Top notch EM training center launches in China Learning to think on your feet in the ED EM and the non-communicable disease burden Can you fight a pandemic over Skype? EMERGENCY PHYSICIANS INTERNATIONAL
ISSUE 16
. SUMMER 2015 . WWW.EPIJOURNAL.COM
THE UBER-FICATION OF EMERGENCY RESPONSE
Communitybased “brancardiers” – stretcher bearers – undergo training in southern Haiti.
In 2015, Google awarded Trek Medics a $250K grant to expand Beacon, a low-cost program that uses existing SMS infrastructure to turn local taxi drivers into life-saving first responders. // page 28
havana knights – A new medical conference showcases Cuban emergency physicians’ ability to do more with less.
For all information about the congress (registration, abstract submission, accommodation, etc) please contact Organising Secretariat: MCO Congrès SAS - 27, rue du Four à Chaux - 13007 Marseille T.: +33 (0)4 95 09 38 00 - F.: +33 (0)4 95 09 38 01 - eMail: contact@eusemcongress.org
www.eusemcongress.org
EDITOR’S DESK
Better Together
M
ultiple recent events have pointed out the effectiveness of collaboration on global health and international emergency medicine. The containment of the Ebola epidemic in West Africa is largely owing to the cooperation of civilian and military medical teams, with the prominent involvement of emergency physicians in this effort. Cuba, for example, sent a team of nearly 160 physicians, who returned home just recently, in May 2015 (read our Cuba report, Havana Knights, on page 24). In Syria and Iraq, emergency physicians from around the world have coordinated medical care efforts (also at significant personal risk) for the many refugees of the ongoing conflicts; more than 6 million Syrians have been displaced within the country and the surrounding region, and more than 3 million Iraqis have been displaced within Iraq alone. Here in the US, I just returned from the Society for Academic Emergency Medicine (SAEM) Annual Meeting, in San Diego, California. I was very impressed with the accomplishments and capabilities of the emerging “new” leaders in global health and international emergency medicine. The Global Emergency Medicine Academy (GEMA) of SAEM has put together a number of web-based reference resources and has supported the international emergency medicine annual article review published in Academic Emergency Medicine. GEMA has collaborated with the American College of Emergency Physicians (ACEP) International Section in co-promoting each organization’s annual meeting activities and in addressing complimentary topics at the sequential meetings of each organization. EPI serves as a link between both organizations, with editorial staff members serving both organizations. There has been a recent rift between two of the organizations involved in international emergency medicine, but I am hopeful that this may be resolved amicably, as collaboration—rather than competition—should be the byword for our efforts in promoting the specialty of emergency medicine globally. The opportunities in this field are enormous, if we band together, particularly in central Asia and Africa. I encourage you to attend the upcoming international emergency medicine meetings in United Arab Emirates, Poland, Russia, Cuba, Italy, Japan, Hungary, and Turkey (among others, check out our event calendar on page 6) in the remaining months of this year. Hope to see you at an upcoming conference!
I encourage you to attend the upcoming international emergency medicine meetings in United Arab Emirates, Poland, Russia, Cuba, Italy, Japan, Hungary, and Turkey (among others) in the remaining months of this year.
C. James Holliman, MD, FACEP, FIFEM editorial director
Cameron: Opportunities, threats for Indian EM How to design new EDs for infection control The telemedicine revolution has arrived Wilderness medicine tips for everyday care EMERGENCY PHYSICIANS INTERNATIONAL
ISSUE 15
. WINTER 2014 . WWW.EPIJOURNAL.COM
MAPPING EBOLA Harvard researchers explore how cell phone data could be the key to tracking the next pandemic
This map uses mobile phone data to visualize personal connectedness. Color coding has been based on strength of social ties. page 24
dispatches: Readers from 19 countries explain how they prepared for Ebola
suit up: A physician teams up with a clothing designer to imagine better PPE
ABOUT EPI With a quarterly print and digital distribution and an online network of more than 2,000 members, EPI is the essential hub connecting global emergency care, sparking dialogue and creating a space for new collaborations. Find copies of the
print magazine at international EM conferences around the world, or read it online at www.epijournal.com. Print subscriptions now available for $60, global shipping included. Go to epijournal.bigcartel.com For bulk subscriptions, email logan@epijournal.com
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EDITOR’S DESK
Clinician Cognition
L
ately, I’ve been thinking a lot about the brain. In particular, my brain—and even more particularly, my basal ganglia—and why my own neuropathways in that region have somehow managed to encode and circumscribe any number of annoying behavior patterns and subconscious biases that affect my (hypothetical!) propensity to put off chores or to make a gratuitous purchase. I am predisposed to these musings, because I have edited and written hundreds of articles on the psychiatric and neurocognitive literature over the course of my career. So I welcomed Senad Tabakovic’s contribution in which he explores the brain’s role in forming a diagnostic “gut feeling” in the ED (The Gut Feeling, page 22). Skillful clinical diagnosis is especially crucial in the ED where, as Dr. Tabakovic points out, patients are usually complete strangers, and medical histories are either incomplete or unavailable, but EPs are nevertheless required to make rapid and thorough diagnostic judgments. Naturally, EPs recognize repeated patterns and experiences over time that help them comfortably arrive at a diagnosis based on patient presentation, observation, available labs, etc. In other words, heuristic strategies. More common diagnoses will therefore come to mind more quickly, leading to more efficient diagnosis, yet more complex presentations will interrupt those heuristics and force the mind to enter a more cognitively taxing evaluative strategy. These deductive diagnostic processes are generally the most complex cognitive behaviors the EP will undertake, according to Pat Croskerry, a Canadian EP who has written an extensive body of literature on the cognitive processes (and errors) of EM diagnosis. Given its fast pace and high levels of uncertainty, Dr. Croskerry writes that EM is especially prone to diagnostic errors, which he says are fundamentally cognitive errors made by hard-working and well-intentioned physicians, owing to internal biases, copious inherent distractions in the ED, or fatigue. The way to avoid more of these cognitive errors is to adopt a working knowledge of “cognitive forcing strategies,” which are intended to force selfmonitoring of one’s decision-making, and to limit potential biases and to control for them. Just like developing a gut feeling, this also happens with acquiring greater clinical experience, as in recognizing particular diagnostic pitfalls, which could be associated with painful lessons learned in the past. The point is that working harder, or being more careful, won’t really shake the building blocks of our cognitive processes. Sharpening the mind requires an extrinsic intervention. And that can be a painful process. It can mean admitting that you were wrong, or, heaven forbid, being open to critique. I get a taste of that process as an editor in reshaping a piece of editorial. While often uncomfortable for writer and editor alike, the process of critical pushback and the ensuing engagement is the most pleasing aspect of my job; it allows me to support in my way the marvelous EPs around the world who work against great adversity to bring better health to millions. I am stumbling amidst giants in the field of global EM, and I am grateful for your work, all. My hope is that this issue of EPI finds you ever productive, ever humble, and ever reflective. Lonnie Stoltzfoos Managing Editor
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Summer 2015 // Emergency Physicians International
editorial director C. JAMES HOLLIMAN, MD executive editors PETER CAMERON, MD TERRY MULLIGAN, DO, MPH LEE WALLIS, MD PROF. V. ANANTHARAMAN managing editor LONNIE STOLTZFOOS regional corespondents CONRAD BUCKLE, MD MARCIO RODRIGUES, MD CARLOS RISSA, MD KATRIN HRUSKA, MD SUBROTO DAS, MD MOHAMED AL-ASFOOR, MD JIRAPORN SRI-ON, MD editorial advisors ARIF ALPER CEVIK, MD ANITA BHAVNANI, MD KATE DOUGLASS, MD HAYWOOD HALL, MD CHAK-WAH KAM, MD GREG LARKIN, MD PROF. DONGPILL LEE SAM-BEOM LEE, MD ALBERTO MACHADO, MD JORGE OTERO, MD advertising RHONDA TRUITT
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You read it at CEEM... 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
.
SPRING 2014
. WWW.EPIJOURNAL.COM
India’s MVA Problem: Bystander Apathy EMERGENCY PHYSICIANS INTERNATIONAL
ISSUE 11
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FALL 2013
. WWW.EPIJOURNAL.COM
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
Once the beds in Santa Maria were full, it took 92 trips by military aircraft to transport victims of the fire to Porto Alegre.
As the world’s elderly population continues to grow, the emergency department stands poised to become the hub of geriatric care. page 23
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 $60/YEAR–GLOBAL SHIPPING INCLUDED EXECUTIVE EDITORS: JIM HOLLIMAN, PETER CAMERON, LEE WALLIS, TERRY MULLIGAN & V. ANANTHARAMAN
IN THIS ISSUE
EVENT CALENDAR 08/15–12/15
www.epijournal.com
THE COMPREHENSIVE GUIDE TO GLOBAL EM CONFERENCES
03 | Editor’s Desk
Field Reports 8 | Slovenia
AUGUST 2015 EMSS15 - Emergency Medicine Summer School // Copenhagen, Denmark August 2-8, 2015 emss15.sats-kbh.dk
International Emergency Care Symposium // Melbourne, Australia August 25-28, 2015 www.acem.org.au
SEPTEMBER Conceptos 2015 Conference // Santiago, Chile September 2-4, 2015 conceptos.urgenciauc.cl/eng
Mediterranean Emergency Medicine Congress // Rome, Italy September 4-9, 2015 www.aaem.org/education/memc
Developing EM Cuba Conference // Havana, Cuba September 13-17, 2015 www.developingem.com
OCTOBER
9 | United Kingdom ACEP Scientific Assembly // Boston, USA October 26-29, 2015 www.acep.org
11 | Rwanda
NOVEMBER
Departments
International ED Leadership Institute // Barcelona, Spain
An Ethiopian EM leader lays the groundwork for producing 5,000–10,000 new EM trainees.
November 2-8, 2015 www.iedli.org
14 | Round Table New student ambassador program creates awareness of the EM specialty among med students around the world.
November 7-10, 2015 www.acem2015.org
15 | Next Gen
Australian College for Emergency Medicine Annual Scientific Meeting // Brisbane QLD, Australia November 23-26, 2015 www.acem.org.au Contact: zoe.sum@acem.org.au
What are the tricks to the trade for becoming a professional decision maker in the ED?
