expert about the scary diseases that keep them up at night, Ebola would not have made their list.

Just this past May, at a humanitarian conference I attended in London, one speaker presented some early data collected from Gueckedou, Guinea, where the current Ebola epidemic in West Africa began. After the presentation, one man in the packed audience raised his hand to ask: “Why are we even talking about this disease? After all, it only kills maybe a hundred people every couple years.”

As of this week, Ebola is killing a hundred people every couple days in West Africa, and there will never be another conference where someone raises their hand to ask that question.

But the true impact of the crisis in West Africa should not be measured in the numbers

Fall 2014 // Emergency Physicians International

dying of Ebola itself, but rather in the wider impact the disease has wrought. Every day here in Liberia I hear horror stories of people dying of perfectly treatable diseases as hospitals and clinics have shut their doors: a woman in labor who bled to death, baby half delivered, for lack of a midwife willing to manage her delivery; the driver who crashed his truck and was left to die without a functioning trauma center; the young child seizing from malaria, whose mother visited multiple hospitals and clinics but couldn’t find one open to treat him.

It is not Ebola alone causing the catastrophe in West Africa today – it is an epidemic of fear.

What makes Ebola different from so many other public health threats is the effect it has on healthcare workers, and as a result, on the entire healthcare system. To put it bluntly, Ebola kills nurses and doctors, almost preferentially. This should not be surprising, given that the disease is spread by contact with the body fluids of symptomatic patients, and nobody has more contact with the body fluids of sick people than nurses and doctors. But the toll that Ebola has taken on clinicians and public health professionals alike means that the very people who calmed our fears in the past, who talked us through other epidemics and assured us that everything was going to be okay if we only kept calm and did A, B, and C, are now running scared themselves. And that is frightening indeed.

Ebola, though, is not actually a Hollywood disease. It is not a vampire, zombie, or ghost.

It cannot walk through walls, or even gloves and gowns. It can be destroyed by weapons as simple as chlorine, alcohol, soap, detergent, and even sunshine (sort of like a vampire, I suppose). With the right precautions in place, including protective equipment and triage protocols to identify those most likely to have the disease, healthcare workers can safely treat patients of all types without the fear of dying themselves. And when people see healthcare workers saving lives, they are willing to bring themselves and their loved ones to the hospital early, before the disease has a chance to spread, reducing transmission. And when transmission stops, the epidemic stops, and life in West Africa can return to normal.

Up until now, it has been local nurses and doctors who have borne the brunt of this epidemic, working long hours to care for desperate patients without the proper protection as their colleagues fell ill around them. Yet even

Neighborhood fears that health workers will spread Ebola exacerbate security concerns in Monrovia.

VOICES ON THE GROUND IN LIBERIA

Is it frightening for doctors to work in an environment where they risk infection with such a deadly disease?

Dr. Michelle Niescierenko: The neighborhood [around one hospital in Monrovia] was afraid that patients were going to come into that neighborhood and so it was a medically unsafe environment for the staff who didn’t have a lot of protection. My colleagues at one of the other main hospitals would express fear, but also say that they were worried about their regular patients, the everyday kids with malaria who are seizing and the moms with obstructed labor. Who is going to take care of those patients?

And so their worry was actually more for those patients than about Ebola patients or about themselves getting exposed, which is, to be honest, a heroic story.

Dr. Michelle Niescierenko works for Harvard Medical School and Boston Children’s Hospital. She’s a pediatric emergency physician and she spends about four months a year in Liberia.

Dr. Pranav Shetty: We must imagine so. What we’ve heard from our staff that are currently on the ground is that yes people are of course worried. They understand the precautions that need to be taken, but there’s no place of zero risk. There are many kinds of procedures from the infection control standpoint that are in place, but you know human errors occur. We know that in a lot of facilities staff are not able to attend their regular work. They don’t want to go to a place of high exposure and then bring the virus back to their family.

Dr. Pranav Shetty is the Emergency Health Coordinator for International Medical Corps (IMC)

now, the vast majority of them are more than willing to come back to work once their safety is ensured by the introduction of protective equipment and protocols. The necessary protective equipment isn’t cheap though, and the impoverished countries of West Africa will never be able to afford it on their own. And as brave and heroic as they are, there simply aren’t enough trained doctors and nurses here to stem the tide of this epidemic on their own.

There is a dire need for the international community to stop treating this crisis like a horror movie, closing its eyes tightly until the scary part is over, and start treating it like a real humanitarian disaster that requires an adequate input of monetary, logistical, and yes, human resources.

It is true that most humanitarian emergencies cannot actually be solved by humanitarians alone, but this crisis is an exception to the rule.

A sufficient supply of experienced international aid workers, including nurses, doctors, epidemiologists, sanitation engineers, lab technicians and logisticians, provided with the proper protection and resources, could bring this particular crisis to a halt in a matter of months.

As we finish our morning rounds, tending to both the living and the dead crammed together in the long white tents of the treatment center, I see something quite unexpected. A large group of patients are dancing and singing in the grassy area between the wards, with a handful of nurses and doctors in their full protective equipment trying to bounce a bit with them, despite the heat. The patients are joyous because they have recovered from Ebola, and will soon be discharged home. I can feel the strip of duct tape tug against the skin of my face as I begin to smile.

If the international community is willing to invest the necessary resources now, within a year or so we could all be dancing together as a planet, celebrating the full recovery of the Ebolastricken nations of West Africa. If we fail to act soon, however, we are going to need some very large, nation-sized body bags.

Adam Levine is an Assistant Professor of Emergency Medicine and Director of the Global Emergency Medicine Fellowship at Brown University. He currently serves as the Clinical Advisor for Emergency and Trauma Care for Partners In Health/Inshuti Mu Buzima and as a member of the Emergency Response Team for International Medical Corps.

www.epijournal.com

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J

journal // scan

Tranexamic Acid for Traumatic Hemorrhage Considering the available data, the early use of TXA should be strongly considered for any patient requiring blood products for trauma-related hemorrhage

by joseph watkins, md; bill dribben, md & brian cohn, md

A

45-year-old healthy male arrives to your trauma bay via EMS as an unrestrained passenger in a high speed MVC. He is combative with a BP of 88/50 that improves transiently with two liters of normal saline. He has extensive ecchymosis over his right flank, but no evidence of active external bleeding; bedside FAST is positive for fluid in the RUQ and chest x-ray is normal.