Reports 18 | NCDs
DECEMBER
Non-communicable diseases are increasingly landing in the ED, and EPs can help turn the tide.
International Seminar in Emergency Response // Tel Aviv, Israel
20 | Disaster Prep
December 6-11, 2015 Contact: vickia@mda.org.il
Delivering care in remote Vanuatu after an earthquake and volcanic eruption hit with days
22 | Telemedicine Monitoring and directing the Ebola fight via webcam from 5,000 miles away
24 | Havana Knights Cuba’s fiercely efficient healthcare system comes to light in an upcoming EM conference in Havana
October 11-14, 2015 www.eusem.org
October 22-25, 2015 www.winfocus2015.com
13 | Profile
Asian Conference for Emergency Medicine // Taipei, Taiwan
EuSEM Congress on Emergency Medicine // Torino, Italy
11th WINFOCUS World Congress on Ultrasound in Emergency and Critical Care Conference // Boston, Massachusetts
10 | China
LIST YOUR NEXT INTERNATIONAL EVENT FOR FREE ON THE EPI NETWORK – WWW. EPIJOURNAL.COM/ EVENTS
28 | On the Scene In some countries, a simple text-based first responder program may make more sense than expensive ambulance EMS
34 | Grand Rounds Peter Cameron: Is it time to discharge triage from the ED?
AN 46 2.0 01/2015/A-E
What is needed for Intubation? C-MACÂŽ System: A single instrument is not a plan B
KARL STORZ GmbH & Co. KG, MittelstraĂ&#x;e 8, 78532 Tuttlingen/Germany, www.karlstorz.com
FIELD REPORT
Lake Bled, in Slovenia, set against the soaring Julian Alps. In 2014, the Mountain Rescue Association of Slovenia conducted over 400 search and rescue missions in the mountains, of which 184 involved a physician.
JUNE 2015
SLOVENIA Slovenia is now undergoing a planned transition in which primary health care emergency services will be merged with hospital emergency services. by sabina zadel, md
S
lovenia is a small Central European country with only 2 million people. Emergency medicine in Slovenia is composed of primary health care emergency rooms and ambulances (prehospital emergency care), and separate emergency rooms for internal medicine, surgery, and gynecology. At the primary health care level, physicians’ access to urgent diagnostic and invasive procedures are limited. As a result, patients often have to be referred to an internal, surgery, gynecological, or other emergency room for health problems that could be otherwise easily solved by physicians working at 8
primary healthcare level using chest X-ray, lab work, CT scan, etc. This is a problem in that a large number of patients are referred to hospital emergency rooms for evaluation, and then many patients will also be referred between different emergency rooms within the hospital. Traditionally, mostly general practitioners work in the primary health care emergency rooms and ambulances; anesthesiologists or specialists of other branches can be found there only on occasion. These general practitioners sometimes work in the ED and in the ambulance during the same shift. Professor Ĺ tefek Grmec (now deceased) was a big visionary regarding EM in Slovenia. His vision was to start an EM residency as its own branch and to produce emergency physicians who would treat all urgent and acutely ill patient in the field and in one universal ED, as opposed to multiple specialty EDs. The idea was to merge primary health care emergency and hospital emergency; the emergency physi-
Summer 2015 // Emergency Physicians International
77 83 Life expectancy (M/F) in Slovenia
$2084 (USD)
Annual per capita health spending (2013)
cian would have more competence regarding diagnostic and invasive procedures, and consultants from other specialties would come to the patient at the ED. The intended consequence would be fewer referrals to different EDs and faster treatment. In 2006, Professor Grmec succeded in that residency of EM was accepted by the Slovenian Ministry of Health and the Medical Chamber of Slovenia. During the 5-year EM residency in Slovenia, residents complete rotations in the critical care, anesthesiology, general surgery, prehospital, cardiology, gastroenterology, endocrinology, paediatrics, obstetrics and gynecology, neurology, psychiatry, otorhinolaryngology, and ophthalmology units. Today we have around 60 young EM specialists and residents. Many of the first generation of EM specialists and residents still work in the primary health care emergency room and ambulances. Some of the most recent EM residents are already employed within hospitals, so they have more possibilities regarding diagnostic and invasive procedures. The Slovenian Ministry of Health has issued new regulations for emergency services for a planned merger of primary health care emergency and hospital emergency. This could be a big step in EM development in Slovenia. The transition period should last up to 3 years. During this time, young EM doctors from Slovenia will continue to work hard and provide the best emergency care for our patients.
3 Exit block and poor work environments have been threatening A&Es for years (this protest from 2010 is as relavant today as it was then).
UNITED KINGDOM After relentless media coverage of the state of many EDs in England, Northern Ireland, Scotland, and Wales, the pressure is on to reform key A&E processes and funding mechanisms. by dr. kate clayton
E
mergency Medicine (EM) in the UK is in an unprecedented state of crisis, that much is undeniable. Within the speciality, of course, we have long realised that the situation of increasing demands and ever-dwindling resources was unsustainable. But the lone voice in the wilderness that was EM went unheard, year upon year, until the autumn of 2014. Relentless media coverage over the preceding months exposed the parlous state of the nation’s emergency depart-
ments (EDs) to the public. This finally provided a platform for senior emergency doctors to voice our concerns at a national level. On 25th November 2014 the Royal College of Emergency Medicine launched the STEP campaign, urging government, politicians and National Health Service leaders to take action to address the issues facing EDs. The college holds that there are four key areas to be addressed in order to rebuild EM in the UK, namely staffing, tariffs, exit block and primary care. 1. Staffing – Increasing workload and poor work-life balance has driven many doctors out of the speciality, or deterred them from considering EM as a career option. Many more have left the UK to work overseas, particularly in Australia, at an estimated cost of £130m to the taxpayer. Unfilled training places has led to spiralling costs, estimated at a further £120m, due to reliance on locum doctors. 2. Tariffs –In England, EM is
“The Royal College of Emergency Medicine looks forward to working with the new government to solve the challenges facing emergency care, and to ensure a safe and reliable A&E service for patients as measured by the four hour target.” —May 20 press release by the RCEM
Author Disclosure: Dr Clayton is currently avoiding the crisis in UK EM by working in Australia.
subject to a bizarre system of routine underfunding, whereby the hospital receives only a fraction of the cost of non-elective admissions to hospital. As the hospital can only recoup this loss by increasing the number of elective cases they admit, this increases pressure on acute beds, leading to exit block. 3. Exit Block – Exit block occurs where a patient in the ED requires an acute hospital bed, but none is available. This leads to ED overcrowding, and increased mortality. Exit block affects approximately 500,000 patients per year in the UK. 4. Primary Care – The ED workload is substantially increased by primary care patients attending, particularly outside of office hours. Innovations to remedy this situation have mostly proved ineffective, therefore a new approach of colocating primary care facilities and sharing investigative resources, such as X-ray and laboratory testing, has been suggested. This is likely to be popular with patients, cost efficient and is endorsed by the Department of Health and several Royal Colleges, amongst others. More recently, the College gave evidence to the House of Commons Health Select Committee about the crisis facing emergency departments in the UK. However, despite the high public profile of emergency care in the past year, it would appear most hospitals have not implemented the College’s recommendations, despite £700m emergency funding being made available. Following the general election in May 2015, which produced a non-coalition Conservative government, the future of emergency medicine in the UK remains uncertain.
www.epijournal.com
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FIELD REPORT
This Source Report is an excerpt of a detailed account by Drs. Au and Chu in bringing their AED to international training and operating standards. The full account will appear in the fall 2015 issue of EPI.
JUNE 2015
t Dr. Gary Chu conducts bedside US training.
CHINA The ED at The University of Hong Kong-Shenzhen Hospital is the first in mainland China to run in accordance with international standards. by dr. kin heng constantine au
& dr. gary chu
T
he University of Hong Kong-Shenzhen Hospital (HKUSZH) is a proud collaboration between the Shenzhen Municipal Government and the University of Hong Kong (HKU). This project aims to reform healthcare in China, as well as bringing the best in teaching, training, and research into Shenzhen, all of which meet international standards. Shenzhen is a major city in the southern Province of Guangdong, located immediately north of the Hong Kong Special Administrative Region. Healthcare reform is a huge task with many challenges and obstacles. The Chief of Service, Dr. Gary 10
Chu, arrived at this hospital in September 2012. The second consultant, Dr. Constantine Au, joined in December 2012. At that time, the Accident and Emergency Department (AED) consisted of only a small resuscitation room. Two nursing staff members had to deal alone with anything from minor allergic reactions to major trauma, including falls from a construction site next to this hospital. Staff slowly joined the department. At that time, the Medical School in Shenzhen was still new and there were no medical graduates from Shenzhen. All doctors and nurses came from different parts of China. They had different training, different exposure and different expectations. Since then, many staff have joined the AED of HKUSZH, and many of our doctors and nurses received additional training in a variety of related disciplines, including toxicology and infection control. In China, where grandfather practice overrides evidence-based practice, the staff of AED of HKUSZH is determined to intro-
Summer 2015 // Emergency Physicians International
Shenzhen Stats $260 billion GDP 14 million population AED of HKCEM 250–450 Daily patient load (with weekend surges) 34 Nurses 5 full/ part-time consultants and 26 doctors
duce evidence-based practice to China. Today, patients at AED of HKUSZH are prioritized according to their clinical needs, instead of by specialty. The Hong Kong AED triage system is implemented right from the beginning. As all of our AED doctors and nurses have formal BLS and ACLS training, the AED is responsible for emergency crash calls throughout the hospital, including all the wards and nonclinical areas. A resuscitation record template has been designed to improve and standardize documentation. These records will be audited by the AED to ensure that our hospital maintains its standard and be used for CQI. Spreading the concepts and skills of emergency medicine with international standard to the whole China is one of our missions. Our main working partner is the China Candlelight Education Fund of Hong Kong. This foundation has built over 450 schools in rural China in the past 20 years. Since 2014, it decided to help in medical education as well. Our first joint project with it began in October 2014. Instructors of CPR, and infectious diseases were sent to rural hospitals in Guangdong Province. This exchange was well received. Since then, visits were conducted in every season. The Accreditation Team of the Hong Kong College of Emergency Medicine (HKCEM) visited the AED of HKUSZH on December 2, 2014. The findings were favorable. The Council Meeting of HKCEM approved the accreditation on March 3, 2015. On April 9, 2015, the Hong Kong Academy of Medicine officially endorsed this approval. We are therefore very pleased to announce that AED, HKUSZH is the first training center of HKCEM that lies outside Hong Kong.
RWANDA After a year of clinical and training work at an ED in Kigali, Rwanda, Dr. Rahman returns to his former ED in England and here reflects upon the great importance of the greater health system contexts in EM development. by najeeb rahman mbchb, dha, dph, fcem
I
parked in my usual spot, walked down my usual route to the ED, through the ambulance bay, got changed into my scrubs, and walked into the office for handover. The Matron who was sat there gave me a sideways look. “Where have you been? Pinderfields?” she said, referring to a hospital about 8 miles away. I asked her to guess again, and, after being mistaken for the fourth time, reminded her that I had been in Rwanda over the past year. And so began my first shift back in the familiar setting of the Emergency Department at Leeds General Infirmary after having spent the better part of the year working and developing Emergency Medicine (EM) at the University
Teaching Hospital of Kigali, colloquially known by it’s French acronym, CHUK.
The first patient I reviewed on my first day back was an overweight teenager, who had given birth to her first child 10 weeks prior. After having endured a spinal anesthetic during delivery, she had been suffering with persistent back pain, despite consulting her General Practitioner a number of times, and being prescribed analgesics. Nothing had changed on the day of her attendance except that she couldn’t get an appointment back at her GP’s, and the receptionist advised her to attend the ED. She looked well, and was soon on her way home after being reassured that there were no critical findings, and advised regarding use of painkillers, as well as back exercises and losing weight. The next patient was of the type I had not seen for over a year: • Male • Fifties • Smoker • Chest pain for 20 mins • Now resolved • Normal ECG • Normal clinical exam
p Emergency care in Kigali, Rwanda (above). Author Najeeb Rahman (right)
Almost like riding a bicycle, I completed the protocol documentation to get him admitted to our Clinical Decisions Unit to await results of his Troponin blood tests as well as repeat ECGs, not to mention the valuable period of observation and therapeutic cup of tea that he no doubt received while on the unit— an essential part of healing here in Yorkshire. During the time I was seeing these 2 of the 55 patients in the department, I was aware of a trauma case that had been admitted to our resuscitation room following a motor vehicle accident. The Trauma Team had been activated and the bay was saturated with specialist staff who promptly whisked the patient to the CT scanner, less than 50m away, and then back to our resuscitation room for continuing care and to await the CT findings. Flashback to Kigali As I took stock of this first hour of my first shift back, I reflected on some of my experiences in Kigali, where we (my colleagues, both Rwandese and expats) faced numerous and significant challenges in supporting the growth of EM in a resource limited setting. By extension, those challenges included delivering www.epijournal.com
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emergency care to a severely resource limited population, in terms of both finances and population. Whereas in developed nations public EDs are open to all, in Rwanda the current system to access the ED at CHUK (which serves as a referral hospital to the nation) was usually by means of transfer from a district hospital. Patients may also be brought in by SAMU, the prehospital service that currently functions only in Kigali, although this occurs less frequently than transfers. There are appropriate justifications for the development of such a referral system in this setting, although this system can (and often does) lead to significant delays— typically days as opposed to hours— in the transfer of the acutely ill, which results in patients often arriving in such a critical state that they are usually beyond recovery. There is an admirable model of health insurance now established in Rwanda, but the system is tested severely with the challenges of delivering modern emergency care, which regularly makes use of expensive primary clinical interventions or imaging modalities to guide time critical decision making, particularly in cases of trauma. This results in delays to patient care while family members try to gather together the 10% co-pay of an investigation in question. For a CT head scan, this is $7 too much for most families. Reassuringly, there are continuing attempts, directives, and waivers issued to address this recurring problem, despite barriers to implementation. Our current model of care delivery relies upon clinical practice guidelines to improve the safety and efficacy of care, and legal instruments protect staff and patients, and hold institutions accountable. Against this backdrop, I am reminded of how we 12
There is an admirable model of health insurance now established in Rwanda, but the system is tested severely with the challenges of delivering modern emergency care, which regularly makes use of expensive primary clinical interventions or imaging modalities to guide critical decision making.
tried our best to manage patients in Kigali who suffered from a range of complex injury and illness for which there is no great body of evidence, and for which the only clinical tools within reach were adaptation, experience, and opinion. Such a patient would include one with greater than 50% burns who remained in our ED for days, isolated from no one, without the focused monitoring, fluids, nutrition, dressings, early institution of appropriate antibiotics, surgical debridement and grafting required for survival and recovery. Or others presenting with hyperglycemia, along with other features more consistent with autoimmune etiology, as opposed to insulin resistance. There were also tragic encounters of managing palliation of the severely brain injured (secondary to trauma or cerebrovascular accident), or terminally ill, where medico-legal implications affected decision-making. Additional similar clinical challenges were compounded by lack of access to laboratory tests, basic medication and consumables owing to stock shortages, or risk to patients
Summer 2015 // Emergency Physicians International
and staff for lack of running water, faulty equipment and environmental hazards, or an inability to get the patient the right care in the right place at the right time due to human resource and personnel issues, or simply a lack of space at the hospital. Improving emergency care is now a focus of many global initiatives, and all recognize the need for specialist training. For those involved in such programs there is often a sense of urgency in accelerating the infancy of EM to its running stage, before it has learned to walk.
RWANDAN HEALTHCARE PROGRESS
Conclusions I felt great pride and privilege working among and training the remarkable individuals who are tasked with being the pioneers of EM in Rwanda. I am also reminded of the fragility of establishing EM as a specialty, which, by design, is set to exploit the best of any existing health system in the interest of its patients. It therefore follows that developing EM in resource-limited countries is exposed and at risk of bankruptcy— despite comprehensive education and training programs—if steps are not taken to ensure that the health system is robust enough to perform, whether it be in terms of policy, funding, infrastructure, improved interspecialty and interdisciplinary work, information management, and a culture change that values professionalism and prioritizes the needs of the patient. Surely one would recognize that such an effort is akin to an Ironman endurance race as opposed to a brisk walk in the park. Back in Leeds, I walked out of the ED at the end of my shift, grateful for the familiarity of the work, the place, and the people. I like the parks in my neighborhood, and I can’t remember that last time I endured a race of any sort. I also miss Rwanda.
Hospitals, Clinics 1990: 29 hospitals, 302 health centers 2007: 38 hospitals, 411 health centers
Life Expectancy 1990: 33 2008: 50 Births Attended by Qualified Personnel 1992: 26% 2007: 52%
source: Overseas Development Institute, 2011
Profile
Leading From The East As the current President of the Ethiopian Society of Emergency Medicine Professionals, Dr. Teklu is leading efforts to form the clinical structure for EM in Ethiopio and neighboring countries. by crystal bae
I
magine an ED with no space for patients, no ability to provide blood, constant transfers to other hospitals because of a shortage of beds, and, worse, a staff with no emergency medicine training. This describes the reality of rural Ethiopian emergency rooms only a few years ago. Dr. Sisay Teklu, a trained OB/GYN from southwest Ethiopia, found a need for the development of EM in his country. Dr. Teklu was born and raised in southwest Ethiopia. After high school, he completed a six-year course at Addis Ababa University in Family Medicine, graduating as a general practitioner. He completed his rural service and then continued his medical training, specializing in the registrar program in obstetrics and gynecology. In 2004, he finished his residency in obstetrics and gynecology, and joined the teaching staff in 2006. Several years later, the Dean from Addis Ababa University School of Medicine, Dr. Zufan, formed a task force, including Dr. Teklu,
from major clinical departments to determine who among the patient load seen by Black Lion Hospital’s departments of surgery, anesthesia, internal medicine, and obstetrics and gynecology would benefit from having an ED. The results of this task force led to the formation of a new Emergency Medicine Department, headed by Dr. Aklilu Azazh; the creation of pre-hospital care and training, coordinated by Dr. Assefu Woldetsadik; and the post graduate program for Emergency Medicine, led by Dr. Teklu. In October 2013, Dr. Teklu wit-
nessed the graduation of the first group of Emergency Medicine residents from the Addis Ababa University School of Medicine, who are now imparting their emergency care knowledge to nurses. The EM program has also extended into the undergraduate curriculum, making it much easier for general practitioners to join EM residency programs. With such a rapidly growing program, the Ethiopian Society of Emergency Medicine Professionals (ESEMP) was formed to coordinate activities nationwide and to bring physicians, nurses, and paramedics under one umbrella. Dr. Teklu hopes to take this experience to neighboring countries within the near future to help develop emergency medicine programs. As the current President of ESEMP, Dr. Teklu has optimistic goals for emergency care. He hopes to expand facilities to 1,000 small districts, each with their own EMS system and vehicles. The plan is to continue expanding their curriculum to include 11 modules and to eventually produce between 5,000 and 10,000 trainees. The hope is for ESEMP to gain the support of the Ethiopian government for its efforts in training more emergency physicians. With the hard work of Dr. Teklu and his colleagues, the continuing development for Emergency Medicine in Ethiopia is sure to continue apace.
The EM program at Addis Ababa University School of Medicine has also extended into the undergraduate curriculum, making it much easier for general practitioners to join EM residency programs.