Due to persistent hypotension and a positive FAST exam you activate your Mass Transfusion Protocol and begin administering uncross-matched pRBC’s and FFP. After initiating the resuscitation in the ED, the patient is taken to the OR for an exploratory laparotomy. As the dust settles, you ask yourself: “Is there more I could have done for this patient?” You recall a recent conference where tranexamic acid (TXA) was discussed, so you decide to investigate the literature of its use in trauma.

Initiating an effective resuscitation for a massive hemorrhage is an important and challenging task in the ED — after all, hemorrhage is responsible for 30% of in-hospital trauma deaths worldwide every year1. Naturally, the definitive treatment is the “bright lights and cold steel” of an OR, but we have to make sure the patient survives long enough to make it there. Aside from appropriate IV access, crystalloids, and blood products, our armamentarium is limited, though there is an increasing body of literature that supports a new role for an old drug.

TXA is an analog of the amino acid lysine that blocks the lysine binding site on plasminogen, preventing its conversion to plasmin, which in turn degrades fibrin. By preventing fibrin breakdown, TXA acts as a hemostatic agent and should therefore decrease blood loss in any bleeding condition2. Since the 1960’s, TXA has been shown to decrease blood loss in cardiopulmonary bypass3 and other surgical procedures4, menorrhagia5 and upper GI bleeding6.

Due to its efficacy in preventing blood loss without evidence of significant risk, the use of TXA in trauma has recently been under investigation. It is inexpensive, readily available, and commonly used for traumatic hemorrhage in other countries7.

CRASH-2 Study The CRASH-2 (Clinical Randomization of an Antifibrinolytic in Significant Haemorrhage) trial was conducted to assess the effects of early administration of TXA on survival from traumatic injuries8. This study enrolled patients predominately from low and middle income countries, where 90% of trauma deaths occur.9 More than 20,000 patients from 274 hospitals in 40 countries were included based upon hemodynamic instability (SBP<90, HR>110) and “suspected

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Fall 2014 // Emergency Physicians International

hemorrhage.” Notably, there were no study sites in the United States. Researchers found a small but significant absolute reduction in the risk of death of 1.5% in those that received TXA, without an increase in vaso-occlusive events (ie, PE, DVT, AMI).

A subsequent subgroup analysis suggests that the difference in all-cause mortality can be explained by a reduction in bleeding deaths alone, although there was no difference in the amount of blood products given between the groups. When examining only deaths due to bleeding, the mortality benefit of TXA was only observed within the first three hours after a traumatic injury; after three hours, TXA actually increased mortality10.

In the CRASH-2 trial, patients were enrolled based on “suspected hemorrhage.” Although not defined, patients in whom “a clear indication” for TXA existed were excluded, potentially eliminating the sickest patients from their study population. A secondary analysis of the data that assessed risk of death based on a validated prognostic model found that the highest risk group appeared to benefit the most from TXA11.

MATTERs Study To assess the application of TXA to a sicker population with increased access to advanced resources, we turn to the MATTERs12 (Military Application of Tranexamic acid in Trauma Emergency Resuscitation) study by Dr. Morrison and colleagues.

MATTERs is a retrospective analysis of patients treated at a military hospital in Afghanistan (NATO personnel and Afghan nationals) that suffered a combat injury and received at least one unit of blood. Although the groups were demographically similar, the injury severity score was significantly higher in the group that received TXA. Despite the higher injury score, there was an unadjusted absolute reduction in mortality in the TXA group of 6.5%. In a subgroup of patients that underwent a massive transfusion (>10 units pRBC’s within 24 hrs), there was a decrease in mortality of 13.5% in the TXA group.

Patients who received TXA had a significant decrease in hypocoagulability (INR > 1.5; aPTT > 1.5x normal) from ED arrival to admission in the ICU, whereas there was no difference in the non-TXA group. The TXA group received more blood products than the control group, which the authors attributed to higher injury severity and survival bias. The authors proposed that the increased survival is more profound than the CRASH2 trial due to the “beneficial effect of TXA [being] more prominent in those with higher injury severity.”

Distinct from the CRASH2 data, the rates of venous thromboembolism and pulmonary embolus, though rare and non-fatal, were increased in the TXA group. The authors attributed this potential increase of thrombo-embolic events to higher injury severity rather than to TXA. However, the degree of fibrinolysis was not reported, and as such it is difficult to discount the effects of TXA on these events.

Based on these studies, TXA appears to significantly decrease mortality for trauma in the developing world and in severely injured military patients, but it remains unclear if we can apply these data to the civilian trauma population in the US. To explore this topic, Valle et al performed a retrospective analysis that examined data from two trauma registries of consecutive patients that presented to an urban level 1 trauma center over a three-year period13. These registries identified trauma patients that 1) went directly from the ED to the OR, or 2) received emergency blood products in the ED or the OR. They postulated that this would capture the most severely injured trauma patients that, as suggested by the MATTERs study, would likely realize a greater benefit from administration from TXA. TXA was given in 150 of 1217 patients enrolled in the database. Propensity matching was used to assign controls to these 150 patients from the remaining 1067 that did not receive TXA using 7 variables including age, gender, mechanism of injury, systolic

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

T-RING ADVANTAGES: Due to its efficacy in preventing blood loss without evidence of significant risk, the use of TXA in trauma has recently been under investigation. It is inexpensive, readily available, and commonly used for traumatic hemorrhage in other countries.

blood pressure and severity of injury. They found that patients who received TXA had a non-significant trend towards increased mortality (31% v 23%). After excluding patients who died within two hours of arrival, that increased mortality reached statistical significance (27% v 17%). Similar to the MATTERs study, blood product requirements were increased when compared to those who did not receive TXA. Importantly, TXA was not available until the middle of the study period and was administered at the surgeon’s discretion.



IMMEDIATELY STOPS BLEEDING, PROVIDING IDEAL WOUND VISUALIZATION



ONLY METHOD THAT APPLIES A SAFE, RELIABLE PRESSURE EVERY TIME!



HIGHLY VISIBLE—IMPOSSIBLE TO ACCIDENTALLY FORGET ON THE DIGIT



MINIMIZES THE RISKS ASSOCIATED WITH OTHER DIGITAL TOURNIQUETS



FASTER, EASIER AND SAFER TO USE THAN ALL OTHER METHODS!



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

Now What?

Given the size and scope of CRASH2, it is difficult to ignore its results, and at the very least it illustrates the mortality benefit of TXA in trauma patients that are hemodynamically unstable or suspected of having active hemorrhage. In sicker patients in whom the hemorrhage is obvious, we now have to decide whether to base our decisions on the lower quality retrospective data from Drs. Morrison or Valle. The MATTERs study population was more critically injured than in CRASH2, had access to advanced trauma care, and revealed a decrease in mortality for patients treated with TXA. The data from the Valle study seem to more accurately reflect the acuity and care of the trauma patients in a busy urban center, but its results conflict with the proposed scientific mechanisms and clinical studies examining TXA. While the Valle study was retrospective and the design was not ideal, the authors concluded that with access to advanced resources that may not have been available to patients in CRASH2, TXA was associated with increased mortality.

We are thus reminded of the shortcomings of retrospective analyses and must not interpret association as causality. An important aspect of this study is that propensity matching cannot replace randomization and may not accurately reflect the acuity of patients. It was possible that patients who received TXA were sicker in a manner not reflected in the chosen parameters. This position is supported by the increase in blood product requirements and faster time to the OR in the TXA group. Additionally, the cause of death was not reported for this study. Were more deaths attributable to vaso-occlusive events (MI, CVA, PE) perhaps the results and conclusion would be more convincing.

The only prospective, randomized data that we have available demonstrates a small but significant survival benefit to TXA administration in trauma patients, without a significant increase in adverse events. This is

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CONTACT: PRECISION MEDICAL DEVICES (302) 778-2335

CONTINUED ON PAGE 33

FOR MORE PRODUCT INFORMATION www.epijournal.com WWW.THETRING.COM

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gathering

Iraq: Can Arba’een Rise to a New Health Standard Amidst Terrorist Chaos?

The medical community and local and central governments must work together to meet the growing demands of Arba’een, an annual Shia Muslim religious observance that attracts millions.

with dr. shakir katea

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ach year, millions of Shia pilgrims travel by foot to the city of Karbala in Iraq to observe Abra’een. The event commemorates the martyrdom of Hussein bin Ali, the grandson of the Prophet Muhammad, and is one of the largest pilgrimage gatherings on earth. Undoubtedly, the gathering of some 18 million people in a hot desert climate presents numerous medical issues. Dr Shakir Katea, the President of the Iraqi Society for Emergency Medicine (ISEM), shares some of the problems he and his colleagues face when caring for the participants of Abra’een. These mass casualty lessons 24

public health directorate (PHD) distributed these instructions to other public health departments: 1.

Promote public awareness concerning the avoidance of infectious diseases through educational posters and media.

2. Focus on food safety by monitoring food preparation throughout the event, and particularly that food supplied by volunteers.

3. Encourage personal hygiene from those that prepare the food.

4. Prepare medical teams to provide care to patients.

learned can be used to increase the efficiency of emergency medicine in Karbala specifically and in Iraq as a whole.

EPI: What kind of physical medical infrastructures were put in place during Arba’een? Were they successful?

EPI: What efforts were made to decrease the spread of infectious diseases during Arba’een?

Dr. Katea: Medical departments begin preparing for the event up to two weeks prior to its start. Some of the ways the infrastructure is bolstered are the following: 1. The local hospitals of each governorate (there are 140 hospitals in total) prepare by increasing bed capacity, limiting the admission of non–urgent cases, preparing lists of medical staff on call, and providing an ample amount of

Dr. Katea: We have a public health directorate which is the central directorate in the Ministry of Health. The directorate leads 15 public health departments in the 15 governorates of Iraq (the exception is Kurdistan, an autonomous government). Prior to the event, the

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medicines and appliances.

2. There are 3 field hospitals: Kerbala, Najaf, and Basrah. Each consists of 13 medical units and facilities with surgical theater.

3. Mobile medical tents provided by each PHD are distributed along the way of pedestrians (pilgrims).

4. In selected areas more advanced mobile medical caravans are put in place.

5. There are additional health services provided

by Iraqi Red Crescent, military and civilian defense, and various others by volunteers.

6. There are ambulance services provided by each governorate. There is at least one ambulance vehicle in each mobile team and additional others distributed in selected areas.

7. The ministry of defense also provides additional ambulance services.

The city of Karbala, home to the Imam Husayn shrine, has only three hospitals. One is a teaching hospital, one is for obstetrics and gynecology, and the third is a general hospital. Given that all three hospitals have low bed capacities, the additional measures taken to prepare for the event are absolutely vital.

EPI: Was there any data gathered on the kinds of patient populations seen during Arba’een? If so (or anecdotally) what were the main reasons

that people fell ill or injured during the event?

Dr. Katea: There was some data gathered regarding the patient populations, but it is very limited. Details including age, gender, and even complaints are not included in the majority of patients seen by mobile medical units. We do have a study conducted by our colleagues about the pattern of morbidity of patients during the event. I visited many of the mobile medical units myself, and I have seen that common complaints include: 1. Joint pain due to walking long distances from their home to Karabala, ranging from 80 to 400 km.

2. Gastrointestinal issues due to the ingestion of variable and excessive foods provided by volunteers along the way. The common issues are diarrhea, epigastric pain, nausea, and acidity.

3. Dermatological problems like skin rash and itching due to irritation during the long walk combined with ranges of 3-10 days without bathing.

4. Disturbance of blood glucose regulation for diabetic patients.

5. Ischemic attacks in those with ischemic diseases and cardiac issues.

6. Headaches 7. Common wounds of various causes: scrapes

Pakistani Muslims perform religious flagellation rituals during an Ashura procession in Quetta. Blood loss from self-injury creates an even more complicated public health challenge for those managing Arba’een. Image Courtesy of AFP ImageForum

from falling during the walk, abrasions caused by shoes, dog bites, and many others.

8. Sun burn and heat exhaustion 9. Food poisoning due to the contamination of foods during its preparation.

10. There are some severe wounds due to the ritual itself. Some pilgrims hit themselves with sharp instruments to commemorate the martyrdom of the Husayn ibn Ali. 11. Asthma-like symptoms due to dusty conditions.

EPI: Is there any kind of syndromic surveillance that takes place during events like Arba’een such that emergency health workers might prevent an infectious disease before it spreads? www.epijournal.com

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Arba’een is consistently among the largest peaceful gatherings in history. In 2008, approximately nine million religious observers converged on Karbala. In 2013, Arbaeen reached over 18 million.

Dr. Katea: Unfortunately, no. Syndromic surveillance is dependent upon symptoms and signs witnessed by medical staff in hospitals.

The majority of cases during the event are seen by the mobile medical teams who are chiefly concerned with alleviating the problem in front of them. They are not focusing on symptoms or signs of public health threats. It is important to keep in mind the incredible number of pilgrims, a number that increases each year. The last event exceeded 18 million. That is enough to overwhelm any health system in the world.

EPI: Are there specific lessons learned at events like Arba’een that can applied to emergency medicine in Iraq?