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Round Table
ISAEM Launches National Ambassador Project The International Student Association of Emergency Medicine is beginning to establish regional outposts to provide peer support and resources for EM students and residents around the globe. by anh-nhi thi huynh
& larshan perinpam
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reating and maintaining different collaborations is of great importance for the International Student Association of Emergency Medicine (ISAEM). After attending several international conferences (EuSEM, ACEP, ESEM, etc.), it because clearer that positive developments could not be maintained without excellent networking. ISAEM therefore created new key positions in its infrastructure and launched the national ISAEM Ambassadors Program. The purpose of this program is to lengthen the collaborating arms of ISAEM (and thereby develop further its international network and collaboration with medical students), and to increase the interest and influence of medical students with an interest in Emergency Medicine (EM)—both in countries with and without an independent specialty in EM. An ISAEM national ambassador is a medical student who is already deep involved in the work of a national or local EM interest group in their country. The key tasks of the ambassadors will be to help evolve clinical exchange programs with the executive board, and to maintain and sustain contact with their respective national and local EM interest groups and organizations. There will be bi-monthly meetings with all ISAEM national ambassadors to make sure developments are going well, and to exchange experience and ideas of how to further develop an interest in EM among medical students. Ambassadors, in turn, will hear each other’s updates on EM worldwide, and will attend board meetings within ISAEM. ISAEM currently has three national ambassadors: from Denmark, Brazil, and the US (pictured). With a focus on the different educational, cultural, and organizational aspects of EM, our ambassadors were asked to share their thoughts on the ambassador program and future aspects of the development of EM on both a national and international level. Here’s what they had to say. 14
Summer 2015 // Emergency Physicians International
Why do you think the ISAEM national ambassador project is a great idea? Rebecca Oestervig Denmark is one of the few European countries where EM is not yet recognized as an independent specialty. However, we are fortunate to have many committed students who are very engaged in reaching out and passing on their interest in EM. The ISAEM National Ambassador Project serves an important role in both encouraging and motivating these students and, in general, brings attention to the importance of establishing EM as a specialty. Moreover, it is possible for the ambassador to create a link between new initiatives within the field from around the world, and on the ongoing project of having EM recognized in Denmark. Henrique Puls EM is not recognized in Brazil, so Brazilian medical students don’t even imagine it as a career. I believe that introducing the specialty directly to the students is the most effective pathway to turn this “unknown” specialty in to a desirable field and force its recognition by the medical authorities. Lance Adams This ISAEM program fosters a symbiotic relationship between health care providers in EM throughout the globe, allowing skills, knowledge, training, and networking unhindered by borders or languages. Such a relationship has the potential to bless the lives of millions as its effects trickle down to the lives of our patients. What is your expectation to your position as a national Ambassador for ISAEM? Oestervig I hope to motivate our committed by bringing updates on EM from around the world. We have to look for ideas and inspiration from abroad because EM is not recognized in our country. The collaboration with ISAEM makes this possible. Denmark is divided in 5 regions with different positions on this specialty. Being a part of ISAEM can contribute to narrowing the gaps and to forming a united acknowledgement in all regions of the importance of EM. This will make students as well as doctors aware of the fact that it is possible to pursue a career in EM, because many young doctors do not dream of a career within the field simply because they do not know it exists. Puls EM is an amazing field, and I am sure there is a huge number of people within Brazil that would be interested. The biggest problem is that they do not know that EM exists. My first step
----------Henrique Puls is a fifth year medical student in Brazil and an associate director of the UFCSPA Emergency Medicine and Trauma Interest group.
----------Rebecca Oestervig is a fifth year medical student in Denmark and a board member of the Danish Emergency Medicine Student Organization, SOFAS.
in working for ISAEM will be to introduce EM as a real specialty to my Brazilian colleagues and strive to create an EM support network within our country. During these processes I would get in touch with several passionate EM people, which I am sure will be extremely valuable to further developing EM in Brazil. Adams As an ambassador for ISAEM to the US I will be able to create international relationships establishing health exchanges that allow US students to get a taste of international medicine, as well providing students from the US to gain experience with students outside the US. I believe that there are many US students who would be interested in such an exchange. Such interest is reflected by the new scholarship created by EMRA specifically for EMRA US medical students to travel abroad to gain international experience. What is the biggest problem for developing EM among medical students in your country? Oestervig In Denmark, SOFAS is the Danish student organization for young people with an interest in EM. SOFAS is established in all Danish medical schools and has local and national boards. Our biggest challenge is that there are many takers for the students’ attention and that it can be tricky for students to decide which organization to join. For SOFAS, it has been difficult to allocate members, especially in the capital region. The interest is there, but it is a challenge to recruit members for a specialty that does not yet exist. However, during the past year SOFAS has managed to draw a greater focus on EM in the main region, and has arranged their first course for students, to take place in autumn 2015. Hopefully many more will follow in the near future. Puls Since EM is not a recognized specialty in Brazil, the vast major-
----------Lance Adams a final year medical student from Ross University School of Medicine, and is a medical student Council International representative in EMRA.
ity of students do not even consider following this pathway. When thinking about what specialty to choose, the first question that comes to their minds is “surgery or medicine?” I believe that when Brazilian medical students realize that EM is a real specialty and it is possible to have it as a career, this situation will change and the demand for the specialty will force its recognition by Brazilian medical organizations. Adams The largest problem facing US students is the lack of availability for all students interested in EM to match in the US. What do you expect to have achieved within the next year? Oestervig My ambition is first to help define why EM is needed as an independent specialty. I also wish to endorse our local student organizations in arranging lectures and courses in EM, because that is how we reach our students—the future physicians in EM. Puls I have three goals within ISAEM for 2015. First, start an ISAEM membership in the top 25 Medical Schools in Brazil. Second, make Brazilian ISAEM members active ISAEM members. I want Brazilian members to have a meaningful and productive participation in ISAEM. I am sure that each member has several ideas to share with the ISAEM community. Third, select spots for the ISAEM exchange observership program. That is the toughest task, but it is the one I am most excited about. I believe we have quality spots to offer medical students internationally. Adams Within the next year my goal is to establish the first set of exchanges between US institutions and other international EM establishments.
Next Gen
The Gut Feeling A new EM resident explores the ins and outs, and the basic neuropsychology, of becoming a professional decision maker especially in the ED. by dr. senad tabakovic
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hen I began my residency in the ED I felt like jumping in at the deep end. Coming from internal medicine, a world of structured visits at fixed times with clear hierarchies, the somewhat chaotic and informal environment in the ED fascinated me. Noise, overcrowding, frequent interruptions, limited patient information, and constant time pressure didn’t bother me a lot. I quickly realized that the biggest challenge for me would be dealing with the huge number of decisions one had to make. There were so many questions I had to deal with, starting with triage, diagnostics, therapy, in- or out-hospital treatment, admission to which department, involvement of other specialists—just to mention a few. Many of these questions were new to me, and my existing knowledge seemed to help little. I had to develop some decision-making skills, and fast. By analyzing and trying to copy my senior physicians, I soon realized that there were big inter-individual differences concerning these skills. For example, there were risk takers and precautious types, some relied on their clinical skills, others ran lots of imaging, yet others always asked for specialist support. In many Swiss hospitals, the ED is still subdivided into internal medicine and surgery. So as a resident, you work with senior physicians with very different backgrounds and emergency medicine experi16
ence, which also reflects in their decision-making. However, one thing was universal to all the attendings I was working with: most of the time, their decisions weren’t based on textbook knowledge; they were often just made based on gut feeling and clinical rules of thumb. Until then, being an evidence basedrilled internal medicine resident, I hadn’t been aware of this particular dimension of medical work, and I wanted to understand it better in order to improve my decision making skills. First, I had to get an idea of how my brain copes with the large amount of information it is being confronted with. This would help me understand how I assess a patient. The main information processing strategy is probably pattern recognition, which is the basis for everything from doorway diagnosis to gut feeling. Take the herpes zoster virus for example, which is for most of us a doorway diagnosis. When I learned about herpes zoster for the first time, I had to con-
Summer 2015 // Emergency Physicians International
sciously define the characteristics of the rash and to distinguish it from other differentials. This was a conscious, analytical, time- and energyconsuming process. With repeated exposure to this diagnosis, however, my brain felt convenient and safe enough to automate the processing of information and to massively accelerate it by doing so. Pattern recognition plays an equally important role in complex patient presentations because of its associative characteristics. Our brain always subconsciously and automatically tries to interrelate the information it processes. So this interrelation of patterns allows experienced physicians to group information like disease-related history, physical examination, and laboratory findings. Thus, the greater the experience, the greater the collection of patterns we can work with. The subconscious association of these patterns also allows us to capture the patient’s condition at a glance. We call this phenomenon gut feeling. During the years of my residency, I understood that one of the biggest differences between individual emergency physicians is the extent to which they rely on their gut feeling. My second step to improving decision-making skills was to understand the role of clinical rules and mental shortcuts. In emergency medicine, we love clinical rules of thumb and use them to a much greater extent than other specialists do, because most of the
In emergency medicine, we are often forced to assess patients without having the full picture and complete information. The missing information is replaced by assumptions that are based on our experiences, prejudices, beliefs, and superstitions.
This interplay between pattern recognition and use of heuristics is indispensable for fast patient assessment and triage. From the moment I realized this, my metamorphosis from internist to emergency physician began.
time we are forced to assess patients without having the full picture and complete information. The missing information is replaced by assumptions that are based on our experiences, prejudices, beliefs, and superstitions. These strategies are also known as heuristics. An alternative use of heuristics is to just intuitively ignore irrelevant information and, in so doing, speed up the diagnostic process. So, is less information sometimes more? Just imagine a typical patient with a renal colic. Having recognized this particular pattern, experienced emergency physicians would probably choose the most direct way to diagnosis without actively considering all the differentials of acute flank pain, and by looking for evidence that supports their assumption. This interplay between pattern recognition and use of heuristics is indispensable for fast patient assessment and triage. From the moment I realized this, my metamorphosis from internist to emergency physician began. Of course, not all patients will fit into a known pattern, forcing us to step back and still think analytically. We ask ourselves what the patient could have, we make a list of differentials and try to prove them with tests. We make use of the hypothetico-deductive strategy. This is a more accurate and conscious way of processing information, but it also expends a lot of our cognitive capacity. But even here, we are not strictly analytical as human beings. Our top list of differentials reflects
not only the prevalence of a disease with the given symptoms; we also consider diagnoses that are disproportionally prevalent, those more readily available to our mind, those that are more easily treated (we intuitively don’t want to miss those), and those that are serious. Depending on the seriousness of the differential, we might even choose the “rule out the worst” strategy before we continue testing other hypotheses. So in clinical reality, we still use this rational strategy in our naturally irrational way. As a young resident, I always felt a mismatch between the way we make decisions and the way we explain them. Sometimes, when I tried to rationalize the irrational, it led to misunderstandings with supervisors. Those were the moments when I thought, “If you would just see the patient, you would understand what I’m talking about.” Today, as a young attending, I accept the gut feeling as an argument, and I think that we should try to sensitize the residents for this dimension. In countries like Switzerland, where we try to emancipate emergency medicine, we should actively teach heuristics and emphasize their importance for our specialty. Further investigation in the field is needed, and, with more knowledge, we could perhaps one day even make adjustments to the workflow in EDs, making it more adaptable to our evolutionarily derived intuitive skills, with all their capabilities and limitations.