Dr. Katea: There are many lessons presented by the event, but they are not always learned!

As the prophet Mohammed said “A believer shouldn’t be bitten from the same hole twice.”

Here is a list the lessons, pitfalls, and issues particular to this event, and in all religious events in Iraq in general: 26

• The event is usually staged by the community, or volunteers. The central and local governments must develop rules, regulations, and measures to ensure the safety of the event and the health of its participants.

• There is a fundamental lack of communication and coordination among relevant agencies which leads to improper staging of emergency care during mass casualties. There is a vital necessity to work as a team.

• There should be better organization of the hosting tents of pilgrims. Currently, these are scattered in such a way that disturbs traffic flow, promotes crowds and road accidents, and creates difficulty for ambulances to respond.

• There is great difficulty in evacuating the pilgrims from Karbala after the event ends.

There are low numbers of transport vehicles and those that are available (military vehicles) are very difficult for elderly and disabled persons to use. Overall, the transportation is unsafe and inefficient.

EPI: What do you think the

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medical community should do differently at the next Arba’een festival?

Dr. Katea: We believe that the medical community are most efficient when they are well prepared in terms of supplies and properly trained in terms of skills. We should work toward coordination, communication, and working together as a team to best serve the participants of the event.

Each year there are gaps and clear cases of what we need to improve. We need to document this and use it for the next year, when the number of participants always increases as will their demands.

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Psychological First Aid: As Essential for Providers As for Their Patients While it can be easy for emergency physicians to focus on the physical wounds in need of immediate attention, psychological harm caused by traumatic events can be just as detrimental, both for patients and caregivers. Here’s a primer on why psychological first-aid should be an essential part of any disaster relief effort.

by graham plaster

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rauma experts from the Institute for Disaster Mental Health at SUNY New Paltz recently returned from the Middle East where they had led workshops for Palestinians and Israelis on Psychological First Aid (PFA).1 The institute director, Dr. James Halpern, conducted the training near the Dead Sea in Israel, with nearly 30 mental health and educational professionals, who in turn trained 700 others in their own communities.

Humanitarian groups have been taking PFA seriously for quite some time. What do we need to know about it in the field of emergency medicine?

Defining Important Terms Psychological First Aid (PFA) and the related concept of Psychosocial Support (PSS), are research-based approaches to helping individuals in the immediate aftermath of crises. Usually, PSS is offered by mental health professionals and disaster response workers to children, families, and adults as part of an organized disaster response effort. These providers may be imbedded in a variety of response units, including first responder teams, incident command systems, primary and emergency health care, school crisis response teams, faith-based organizations, Community Emergency Response Teams (CERT), Medical Reserve Corps, the Citizens Corps, and other disaster relief organizations. However, lay counsellors are an important part of PSS as well. Lay counselors are part of the continuum of care for both medical professionals and individuals in the community. Anyone, given the right tools, can deliver psychosocial support to those affected by disasters, suffering from loss or serious illness, and

people living in isolation. A Lay Counselling Trainer’s manual is available online through the International Federation for the Red Cross and Red Crescent Psychosocial Centre.3

Basic Objectives of Psychological First Aid4 • Establish a human connection in a nonintrusive, compassionate way • Enhance immediate and ongoing safety, while providing physical and emotional comfort • Calm and orient emotionally-overwhelmed or distraught survivors • Help survivors to articulate immediate needs and concerns while gathering additional information • Offer practical assistance to survivors • Connect survivors to social support networks, including family members, friends, neighbors, and community resources • Support adaptive coping, acknowledge coping efforts and strengths, and empower survivors • Encourage adults, children, and families to take an active role in their recovery

Causes of Traumatic Stress Traumatic stress can result when we witness death, serious injury, or danger. Our abilities to cope can be overwhelmed at physical, emotional, or spiritual levels. Cultivating inner resilience is the essential capacity to adapt, survive, and thrive despite adversity. Resilience is rooted in character, grace, social support and a number of other factors that sometimes get ignored during emergency medical attention.

Although both patients and care-givers may display tremendous fortitude in the face of difficulties, their internal resilience is something that must be monitored and treated as a part of the whole.

Traumatic Stresses might include: • threats to life • torture • persistent exposure to trauma and violence • austere living conditions • cultural differences • lack of space and privacy • lack of medical infrastructure • separation from natural support systems The less dramatic challenges, when stacked together, can still amount to psychological pressure effecting performance as a medical professional.

The Importance of Peer Care A care-giver with untreated psychological trauma may be subject to compassion fatigue, also known as secondary traumatic stress (STS).

Both patients and care-givers are susceptible to Post Traumatic Stress Disorder (PTSD). Compassion fatigue is a condition characterized by the waning of compassion over time. It is common among those working directly with trauma victims and was first diagnosed in nurses in the 1950s. Symptoms include hopelessness, a decrease in experiences of pleasure, stress, anxiety, sleeplessness or nightmares, and pervasive negativity. In one study, approximately 85% of emergency room nurses met the criteria for compassion fatigue.5 Stress reduction practices have been shown to be effective in preventing and treating STS among physicians.6 Ignoring PSS for care givers and patients in conflict areas can also result in more severe affective or cognitive problems, such as PTSD. While PTSD requires professional care, and develops long after a traumatic event, PSS offers an immediate intervention before the disorder runs its course. For physicians, PTSD often carries the stigma of mental health issues and needs. PSS on the other hand remains informal and focused on positive, proactive intervention. PSS provides the opportunity for peers in the professional environment or family and friends at home to provide support.

In one anecdote, during a shootout in Latin America, an emergency responder began providing first aid to a person caught in the cross-

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fire. An armed individual from the other side of the conflict instructed the care giver to stop helping the wounded. When the medical professional attempted to explain the principle of neutrality and continued to help the wounded, the armed man shot the patient in the head.

Performing emergency care in conflict areas such as these can have lasting psychological effects on physicians, potentially leading to feelings of guilt, powerlessness, and hopelessness.

Prolonged exposure to psychological stresses can leave the emergency professional impaired.

We are all familiar with the standard safety warning before an airplane flight that if pressurization should fail, you should don your own oxygen mask before trying to help others.

The reason why this instruction is necessary is because many of us neglect self-care in order to provide emergency assistance. Aboard a turbulent plane this kind of heroism, while admirable, can lead to pandemonium or even additional deaths. The oxygen mask falling from the ceiling is a symbol for the things which must be done in order to survive both physically and mentally. For those EPs operating in conflict areas around the world, failing to identify risks to their own health and wellbeing could in turn limit their ability to extend care to those around them.

One study of an emergency team in Europe showed that a third of those who provided care after a terrorist attack developed symptoms of PTSD within 5 years.7 A U.S. study of over 60 emergency medicine residents and interns showed over 10% suffered from PTSD, and the odds of getting the disorder increased with time spent in the ED.8 Younger physicians seem more susceptible to risk. Not surprisingly, emergency physicians accumulate significantly more stress compared with other salaried physicians.9 Nevertheless, the fear of stigmatization has kept many from getting help.10

The Solution While it is tempting to deal first with the symptoms that are most visible, it is in the hearts and minds that systemic problems exist.

Emergency physicians are part of a continuum of care for the whole person. Trained psychological first aid providers and also members of the community are able to provide immediate support to mitigate against long term damage.11 The main components of PSS include active listening, exploring positive coping mechanisms through asking open ended questions, 28

One study of an emergency team in Europe showed that a third of those who provided care after a terrorist attack developed symptoms of PTSD within 5 years.7 --------------

An American study of over 60 emergency medicine residents and interns showed over 10% suffered from PTSD, and the odds of getting the disorder increased with time spent in the ED.8 Younger physicians seem more susceptible to risk. and referrals to professional support when appropriate. Core actions include12: 1. CONTACT AND ENGAGEMENT Goal: To respond to contacts initiated by survivors, or initiate contacts in a non-intrusive, compassionate, and helpful manner.

2. SAFETY AND COMFORT Goal: To enhance immediate and ongoing safety, and provide physical and emotional comfort.

3. STABILIZATION (IF NEEDED) Goal: To calm and orient emotionally overwhelmed or disoriented survivors.

4. INFORMATION GATHERING: CURRENT NEEDS AND CONCERNS Goal: To identify immediate needs and concerns, gather additional information, and tailor Psychological First Aid interventions.

5. PRACTICAL ASSISTANCE Goal: To offer practical help to survivors in

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addressing immediate needs and concerns.

6. CONNECTION WITH SOCIAL SUPPORTS Goal: To help establish brief or ongoing contacts with primary support persons or other sources of support, including family members, friends, and community helping resources.

7. INFORMATION ON COPING Goal: To provide information about stress reactions and coping to reduce distress and promote adaptive functioning.

8. LINKAGE WITH COLLABORATIVE SERVICES Goal: To link survivors with available services needed at the time or in the future.

Providers should be flexible, and base the amount of time they spend on each core action on the survivorsâ&#x20AC;&#x2122; specific needs.

Conclusion Emergency physicians on the front lines of care around the globe must be proactive in caring for themselves and each other physically, mentally and spiritually. All aspects of the human experience are affected by trauma, and EPs must integrate with PSS aid providers in order to establish a continuum of care for the community. Hanselâ&#x20AC;&#x2122;s Law says that the effectiveness of a crisis intervention service increases directly as a function of its proximity in both time and place to the crisis event.13 Immediate action is incredibly important to stem systemic damage from community wide trauma.

What you should do: 1. Learn about PSS training tools and groups focused on PSS in conflict zones 2. Learn how trauma affects the body and behavior 3. Develop self-care strategies to build resilience and prevent compassion fatigue

Final thought Untreated trauma is a factor in the cycle of violence for communities suffering from ongoing conflict. You can be a part of the continuum that not only brings physical healing, but also peace and emotional stability to a community.

But in carrying out this mission, be sure to take care of yourself and your colleagues as well.

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A mobile health unit sees patients in Phitsanulok, Thailand. When humanitarian volunteers make medical mistakes, should they be held fully liable?

Legal Liability for Healthcare Volunteers International healthcare volunteerism is growing, and along with it the opportunity for medical errors. The legal framework governing medical volunteering is unclear and varies between legal jurisdictions. Evidence suggests that the incidence of a practitioner being held liable for medical malpractice is increasing. Despite this, the availability of malpractice insurance is limited.

by dr. sharif elgafi

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edical volunteerism is growing. A recent survey of medical graduates in the United States demonstrates that 27 per cent of medical students have had international experience during their four years of medical school, up from 6 per cent in 1982.2 A 2008 study by the World Health Organization (WHO) found that volunteer organizations are significant healthcare providers in developing countries, providing, for example, 40 percent of health services in sub-Saharan Africa.3

Medical volunteering has the potential to cause harm as well as benefit. Limited accountability as well as inadequate knowledge, preparation or resources can lead to poor outcomes

for the recipient population as well as increased chances of litigation.

Despite their increasing popularity, there are many legal and ethical issues surrounding medical volunteerism and medical humanitarian missions that remain unclear.

The right of a person in need for help Human rights treaties as well as other international legal instruments contain numerous provisions aimed at protecting the right to health and healthcare. The Universal Declaration of Human Rights (1948) affirmed that:

“Everyone has the right to a standard of living adequate for the health and well-being of himself and of his family, including food, clothing, housing and medical care and necessary social services, and the right to security in the event of unemployment, sickness, disability, widowhood, old age or other lack of livelihood in circumstances beyond his control.”4 The Constitution of the World Health Organization provides that “the enjoyment of the highest attainable standard of health is one of the fundamental rights of every human being without distinction of race, religion, political belief, economic or social condition.”5 These treaties imply that victims of natural disasters or conflict have a right to the necessary measures being taken to safeguard, protect and improve their lives if threatened and that it is the duty of others to take these measures, notably the state under which they live, but other actors should the state fail to do so.7

The right to compensation in case of malpractice In any legal system the failure to respect a commitment, contract or treaty creates a liability on the part of the defaulting party. Generally, there arises a duty to provide compensation for any resulting damage.

The elements of any successful negligence www.epijournal.com

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claim must include the following three elements: (1) The organisation has a legal duty of care to conform to a certain standard, (2) The organisation fails to meet that standard, and (3) An injury has occurred as a result of this failure.

If a duty is owed, the standard of care is generally determined by what a reasonable and prudent organisation under similar circumstances would do. The relevant standard of care for medical volunteers relates to standards used by the international development community as a whole.9

Ethical rules of conduct for healthcare workers There are ethical rules of conduct that should direct a healthcare worker’s actions in humanitarian efforts, which have their basis in the fundamental principles of medical ethics.

The Foundation for the Ethical Care of International Patients is in the World Medical Association’s (WMA) Declaration of Helsinki. The Declaration was first adopted in 1964 and has subsequently undergone a number of revisions.