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// ncd
The EP’s Role in Facing the Non-Communicable Disease Pandemic Cardiovascular and pulmonary disease, diabetes, and mental illness are all managed regularly in the ED, but their burden is falling disproportionately on developing countries. Could EPs intervene and change the course of their country’s health trajectory? by christine ngaruiya, md, dtm&h
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on-communicable diseases (NCDs) form the inescapable pandemic of the twentyfirst century that now threaten the developing world’s advances in health and economic stability.1-5 Through what has been coined the “double burden” of disease, involving the superimposition of NCDs on existing infectious diseases, healthcare systems now face greater strain with more complicated patients, particularly given patient presentations in late stages of disease, longer durations of follow-up, and more expensive testing and treatment for care.4,6 The World Health Organization (WHO) convened a highlevel assembly meeting in September 2011 to raise concerns and to set actionable targets on this major problem.7-8 Prevalence and Repercussions of NCDs NCDs annually constitute more than 60% of deaths worldwide, reported at 36 million deaths in 2008.1,5 Furthermore, current disease trends suggest significant growth over the next decade, with the WHO projecting 55 million deaths from NCDs annually by 2030 if there is no acute action made.1 Furthermore, NCDs have surpassed communicable diseases as the lead cause of death in all continents except Africa, where NCDs are nevertheless projected to surpass deaths from communicable diseases, maternal and perina18
tal conditions, and nutritional deficiencies by 2030.1,7 Eighty-percent of deaths from NCDs occur in low- and middle- income countries (LMICs) with the majority of these occurring prematurely as compared to high-income countries. 1,4,9 Not only do the majority of NCDs require more involved care but these diseases also complicate infectious disease presentations. This is seen in the case of cardiovascular complications with HIV patients, diabetes in TB patients, and rheumatic heart disease with under-diagnosed or mismanaged rheumatic fever cases in childhood.1,6,7 Additionally, some NCDs have primary infectious causes such as Kaposi’s sarcoma with HIV and herpes virus, liver cancer due to hepatitis viruses, chronic kidney disease due to schistosomiasis, and cholangiosarcoma due to liver flukes.1 So what can the Emergency Physician (EP) do about it? How and Where Emergency Physicians Can Battle NCDs The World Health Assembly released the global NCD action plan for 2013-2020 building on the 2008-2013 work plan with a multi-tiered strategy to address the rise in NCDs, including a goal for a “25% relative reduction in premature mortality from cardiovascular diseases, cancer, diabetes or chronic respiratory diseases (especially chronic obstructive pulmonary disease and asthma) by 2025”.1 These four
Summer 2015 // Emergency Physicians International
disease groups highlight the lead causes of death from NCDs, but are also diseases managed routinely in the Emergency Department (ED).4 While there is only sparse literature on the distribution of NCDs amongst ED populations in LMICs, the concerning death rates from diseases that are likely to present to the ER cannot be debated. This is shown by the 2013 Global Burden of Disease study, which reported a 41% increase in global deaths from cardiovascular disease, given aging and burgeoning populations. Multiple sources also report injury as one of the leading causes of mortality and morbidity in these regions.4,5,9,10,11 Ogunmola and Olamoyegun published a retrospective review on patient admissions presenting through the ED to a federal hospital in Nigeria, between 2010-2012, which revealed cardiovascular disease as the lead cause of death at 33.5%.12 Another retrospective review on patients accessing care through the ED in Karachi, Pakistan found that among >78,000 patient visits and 601 deaths, the lead causes of death were sepsis at 23%, followed closely by myocardial infarction at 20%, and cerebrovascular accident as the third leading cause at 11%.13 Some of the most important tools in the case of global NCD control are prevention, patient empowerment, and health promotion.5,14,15 The NCDs causing the highest burden of deaths are primarily tied to actionable risk factors, which are diet, exercise, and alcohol and tobacco use, and WHO recommendations suggest that targeting these risk factors are cost-effective best practices in addressing the burden of disease.1,16,17 The ED has the potential to act with regard to this, and there are different means of doing so. Ensuring adequate drug therapy for diabetes and hypertension control, especially in those with a history of cardiovascular disease (eg, ensuring acetylsalicylic for myocardial infarction patients), are highly cost-effective interventions.1,4 Educating patients on their diseases, as well as important attributable risk factors to address them are also cost-effective and critical actions.1,4,7 Concerningly low rates of
patient awareness on disease presence such as in the case of the “silent killer” and most important risk factor of cardiovascular disease, hypertension, is still seen in LMICs, along with dismal control rates in those already on treatment.18 Alcohol, tobacco, and other drug use have been associated with violence and unintentional injuries, so providing education, resources, and treatment where possible for cessation of these substances is key.1 Additionally, education on diet regarding mitigating salt intake and saturated fats, and increasing consumption of fruits and vegetables, are further best practice actions.1,4,7 Task-shifting to enable greater realization of some of the educational needs addressing NCD care may be considered.9,19 Appropriate management of asthma, and influenza vaccination for COPD patients are equally important. Other risk factors that can be highlighted to patients are minimizing occupational exposures/ hazards and indoor pollution owing to cooking gases, which worsen chronic respiratory disease and increase the risk of
1. WHO global action plan: for the prevention and control of noncommunicable diseases, 2013-2020. http://apps.who.int/iris/bitstre am/10665/94384/1/9789241506236_ eng.pdf. Accessed 4/2/2015. 2. Bloom DE, Cafiero ET, Jané-Llopis E, et al. The global economic burden of non-communicable diseases. Geneva (CH): World Economic Forum; 2011. 3. Diez-Canseco F, Boeren Y, Quispe R, Chiang Ml, Miranda JJ. Engagement of Adolescents in a Health Communications Program to Prevent Noncommunicable Diseases: Multiplicadores Jóvenes, Lima, Peru, 2011. Prev Chronic Dis. 2015; 12:1 40416 4. Murray CJL, Vos T, Lozano R, et al. Disability-Adjusted life years (DALYs) for 291 diseases and injuries in 21 regions, 1990-2010: a systematic analysis for the Global Burden of Disease Study 2010. Lancet. 2012; 380: 2197-223. 5. WHO Global status report on non-communicable diseases 2010: executive summary. 2011. http://www. who.int/nmh/publications/ncd_report_ summary_en.pdf?ua=1. Accessed
lung cancer.1 Recognizing the association between other NCDs and mental illness is also important for EPs, as well as the critical underrecognition of NCDs in patients with mental illness. Finally, using available infrastructure to refer early—and stressing this to patients—is paramount, especially in light of the danger of delayed care for hypertension and its effect on chronic kidney disease progression.1,6 The ED also has a unique role in acting as the safety net in many cases, with the ability to influence the trajectory of patient care and refer patients that may otherwise never get looped into the healthcare system. Additionally, ED and hospital leadership may implement guidelines and protocols addressing treatment and prevention for clinical providers to follow, as well as prioritizing access to basic diagnostics and respective in-country essential medicines to help treat these diseases.7,20 As EPs, we have a golden ticket to influence the inner workings of an already strained system, especially with the potential to catch patients during early stages of disease before
4/7/2015. 6. Bukhman G, Kidder A. The PIH Guide to Chronic Care Integration for Endemic Non-Communicable Diseases. http://parthealth.3cdn.net/ e9df3e9c18f698e02e_mlbrr0ygv.pdf. Accessed 4/7/2015. 7. United nations general assembly: sixty-sixth session, agenda item 117: Political Declaration of the High-level Meeting of the General Assembly on the Prevention and Control of Non-communicable Diseases. http:// www.who.int/nmh/events/un_ncd_ summit2011/political_declaration_ en.pdf?ua=1. Accessed 4/7/2015. 8. WHO Global Coordination Mechanism. http://www.who.int/global-coordination-mechanism/background/en/. Accessed 4/10/15. 9. Binagwaho A, Muhimpundu MA, Bukhman G, NCD Synergies Group. 80 under 40 by 2020: an equity agenda for NCDs and injuries. Lancet. 2014; 383(9911): 3–4. 10. Yusuf S, McKee M. Documenting the Global Burden of Cardiovascular Disease A Major Achievement but Still a Work in Progress. Circulation. 2014; 129: 1459-1462.
they progress.4 Conclusions All in all, the problem requires a communal awareness and urgency of action amongst all global health players at different levels and from a wide range of sectors.7 By recognizing the problem as a significant concern in the ED, we can then consider NCDs with greater awareness as we address our patients, guide trainees, and refer patients to outside care. EPs can also be active in joining the effort to raise awareness locally, both in their own communities and at the healthcare level. Along with further research to document specific population-based data on NCDs, there is a need for greater prioritization of NCDs by governments and policy makers.4 We each have a role to play in curbing an alarming rise of highly preventable diseases and their sequelae in the most vulnerable populations, and the time for action is now.1
11. Wachira B, Wallis LA, Geduld H. An analysis of the clinical practice of emergency medicine in public emergency departments in Kenya. Emerg Med J. 2012; 29: 473-476. 12. Ogunmola OJ, Olamoyegun MA. Patterns and outcomes of medical admissions in the accident and emergency department of a tertiary health center in a rural community of Ekiti, Nigeria. J Emerg Trauma Shock. 2014; 7(4): 261-7. 13. Khan NU, Razzak JA, Alam SM, Ahmad H. Emergency department deaths despite active management: experience from a tertiary care centre in a low-income country. Emerg Med Australas. 2007; 19(3): 213-7. 14. Scaling up action on noncommunicable diseases: how much will it cost? World Health Organization, 2011. http://whqlibdoc.who.int/publications/2011/9789241502313_eng. pdf?ua=1. Accessed 4/7/2015. 15. Rollnick S, Miller WR, Butler C. Motivational interviewing in health care: helping patients change behavior. 2008. New York: The Guilford Press.
over the year: SNAP/Food Stamp participation 2014. Washington (DC): Food Research and Action Center; 2014. http://frac.org/reports-andresources/snapfood-stamp-monthlyparit 17. Wachira BW, Owuor AO, Otieno HA. Acute management of ST-elevation myocardial infarction in a tertiary hospital in Kenya: Are we complying with practice guidelines? African Journal of Emergency Medicine. 2014; 4(3): 104–108. 18. van de Vijver S, Akinyi H, Oti S, et al. Status report on hypertension in Africa - Consultative review for the 6th Session of the African Union Conference of Ministers of Health on NCD’s. Pan Afr Med J. 2013; 16: 38. 19. Binagwaho A, Kyamanywa P, Farmer PE, et al. Rwanda’s human resources for health program: a new partnership. N Engl J Med. 2013; 369: 2054–59. 20. WHO model lists of essential medicines. http://www.who.int/medicines/publications/essentialmedicines/ en/. Accessed 4/7/2015.