The Declaration states, “it is the duty of the physician to promote and safeguard the health of patients, including those who are involved in research. The physician’s knowledge and conscience are dedicated to the fulfillment of this duty.” It also states that for a physician, “The health of my patient will be my first consideration.”10 Although the specific purpose of the Declaration is to provide ethical standards for the conduct of research, it also addresses the general ethical responsibilities of physicians toward their patients.

The implication of this Declaration is that a physician has a similar ethical duty to all patients, regardless of locality or circumstances.

Thus, the physician is bound by common ethical principles of autonomy, beneficence, non-malfeasance, and justice when caring for patients during international humanitarian medical missions.12

Risks of error in medical volunteering Medical volunteering has the potential to cause harm. Unfamiliarity with the patient population, the language and common health problems as well as the short-term nature of many trips can lead to inappropriate treatments.3 30

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10 Tips for Global Health Volunteers kenneth v. iserson, md, mba

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hysicians frequently desire to work in international settings to provide assistance to less-fortunate people, to break out of their daily routine, or to expand their personal horizons.

Before leaping into international medicine, physicians should carefully consider not only the benefits they can expect from the venture, but also the professional challenges and personal costs involved in such trips. After teaching and practicing medicine on all seven continents, I have found that the following 10 tips (extracted from The Global Healthcare Volunteer’s Handbook: What You Need To Know Before You Go) will greatly improve the chances of an international healthcare worker having a successful experience.

1. Select the right organization for you. Many non-governmental (NGO), international and governmental agencies seek healthcare professionals and student volunteers for various projects. Finding an international organization that wants your services may not prove too difficult. Look for them online or through colleagues who have done similar work, your religious organization, university, employer or school. (There is an annotated list in The Global Healthcare Volunteer’s Handbook.) Once you

find an organization, be sure that its mission meets your expectations, the time commitment is doable, you have the right skills to do the job they need, and you can afford any costs involved. Much of this information can be found on the organization’s web site.

2. Eat and drink with care. Many people find the food on international trips to be a memorable part of the experience, especially if they are adventurous eaters. The caveat is that you must be careful about where you eat. Also, in most locales, only drink bottled (or bagged) water, or water you or your team prepare. Even with these precautions, expect to get traveler’s diarrhea and come prepared to treat it. Lastly, don’t consume excessive alcohol, since it may compromise both your safety and your work.

3. Sleep well. To maximize your experience, arrange to sleep in as much comfort as possible. Ensure that the site is quiet (in the back rooms if you are in a hotel, with wax earplugs to block other noise or a roommate’s snoring) and comfortable enough to sleep (controlled temperature, adequate mattress, and safe). Use an insect-protective bed net where appropriate

4. Expect (and avoid when possible) international travel hassles. Peace of mind comes from expecting delays, misplaced bags, and a multitude of long lines when traveling internationally. Consider it an exceptional bonus if this does not happen on a trip. To avoid problems, carry your documents, including your passport, immunization “Yellow Card,” and airline flight confirmation papers with you (you need them to get into many airports) and have another copy on a thumb drive, on your phone, and in your checked luggage. Finally, unless you simply want to test your mettle, don’t always opt for the cheapest transportation method, since it may leave you exhausted and in pain.

5. Travel carefully when on-site.

Balance adventure (using local transportation such as auto-rickshaws and motorbikes) with safety (seat belts, helmets, and known drivers). Learn how much the ride should cost and agree on a price before getting into the vehicle.

6. Communicate effectively. Carry an unlocked Quad Band Phone and purchase a local SIM card at the airport to insert into it. That way you can call for local transportation if your ride doesn’t show up (a fairly common situation).

With Internet connecting the world, arrange for access to Wi-Fi where you live and work or use a “dongle” that connects through the local cellular service. Also, try to learn at least a few words and phrases in the local language; your colleagues and patients will appreciate it. Note that few people in “English-speaking” countries may speak the language; the same is true of French, Spanish and Arabic.

Come ready for a learning curve: Iserson, pictured, holds a premature newborn under a makeshift infant warmer—a light bulb—in a rural Zambian district hospital

7. Work and learn. No matter your level of medical expertise, anticipate a significant learning curve as you work outside your comfort zone. Healthcare delivery sites often lack common equipment and supplies (resourcelimited regions), may use different medications (or names) than you’re used to, may not have many specialty consultants, and may have different procedures and protocols. Realize that you have as much or more to learn from your local colleagues as they have to learn from you.

8. Enjoy your surroundings. Explore your local area and interact with the community. Take advantage of any available tourist sites and ask your local colleagues for advice (and to accompany you, if appropriate).

9. Stay safe. Most areas of the world are as safe as a major U.S. city; take the same precautions as you would there. In more dangerous areas of the world, be certain that there is adequate security (at living and work sites and for transportation). To avoid preventable infectious diseases, consult with a travel clinic to get the appropriate immunizations far enough in advance of your travel, take malaria prophylaxis in endemic areas, and use

insect repellent (100% DEET) to ward off other mosquito-borne ailments. Finally, have medical insurance, evacuation insurance and an evacuation plan. Bad things happen at the most inopportune times. Plan ahead!

10. Be aware of “re-entry culture shock” when you return home. Your international experience will change your perspective on your home life and community. Avoid the negative effects of re-entry shock by sharing your experiences with others and be wary of making unfair comparisons between the site where you worked and your home environment.

It’s hard for a single practitioner or even a single NGO to make a significant impact on the world’s healthcare woes. However, even during shortterm stays, volunteers may be able to assist local healthcare providers by providing education and collaborative research. These experiences also allow them to grow personally and professionally. International healthcare work provides not only the adventure of working in an unfamiliar and remote area, but also the opportunity for true cultural immersion while working alongside local practitioners and their patients.

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// global volunteers

There are several reasons volunteer health care workers may have an increased risk for medical errors, including unavailability of or inadequate health records, laboratory testing, emergency services, examination facilities and referral services for follow-up. Language barriers and limited time with the patient further inhibits the ability to perform a proper medical assessment. Furthermore, the visiting provider is most likely unfamiliar with the standard of practice in the host country while, similarly, the host country providers may be unfamiliar with medications and treatments provided by volunteer health care workers.13 Limited accountability and liability, as well as inadequate knowledge, preparation or resources to meet the needs of the community can lead to providers practicing beyond their scope of training. The increased popularity of students participating in medical missions as part of their educational programs may contribute to this problem. Student volunteers are often at the early stages of their training and may take advantage of the unregulated environment to practice skills and techniques that are beyond their scope and level of training.13

There is a very nonuniform approach to legal protection of volunteers in emergencies amongst various jurisdictions.

AUSTRALIA Civil Liability Act (2002) Protects volunteers from liability, including in an emergency response.

According to the Act, “A volunteer incurs no personal liability for an act of omission done or made in good faith and without recklessness in the course of carrying out community work for a community organization,” including governmental and non-governmental organizations (NGOs).

THE UNITED STATES The Volunteer Protection Act of 1997 Shields volunteers from certain forms of liability, excluding acts of criminal or gross negligence. Under the Act, protection does not extend to crimes of violence or hate, sexual offences or civil rights violations, or acts committed under the influence of alcohol.

The legal framework for volunteering in emergencies There is a general legal obligation to assist a person in danger and failure to do so may result in criminal liability for the volunteer. The humanitarian organization itself may be held liable in some jurisdictions (due to the volunteer being considered their agent). The volunteer may be solely liable if they act in disregard of the tasks or duties assigned to them.

There is a very non-uniform approach to legal protection of volunteers in emergencies amongst various jurisdictions. Many jurisdictions have exemptions from liability for acts carried out in “good faith”. For example, in Australia, the Civil Liability Act (2002) protects volunteers from liability, including in an emergency response.

According to the Act, “A volunteer incurs no personal liability for an act of omission done or made in good faith and without recklessness in the course of carrying out community work for a community organization,” including governmental and non-governmental organizations (NGOs).16 The United States has a similar law, the Volunteer Protection Act of 1997, which shields volunteers from certain forms of liability, excluding acts of criminal or gross negligence.

Under the Act, protection does not extend to 32

SOUTH AFRICA Disaster Management Act of 2002 Provides some protection for volunteers acting in emergencies.

crimes of violence or hate, sexual offences or civil rights violations, or acts committed under the influence of alcohol.17 South Africa also provides some protection for volunteers acting in emergencies, under the Disaster Management Act of 2002.14 In some countries there is specific legislation covering volunteering or disasters, while in other countries volunteer work is covered by general laws. Only a small number of countries have specific legislation regarding volunteering in emergencies.

The legal position, however, remains largely uncertain, as only a few cases of alleged malpractice in an emergency have ever been brought before federal courts. According to the

Fall 2014 // Emergency Physicians International

author Kuhn, “no malpractice claim has ever been filed against any American health care worker providing humanitarian services without charge in the developing world.”29 He states that the malpractice risk is almost non-existent as long as the practice is limited to the local population and that care is provided at minimal or no charge.

Marcus also states that “extensive searches of U.S. and international case law have yielded no active or past cases of medical malpractice against a physician who has volunteered internationally.”17 Generally, volunteers are protected if they can show that they acted in “good faith” i.e. without any indirect or improper motive.14

Negative effects of (over) regulation On June 21, 2012, the Philippine Professional Regulatory Commission (PRC) issued regulations for issuing temporary permits for the conduct of humanitarian missions by foreign medical professionals within the Philippines.

Each medical volunteer is required to purchase liability insurance in the Philippines, prepare specific documentation and pay administrative fees. Additionally, the healthcare worker and host organisation are required to assume full responsibility for the outcome of the mission. In other words, they are held accountable for any post-operative follow-up and the financial costs of any post-operative complications. As a result of this unilateral PRC decision, several groups have cancelled their forthcoming medical mission projects to the Philippines.18

Risk of liability A 2008 survey of full-time medical missionaries, serving in twenty-nine different countries as part of a Christian organization, was conducted by the Center for Medical Missions.19,20 Of the fifty-six physicians who were surveyed, 20 per cent stated that they had liability coverage, either through the organisation or through conventional medical liability insurance. One in five also stated that he or she had been sued while working in the mission field. Settlements were generally in the thousands of dollars.

The largest settlement cited was for $100,000 to $200,000 USD in Taiwan. There was one pending case in Kenya where the demand appeared to be $500,000 USD. The survey does not mention whether the lawsuits were surgical, medical or anaesthesia-related, but the incidents appeared primarily to involve longer-term vol-

field report // rwanda

txa for traumatic bleeds

CONT’D FROM PAGE 12

CONT’D FROM PAGE 23

specialties, emergency medicine is slated to be a full department within the new College of Medicine. The Department of Emergency Medicine will support graduating faculty, help drive national emergency care standards and policy development, and deliver relevant curricula in medical education.

The Clinton Foundation has been instrumental in supporting the HRH-Rwanda program through the foundation as well as the Clinton Health Access initiative which provides logistics and management support to US faculty and the Ministry of Health.

This past year, two full-time emergency medicine faculty were working in Rwanda; myself on behalf of HRH and Dr. Joseph Becker, MD with sidHARTe. By August of 2014, there will be at least three full time HRH and one sidHARTe EM faculty implementing the EM programs. Additional EM faculty support is planned for shorter intervals to facilitate larger

curricular goals such as emergency ultrasound workshops and resuscitation simulations.

Graduates from the EM residency will be the first Rwandan champions of emergency medicine and are expected to graduate in 2018. It is an exciting time to help build EM in Rwanda, and I’m honored to be part of such a team effort.

unteers. The data was gathered through a survey of volunteers; 1,000 surveys were sent with only 59 responses, a 5.9 per cent response rate, which raises questions about the validity of the survey. Almost all of the respondents thought that they would be involved in a medical negligence lawsuit within the next 5 years.

Overall, medical malpractice laws are weak in the developing world. Patients in developing countries often have problems with access to justice. Pertinent issues include massive case backlogs, weak judicial institutions, inadequate legal infrastructure, corruption, and other problems endemic in the developing world. For many of these reasons, parties in developing countries often prefer to settle their disputes informally.21,27

and lack of availability in certain locations.22 There is no consistency regarding coverage by sponsoring organizations. Most organizations do not provide medical malpractice coverage, and some go as far as to state that coverage is not necessary because the likelihood of a lawsuit is negligible. Some organizations recommend that volunteers should consider carrying malpractice coverage while overseas.

Many non-profit organizations that send physicians abroad have volunteers sign a waiver stating that no medical liability insurance is available within the program.17 A few organizations, such as Doctors Without Borders, will provide professional liability coverage for all field staff in addition to health insurance, accident insurance, private liability, repatriation and flight insurance.25 The most common scenario currently is that the healthcare provider travels without liability coverage. In addition, many agencies proactively offer families settlements for adverse events, eliminating the need for litigation.