16. April 2014 SNAP caseloads down
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// disaster prep
Trouble in Paradise A 4-physician team lands in the remote islands of Vanuatu soon after it was hit with a massive earthquake followed by a volcanic eruption. by kenneth v. iserson, md
I
magine black sand beaches, swaying palm trees, more than 80% of the population living in thatched houses, dense jungles, and a towering volcano at the center of a remote South Pacific island. A former English/French cooperative colony with a remote history of cannibalism, Ambrym Island in Vanuatu (formerly the New Hebrides) had an aura of mystery. Sounds idyllic, and the sort of place that Michener would use as a backdrop for his Tales of the South Pacific (which he did). Now imagine the same setting after a magnitude 8+ earthquake followed, a day later, by a gigantic 20
volcanic eruption with ash and acid rain fallout and, a week later, by Category 5+ Cyclone (hurricane) “Pam.” Not so pretty. At least half the trees were down, coral pieces covered the beaches, nearly all the outhouses and at least half the thatch-covered household kitchen and houses were decapitated or destroyed, and the people who mostly survived on the vegetables and fruits they grew or harvested from their surroundings were starving. The most acute problem, however, was that their drinking water had been seriously compromised. I entered the picture on March 23, a week or so after the cyclone.
Summer 2015 // Emergency Physicians International
s A rainbow emerges over one of the two small open boats used to traverse the Pacific Ocean between the team’s initial work location on the southeast corner of the island and their next work site, the southwest corner. Three primary population sites exist on the island, and they are isolated from each other by precipitous cliffs and a volcano at the island’s center
I arrived as a member of the small International Medical Corps team, via a 4-hour flight from Australia, in Port Vila, Vanuatu’s capital on Efate Island. Other non-governmental organizations (NGOs) and New Zealand, Australian, and French military units had already arrived and deployed to the well-known and hard-hit Tanna Island to the south. We were the only ones tasked to go to Ambrym and the smaller nearby Paama Island; no one had much information, since their communications were down. A tiny plane delivered our team— four-physicians, a logistics/communications expert, one interpreter (Bislama is the main language)— and our equipment into the isolated southeast corner of the island. We later augmented our team with several local interpreters. More equipment, medications, and another logistics expert were coming via a 36-hour ferry journey. As soon as we arrived, we then sped off using the one unpaved path along that PHOTOS BY KENNETH ISERSON
Dr. Iserson sewing a 2-year old girl’s fingers after she tried to grab a knife. Doing this using only available equipment and his own headlamp was not ideal, but it was the best care available
part of the coast to meet the Area Secretary, essentially the mayor for that one-third of the island’s population. Sitting in what remained of his thatched kitchen, he graciously offered us what was perhaps the last orange he had while welcoming us to the island. We couldn’t refuse his offer, although we desperately wished that he would save it for himself and his family. Over the next two weeks, we helped deliver health care, distributed thousands of water purification tabs and plastic jerry cans, did some surgeries and dental extractions, and helped hone the skills of some of the local nurses and nurse aides who generally deliver care for the island—although they were often highly knowledgeable. We traveled in small open boats across choppy seas to Paama Island and the isolated southeast and north parts of Ambrym. Our sleeping accommodations were on the ground or on
wooden platforms; our water was prepared by filtering and purification tabs, and our food was often locally acquired, including flying fox (bat), fish, yams, taro, island cabbage and, of course, coconut. We also tried (and did not enjoy) Kava, the traditional root-based drink. I won’t do that again! As we left, we found that the New Zealand military was coming in to fix the water supply, an NGO was coming to fix the schools, and others would eventually arrive to help put the situation back on course. Within 3 months, Ambrym will again have locally grown vegetables, a good clean water supply, and functioning schools. Bananas will be available within a year and the tops of the lopped off coconut trees seemed to be growing at least a foot every few days. This was a rare opportunity to make a timely difference in a devastated environment with the
International Medical Corps, an extremely knowledgeable, organized, and experienced organization. As a side benefit, it showed me an amazing place to come back and visit as a tourist in the future. Wonderful people and an awesome setting. That’s what practicing global medicine is all about. Dr. Iserson is the author of “The Global Healthcare Volunteers’ Handbook: What You Need to Know Before You Go” 2014 www.galenpress.com and “Improvised Medicine: Providing Care in Extreme Environments” 2013, McGraw-Hill.
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// telemedicine
Logging In For Pandemic Practice African health drill demonstrates the power of low tech telemedicine tools like web cams and basic internet connectivity. by scott johnson & dr. fanie hattingh
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n October 20, 2014, as the Ebola outbreak in West Africa was advancing and crossing borders, an international telemedicine field test commenced between South Africa and the United States. The goal of the exercise was to prove the power and potential of robust telecommunication connectivity for telemedicine procedures in screening, treating, and monitoring Ebola patients in remote locations through the virtual collaboration of experts. In one hour of uninterrupted connectivity, the possibilities of driving healthcare into austere locations and orchestrating a global response to an infectious disease outbreak over the information highway were demonstrated. Directing this particular exercise was African health technology entrepreneur Dr. Fanie Hattingh (founder of The Ebola Project) and Prof. Lee Wallis, President of the African Federation for Emergency Medicine (AFEM). With assistance from local Emergency Medical Services, an inflatable “mock” Ebola screening tent was deployed in a field outside Cape Town next to Tygerberg Academic Hospital, simulating a temporary clinic that could be erected anywhere in the world. Gondwana Communications provided a
Lessons Learned
VSAT (Very Small Aperture Terminal) antenna and mobile base station outside the tent, creating satellite-internet connectivity and supplying live video and audio feed for the laptops and web cams positioned inside the tent and mobile command center. Using the low-bandwidth capabilities of the video telemedicine platform VSee, the team in Cape Town initiated a telemedicine call with Johannesburg-based Dr. Brian Levy, a Specialist Anaesthetist and Intensive Care Physician who represented the “Remote African Specialist”. In addition, Scott Johnson, Director of Communications at the Beth Israel Deaconess Medical Center (BIDMC) Fellowship in Disaster Medicine and telemedicine consultant, was video-linked from Ohio as the “Remote US Advisor”. The proof of concept was delivered with basic laptops, projectors, USB webcams and 3G dongles – technology currently available from most computer shops across Africa. The simple web cam placed the eyes of the world on the screening tent, and the personnel inside were guided virtually throughout the assessment of an “acutely ill” patient. With video and audio connectivity, the international team was able to simultaneously coach and advise the healthcare worker, interview the “patient”, connect the “patient” to family located 10,000 km away, and communicate to other healthcare workers. The mixture of relatively inexpensive components allowed for accurate patient assessment, remote documentation of observations, technical advice and guidance to medical personnel, as well as support for
• Having something (even a web cam) is better than having nothing when lives are on the line • Healthcare challenges in austere areas can be overcome through improvisation and combinations of relatively inexpensive, widely available technology • High tech solutions are the future of disaster and emergency response in remote and low resourced environments; • Collaborators can offer virtual support in any global “hot zone” and instantly guide local health workers without expensive logistical operations and unnecessary personal risk • International collaboration along with access to global health communities and joint-funding, are essential components for effective and timely deployment of these life-saving solutions. healthcare workers in an under-resourced environment. The international team also used the telemedicine interface to observe and instruct the healthcare worker about infection control procedures, such as disrobing and decontamination – a step that is critical in disease control and potentially lifesaving for all workers. The simulation and all procedures were documented on a customized, Africanbuilt, electronic medical record platform. This EMR was stored on a secure site for future access and shared confidentially with colleagues globally via the telemedicine platform. Even though digital stethoscopes, otoscopes, and other higher tech telemedicine peripherals were not available at the time of this field test, the exercise nonetheless demonstrated the power of a basic web cam as a cost-effective telemedicine tool when telecommunication networks are intentionally employed. It also proved that with mobile VSAT connectivity, many telemedicine procedures can be employed, data gathered and shared with global collaborators, and experts virtually consulted in a prudent way and with immediate impact and results.
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Design: The Future of Psych EDs
How Important is Training Standardization?
Surfing doctors put new spin on training
Cameron: Less Turf War, More Collaboration
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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
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India’s MVA Problem: Bystander Apathy EMERGENCY PHYSICIANS INTERNATIONAL
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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
Once the beds in Santa Maria were full, it took 92 trips by military aircraft to transport victims of the fire to Porto Alegre.
As the world’s elderly population continues to grow, the emergency department stands poised to become the hub of geriatric care. page 23
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.