Medical malpractice insurance Most traditional professional liability insurance policies do not cover actions abroad. Such coverage is only available in the form of specialized policies. These policies have limitations in the form of high premiums, limited coverage

Dr. Novik is an assistant professor at Brown University Department of Emergency Medicine

supported by physiologic data that demonstrates normalization of coagulation panels14 and decrease in pro-inflammatory factors with TXA3, as well as clinical studies that show improvement in other bleeding conditions such as elective surgery4, traumatic hyphema15, upper GI bleeds6, epistaxis16 and menorrhagia5. Subsequent retrospective studies in trauma patients demonstrate conflicting results in severely injured patients, reinforcing the need for a randomized, prospective trial that is more applicable to trauma patients in the US. However, considering the available data, the early use of TXA within three hours of injury should be strongly considered for any patient requiring blood products for trauma-related hemorrhage and especially in patients requiring massive transfusion.

THIS ARTICLE ORIGINALLY APPEARED IN THE OCTOBER EDITION OF EMERGENCY PHYSICIANS MONTHLY. FOR A FULL LIST OF REFERENCES, GO TO WWW.EPMONTHLY.COM

Reducing liability In order to reduce the chance of medical errors and subsequent liability, volunteers being deployed in emergencies should undergo pre-employment screening (including qualifications check, psychological testing and verification of prior experience). They should be provided with proper equipment and undergo adequate briefing, including of their legal rights and responsibilities.26 Additionally, adequate training for volunteers is an important aspect of risk management. Indeed, some volunteer organizations do not allow deployment of volunteers until they have completed mandatory training. Following best practice guidelines of medical missions will improve safety and minimize risks.

Dr. Elgafi is a Senior Consultant Emergency Physician at the Liverpool Hospital Emergency Department in Sydney, Australia FOR A FULL LIST OF REFERENCES, GO TO WWW.EPIJOURNAL.COM www.epijournal.com

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Grand Rounds

PETER CAMERON, MD // IMMEDIATE PAST PRESIDENT OF IFEM

Which Tests Are Best?

Clinical postgrad examinations try to ensure that matriculating physicians are ready for the world of emergency medicine. But can written exams assess the soft skills necessary to practicing EPs?

O

Over the last few months, I have had the chance to observe exit examinations for training programs in three different regions around the world. I have been asked to assess the examination, comment on the robustness of the process and the level of training for the candidates. In an ideal world all the

candidates would be perfect and the supervisors would all do their job well and we could just let the trainees undertake the training over a few years and there would be no need for an exam at the end! Unfortunately we don’t live in Nirvana.

Everyone hates doing exams, but every residency has exams – we want some external validation of the resident training and the ability of the resident to act as a specialist at the end of training. So when do we know that the examination process is good?

To determine this, we must ask what we are actually assessing in the examination. Mostly we want to ensure that the candidates have learnt the material we have presented during the residency program.

However there are some other less obvious objectives. I have often heard examiners state that they want to make sure that the candidates have had adequate clinical exposure to be able to make good clinical decisions. I have also heard examiners state that they want to “weed out” the psychopaths and make sure that the people who pass the exam are reliable doctors.

Some have gone further and suggested that to be admitted into our “club” of emergency specialists, they need to be “in-culturated”, learning the values necessary to treat the poor, the desperate and manage other specialties in the middle of the night! Still other examiners want to assess skills such as management and teaching ability as these are all part of our spectrum of activity.

There are other reasons for having exams, some of these are not stated openly. Sometimes we want to prove to other specialties or the community that emergency medicine is a bone-fide specialty and that our graduates are as expert as other more traditional specialties such as surgery. We also want to use an exam rather than another colleague’s opinion about competence on the floor, because we don’t really trust their objectivity. The colleague might be a friend or enemy of the candidate and may not be able to objectively assess the candidate.

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Fall 2014 // Emergency Physicians International

If I were asked what I really wanted to know from an examination process, it would be this: Can I rely on the candidate working as a clinical colleague by my side. Who better to answer that question than the colleagues with whom they have worked? The problem is that when you work closely with someone, you lose objectivity.

Is it possible to have an examination process that covers all the requirements of a residency exit assessment process? No matter how robust an exam, smart candidates can play the game and pass and yet not really do the components of training desired by their residency supervisors. Nevertheless, one thing is clear: examinations and assessments determine the curriculum. That is, if it is not tested, the candidates will not spend much time on it. So if you want residents to focus on specific content or skills, make it a meaningful part of their final assessment.

No matter how robust an exam, smart candidates can play the game and pass and yet not really do the components of training desired by their residency supervisors.

Examinations are a relatively quick and efficient way of assessing candidates, compared with in-service evaluations or other real world observational techniques. They are also easier to standardize across a region or country and make it simpler to compare training outcomes and levels of knowledge between regions. Exams also make reproducibility of assessments more feasible.

Testing basic knowledge in an exam is relatively straightforward and can be administered in an MCQ format with high reproducibility. I think that most of us would accept that although this is a useful component of the assessment, it is a very small part of what we expect from a specialist physician. What about clinical skills, clinical judgment, teamwork, teaching and administrative capability? These can be tested in an examination environment, but the “soft” skills are much more difficult to assess in the artificial simulated environment of a centralized exam. The examiner is much more subjective in their assessment and skilled candidates can take advantage of the situation. These candidates can be good at the exam, but poor in the clinical environment. Importantly, a resident exhibiting behaviours over the lifetime of a residency is much more likely to continue those behaviours after residency. Thus, the exit assessment process should not rely only on a single exhibition of desired attributes. Log books, project work and pre-

The Morgan Lens for Emergency Ocular Irrigation Testing knowledge is the easy part; testing the components that make up a “good” EM specialist is much more difficult and likely to vary between regions – and even within regions.

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sentations throughout the residency are important markers of consistent progress. Sign off by multiple mentors is also useful.

There are other skills we want our residents to develop, including research methodology and critical appraisal. These can be tested in a single exam, but does it really inculcate the critical thinking, ethics and research rigor necessary for a clinician to undertake evidence-based practice or to be involved in a research project? This may be better undertaken as a separate module within the course with exposure and assessments (eg on-line) over a longer period of time.

The way different emergency medicine organisations around the world have approached the issue of residency exit assessments is widely variable. Often the objectives of the examination are not clear and there has not been enough thought put into what the desired product (i.e. specialist) at the end of the residency looks like. We have the lofty goals espoused by the CanMeds and ACGME of what an expert clinician looks like. Assessing this with limited resources in a standardized fashion across cultures and regions is more difficult than it might first seem. Testing knowledge is the easy part; testing the components that make up a “good” EM specialist is much more difficult and likely to vary between regions and even within regions. Healthy discussion of the various approaches will help everyone improve their programs. A group led

by James Kwan in the IFEM curriculum committee has developed an important document looking at assessment techniques and how to use them. This will form a valuable reference document for EM programs internationally.

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

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