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Havana Knights A new EM conference aims to showcase how Cuban emergency physicians have modeled high quality healthcare on a budget 24
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The founders of a young EM conference prepare for their fourth meeting, to be held in Havana, Cuba—their second in that city. How can the dialogue from this unique conference benefit regional and international leaders of EM development?
by mark newcombe, bmed, facem & steven lee fineberg, bmed, facem, with lonnie stoltzfoos
In March, a regional committee of independent experts convened by the Pan American Health Organization/ World Health Organization (PAHO/WHO) visited Cuba to analyze the country’s progress toward the elimination of mother-to-child transmission of HIV and congenital syphilis. Photos courtesy of the Pan American Health Organization
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uba’s healthcare establishment is well known for its astonishing regional and global outreach. As a core tenet and priority of the Castro brothers’ government, national healthcare in Cuba has expanded systematically over 50 years of revolutionary rule. Today, over 70,000 highly trained physicians in Cuba serve its national population of 11.2 million people, with 6.72 physicians per 1,000 in the population, which is among the highest physician-patient ratios in the world. These healthcare accomplishments occurred despite decades of economic turmoil and adversity, and Cuba’s doctors and researchers are justifiably famous in the medical community for their innovative and efficient approaches to problems that challenge even the most well resourced healthcare systems. There is no formal EMS system in Cuba, but the Cuban physician’s training ethos and armamentarium are uniquely well suited to emergency care. As a result of its medical presence around the world, we see Cuba as a poster child for medical internationalism and for how we can contribute meaningfully to the practice of medicine around the world. That is one of the reasons we are hosting the third Developing Emergency Medicine (DEM) conference there, to not only support Cuban physicians’ efforts in a nominal way but also to expose our
THE LEDE Cuban Healthcare in the Global Headlines THE INDEPENDENT “American researchers are about to be given access for the first time to a breakthrough lung cancer vaccine developed in Cuba, in what could be one of the most significant benefits to the US of improving relations with the Communist state…One of the most prominent is a drug which suppresses the growth of tumours in the lungs. Cimavax has been available for free to all Cuban citizens since 2011, is believed to have minimal side effects and can prolong the life of a patient in the late stages of the disease by as much as six months.” —May 14, 2015
faculty and delegates to the great medical efforts that can be achieved even with limited resources. ‘Emergency Medicine’ in Cuba Emergency medical care is practiced somewhat differently in Cuba, partly as a result of effects from the US trade embargo. There is no traditional western style EMS system with a centralized phone number and a fleet of ambulances ready
to be dispatched, but there is a network of ~470 polyclinics in communities across Cuba that is designed to be easily accessible by a great part of the population. This is critically important for a population where access to a working, private vehicle is uncommon. Polyclinics are usually staffed by a surgeon or ambulatory general practitioner who can provide first-line care. Some may be staffed by a midwife or nurse, depending on the historical medical needs of the local population. If an injury or illness proves beyond the capability of the polyclinic, the patient will be escalated to the nearest medical center, then to a tertiary care center. For an even more rapid escalation of care, patients might be transported directly from a polyclinic to tertiary care. This EMS arrangement resembles a mash up of the French style of field-treatment and the US style of rapid hospital admission. There is a lot of overlap between intensive care and EM. We found that most of the medical doctors we interacted with during our first DEM Conference in Havana had intensive care backgrounds and later branched out into emergency departments, which are a concept that is still evolving in most Cuban hospitals. There now seems to be a small but growing recognition inside Cuba that it is time to devise a slightly more advanced system for dealing with emergencies. Unlike www.epijournal.com
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Cuba has 40,000–50,000 health workers dispatched in nearly 70 countries around the globe. Tince Frederica Jempaut (pictured) is a trainee doctor working in Liquica Hospital, East Timor, under the guidance of a delegation of Cuban doctors. Photograph by Dean Sewell/oculi/Agence Vu for WaterAid.
many developing countries Cuba already has a strong and responsive healthcare system to build upon, and it is beginning to adopt some EMS processes that its leaders have observed in the US, Australia, Canada, and, to some extent, Western Europe. Prior to our first Havana DEM conference we were unable to secure approval for site visits to EDs in Cuba. We are hopeful, however, that site visits will be approved for the 2015 conference and that we will be able to see our Cuban colleagues in action. Cuba’s Medical Diplomacy Cuba has 40,000–50,000 health workers dispatched in nearly 70 countries, especially South and Central America, the Pacific, the Caribbean, Africa, and to a lesser extent Asia. Cuba has conducted these brigades for decades, which are not only a significant component of its soft diplomacy but can also function as a commodity in its international trade relations, as in the case of trading health care for oil with Venezuela, which alone as 30,000 Cuban health care workers. Many of those health workers have a skill base that we know as EM care, especially in regard to the practice of medicine in challenging environments for long periods of time. Cuban delegations have also set up ophthalmology clinics and hospitals in South America, Africa, and the South Pacific, providing sight-saving care to millions of patients. Most recently, Cuba sent 180 practitioners to Sierra Leone to staff a semi-permanent 26
Ebola treatment operation. Medical training is another central component in Cuba’s medical outreach efforts. Escuela Latinoamericana de Medicina (ELAM), located in Havana, is one of the largest medical schools in the world. ELAM alone produces between 1,000– 1,500 doctors each year, and hundreds of graduates have come from developing countries around the world, especially countries from South and Central America, and Africa. The total number of in-
Summer 2015 // Emergency Physicians International
coming medical students enrolled in Cuba’s entire medical education system now exceeds 25,000 per year. All students are provided full scholarships by the Cuban government (including room and board), with the expressed caveat that graduates provide services in their home communities or other underresourced regions after their training. DEM 2015 With decades of EM experience between
Unlike many developing countries Cuba already has a strong and responsive healthcare system to build upon, and it is beginning to adopt some EMS processes that its leaders have observed elsewhere around the world. us, we originally pursued the concept of DEM because we wanted a conference where we could learn something practical to take to the next shift. DEM 2015 will accordingly focus on the core elements of EM: pediatrics, trauma, and adult critical care. We have a whole day of global focus, so a Cuba and Caribbean morning, and an IFEM afternoon, with Dr. Jim Holliman. We will have a preconference ultrasound workshop in Havana with the folks from Ultrasound Podcast, and the National Association of EMS Physicians will be conducting a Medical Directors workshop. DEM 2015 receives no financial sponsorship. Delegate registration fees and individual contributions comprise the sole revenue stream for the conference. Delegates from Cuba and other local Caribbean nations are wholly sponsored by the conference, and will also receive USB sticks preloaded with EM literature and information. In 2013 we were privileged to sponsor ~75 local delegates; in 2015 we hope to increase local sponsorship to surpass the 2:1 ratio with international delegates that we achieved in 2013. Future International Engagement with Cuba’s Medical Community As a result of the US trade embargo against Cuba, which straitens Cuba’s economy and effectively bars outside pharmaceutical and medical device companies, Cubans are very frugal with their public health measures. Every treatment guideline and every initiative must provide the maximum public health utility for the lowest possible expenditure. Its research initiatives are razor focused and innovative by necessity, and findings are woven into
THE LEDE Cuban Healthcare in the Global Headlines FOREIGN POLICY “A joint U.S.-Cuban physician-training effort would not only solve the human resources crisis in the Ebolahit nations, but would further open the doors of diplomatic cooperation between Washington, and Havana. Through funding from USAID and perhaps private sources — from the likes of, say, the Bill & Melinda Gates Foundation — the costs of travel, housing, and education for African nurses, as well as subsidies for educating their nursing replacements inside the West African countries, could allow rapid deployment of 200 or more nurses to ELAM. Within three to four years the African nations would see their physician ranks swell, thanks to the United States and Cuba.” —May 6, 2015
HAVANA TIMES “An initial team of 158 medical doctors and nurses returned to Cuba from Sierra Leone and Liberia on March 23. Since then, small groups of doctors have been returning to Cuba, until all of those mobilized to Western Africa (where, next to physicians from other countries, they saved lives and halted the spread of the epidemic), had come back. There were two regrettable losses, victims of malaria.” —May 6, 2015
practice. Cuba’s biotechnology advances are especially noteworthy, with vaccine research into cholera, dengue, tuberculosis, leptospirosis, and even a lung cancer vaccine, which the United States FDA is reportedly pursuing for clinical trials in the US. Cuba’s national pharmaceutical company produces a comprehensive lifetime schedule of childhood vaccinations, as well as analgesics, antibiotics, antiretroviral medications for HIV treatment, a number of cancer treatments, anesthetics, and other generic drugs. These advances have not come without sacrifice, much of which is borne by Cuban health care workers themselves. Cuban physicians working in Cuba are paid no more than the equivalent of $67 USD per month, depending on their level of training, and nurses may receive half that. Physicians working on some medical brigades may be paid many times more. And although Cuba’s biotechnology production is finally reaping the benefits of decades of experience, memories of extreme drug scarcities during the 1990s are not far removed from the present. These adversities mostly serve to bring into sharp relief the tremendous spirit of cooperation, education, and engagement seen in Cuba’s health care workers and researchers in the face of many challenges. This group of dedicated professionals is one of the many reasons we are privileged to organize our third DEM conference in Havana.
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Beacon of Hope In 2015, Google.org awarded Trek Medics International a $250,000 seed grant. The objective? To use a program called Beacon to help implement localized emergency response with SMS technology and available transit, rather than driving toward Western-style ambulance EMS. By Jason Friesen, MPH, EMT-P
ww Community-based Community-based“brancardiers”— “brancardiers”— “stretcher “stretcherbearers”—undergo bearers”—undergotraining traininginin southern Haiti. Photo by Thomas southern Haiti. Photo by ThomasFreteur Freteur
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There are 5–7 billion people worldwide who have no reliable way to call for trained emergency medical response in the event of life- or limb-threatening illness and injury.1 Most of these people live in low- and middle-income countries (LMICs) where the existence of formal emergency medical systems is all but nonexistent, save occasionally in the wealthiest neighborhoods. This lack of access has a crippling effect on LMICs, as the rates for premature death and disability are extraordinarily high, particularly from conditions that would be otherwise considered “preventable” in the wealthiest nations. Despite the massive human, social, and financial tolls, most communities in LMICs still can not manage to transport emergency patients to the hospital in a coordinated fashion. Are Ambulances the Answer? While the obstacles preventing equitable access to emergency care in the neediest countries are undoubtedly multifactorial and multidisciplinary, there’s at least one common pattern among communities where access is limited: patients with life- or limb-threatening illness and injury in LMICs have the odds stacked against their favor. According to the World Health Organization, more than 90% of road traffic fatalities occur in LMICs,2 despite owning just over 50% of the world’s registered vehicles, and over 99% of maternal fatalities occur in LMICs,3 frequently for lack of access to transport to available facilities. Ambulances, however, are typically not the answer. At least not Western-style ambulances. To run those types of emergency medical systems—24/7, door-to-door, 30
on-demand ambulance services that will locate, treat and transport the richest and poorest citizens in the same amount of time—a community needs two things: lots of money and robust public infrastructure. Without money or roads—or mechanics, spare parts, maps, street names, building numbers, and fuel—it’s very difficult to replicate Western-style ambulance systems and expect the same performance and outcomes. Just imagine the hillside shantytowns of Rio de Janeiro, or almost any sprawling city slum and remote rural road, and it’s easy to see how waiting for an ambulance could lead to a lot of unnecessary death. The good news is that equitable access to emergency care and transport is possible in even the most resource-limited settings, and for a fraction of the cost that wealthier nations pay: through the informal response systems that inevitably fill the formal ambulance void. Though they are uncoordinated, unreliable, and inefficient, these informal systems, composed of bystander good Samaritans, the phones in their pockets, and available vehicles on the road, work to form a surprisingly robust response infrastructure. The Timeless Emergency Medical System Emergency medical response systems can be boiled down into three parts: people willing to help, transport, and communications. These elemental components have been put to effective use for as long as there’s been a need to transport the sick and injured to medical aid. Any emergency practitioner who has worked at a hospital named after the Good Samaritan would recognize the implications: a man is robbed and left for dead at the side of the road; members of the community pass him by (likely for lack of preparedness) until a man—a good Samaritan—comes along, shows compassion, and stops to tend to the victim’s wounds with oil and wine. The
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Good Samaritan then places the injured man on his donkey, takes him to the nearest facility for definitive care, and covers his expenses. And then, in perhaps the surest sign that little in emergency medicine has changed over the past 2000 years, the Good Samaritan promises to return the next day and pay the remainder of the injured man’s bill. For LIMCs that find themselves waiting for ambulances, the challenge today may be more in learning how to preserve the Good Samaritan instinct than in finding the money to replicate conventional systems that are yet out of reach. In his book, Medical Nemesis, Ivan Illich wrote, “Boy-scout training, good-Samaritan laws, and the duty to carry first-aid equipment in each car would prevent more highway deaths than any fleet of helicopter-ambulances.”4 If we know that laypersons in the community are willing to be trained to respond in the event of an emergency, and that a range of vehicles able to safely transport patients are already on the roads, then the remaining step—and the one component missing from the parable of the Good Samaritan—is communications. Today, with global mobile-cellular penetration at over 80%, community-wide alerting has never been easier.5 The majority of the global population is now carrying an entire emergency dispatch system in their pockets. Somehow, the focus continues to be on acquiring ambulances. Nonetheless, if currently available technologies can be harnessed effectively to take the sick and injured to hospital, emergency physicians, hospital administrators, and policy experts alike will rightly ask, “What kind of hospitals are you taking all these sick and injured people to? What if the hospital is in as poor shape as the infrastructure that’s preventing them from finding help in the first place?” These are valid questions that truly can’t be ignored, especially when they’re literally dropped at the hospital’s doorstep. However, they are also somewhat misleading as they imply
two erroneous assumptions: (a) that all patients with medical emergencies are always in the most critical condition and any effort is futile, and (b) that prehospital emergency medical response is a zero-sum proposition: “Either they come by a fully-stocked ambulance, or they find their own way.” And that’s really the point: many critical patients do, in fact, find their own way, although often after their condition has deteriorated significantly. A recent article in the Bulletin of the World Health Organization compared time intervals to treatment for patients with femur fractures in high-, middle-, and low-income countries, and found that the mean time interval from injury to admission was 0.09 days (or 2 hours and 16 minutes) in high-income countries, and 6.53 days in LMICs.6 They concluded that “the intervals between injury and admission, admission and surgery, and surgery and discharge for patients with fractured femurs were all easily measurable and highly correlated to known, accessible
and quantifiable country data on health and economics. The strengths of the observed correlations suggest that the intervals can be used as valid clinical indicators of the quality of trauma systems and as guides to resource allocation efforts.”6 With this in mind, it is easier to see emergency medical systems development in LMICs as a chicken-or-the-egg problem: if you pump a country full of state-of-the-art ambulances and emergency medical equipment, and the hospital can’t do anything for the patients, what’s the point? Yet the converse is also true: if you build the most advanced emergency departments with level I trauma centers and primary PCI, but patients are arriving on their last breaths, what’s the point? In both cases the underlying dilemma is the proper allocation of resources to build an integrated system, with both prehospital and clinical emergency care proving irreconcilably dependent on one another. The prospects may appear bleak for taking on as
s Ruth A., Trek Medics’s Dominican Republic Project Coordinator (pictured with patient), and doctors from Columbia University Medical Center (lower left), transport a motorcycle accident victim with a head injury in the back of a bystander’s pickup truck.
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“Paramédicos de Manzanillo,” Dominican Republic
Herculean an effort as developing national emergency response systems in the poorest of countries, but if equitable access to the highest possible quality care is the goal, development of integrated systems becomes more a question of “how?” rather than “if.” Strengthen What Exists In 2009, I founded Trek Medics International as a nonprofit organization to develop and offer solutions for sustainable, coordinated, community-based emergency medical care and transport in any community, irrespective of socioeconomic status. After countless visits to hospitals in impoverished communities, it was clear that, despite having no formal ambulance services, the community was still able to transport patients using local vehicles. The major obstacle, it turned out, was a reliable communications system. But if these communities couldn’t even afford to buy and maintain a single ambulance, there was little chance they’d have the money to build and support an emergency dispatch center. 32
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s Trek Medics is projecting that their program will match or exceed the performance standards and outcomes of ambulance services in comparable U.S. populations for 1% of the cost.
With these limitations in mind, I and a team of volunteer paramedics and software developers began building what became Beacon, an SMS-based emergency dispatching software designed specifically for communities that can’t afford advanced 911 technologies. Using our software, communities can leverage available resources, such as young adults with vehicles and phones, and relay text messages from the scene of an emergency to trained first responders in the vicinity with suitable transport. Much like the smoke signals, air sirens, pagers, and mobile data terminals that have been used in bygone areas, Beacon turns motorcycles, taxis, and pickup trucks into rapid response emergency transport. To date, Beacon has undergone rigorous testing in low-, middle- and high-income countries, including Haiti, the Dominican Republic (D.R.), Guyana, the U.S. and Australia, among others. Early evidence from our pilot program in the D.R. has shown that community-based first responders can be alerted of an emergency
and confirm their response in under two minutes through Beacon, and can put responders on-scene within 10 minutes in village centers, and within 30 minutes in peripheral communities. Thanks to a seed grant from Google.org to develop version 2.0, and with the addition of other innovative, sustainable solutions, including the eRanger motorcycle-ambulance, we’re projecting that our program will match or exceed the performance standards and outcomes of ambulance services in comparable U.S. populations for 1% of the cost. The road ahead is not free of obstacles, but that’s because our overarching goal is to rewrite the playbook on emergency medical systems development for the neediest communities by identifying and refining their resources, talents, and customs that are already used to great effect. There’s no way we can do it alone, so we hope to recruit as many partners as possible, and to develop a community dedicated to more commonsense, outcomes-oriented, and sustainable emergency medical systems at the community level. To that end, we are offering Beacon to qualified organizations and communities free of charge. No need to wait for the ambulance any longer. Join the movement.
Does your community qualify for Beacon? Apply at www.trekmedics.org to find out. Q. What would you do if someone was hit by a car in front of you?
Dial 1-1-2
Dial 1-1-9
Dial 9-1-1
Dial 0-0-0
Dial 9-9-9
Dial 1-1-9
If 90% of respondents give the same answer, as in the countries shown above, Trek Medics considers that community ineligible to use its Beacon software. Outside such countries, however, it is difficult and often cost prohibitive for countries with fewer resources to develop similar EMS systems. If they can’t, and they have a mobile phone signal, Trek Medics says it can help, and for a fraction of the cost of any other system.
1. Trek Medics International estimate based on the number of persons believed to be living in the developing world and carrying mobile phones but without reliable access to emergency care and transport by dialing a simple universal number. 2. World Health Organization. Global status report on road safety 2013: supporting a decade of action. Geneva, 2013. http://www.who.int/violence_injury_prevention/road_safety_ status/2013/en/ 3. World Health Organization: 10 facts on maternal health. Last accessed May 1, 2015: http://www.who.int/features/factfiles/ maternal_health/maternal_health_facts/en/index4.html
4. Illich Ivan. 1975. Medical Nemesis: The Expropriation of Health. London: Calder & Boyars. 5. International Telecommunication Unition. “The World in 2014: ICT facts and figures.” ICT Data and Statistics Division Telecommunication Development Bureau. Last accessed May 1, 2015: http://www.itu.int/en/ITU-D/Statistics/Documents/ facts/ICTFactsFigures2014-e.pdf 6. Matityahu A, Elliott I, Marmor M et al. “Time intervals in the treatment of fractured femurs as indicators of the quality of trauma systems.” Bull World Health Organ 2014;92:40-50.
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Grand Rounds PETER CAMERON, MD // IMMEDIATE PAST PRESIDENT OF IFEM
Triage 2.0 Triage is a big part of what happens at the front door of many EDs, and it is thought to be essential for safe practice and smooth patient flow by many ED clinicians. But is there a better way?
O
The adoption of this disaster/battlefield concept to the ED resulted in many versions of ED triage. English-speaking countries have been most enthusiastic, and the “science” of triage has developed further, particularly in the UK, Australia, Canada, and some parts of the USA. The most popular forms are five-point scales with category 1 being urgent and life-threatening and, category 5 being non-urgent. The major criterion for categorization in most scales is time urgency to be seen. In the US, however, the Emergency SeThe paramedics, nurses, and clerks “own” the processes; doctors verity Index (ESI) combines the concepts of severity and urgency. generally don’t (and don’t want to). Yet many of our clinical delays, The process of triaging a patient can take more than 10 minutes and critical incidents, patient complaints, and overcrowding issues result will almost always add a few minutes to the process of admitting from processes that begin at the front door. There are industrial/pothe patient to the ED. When 10–20 patients litical reasons for this (each discipline wants arrive in a short space of time, this ensures a control), and convenience—it is easiest for lengthy delay! the doctor to just see the patient when they The question I would The triage process had a number of poare in the bed in the ED and “packaged.” Trilike to pose is: has tentially beneficial spin offs, including the age is a big part of what happens at the front the adoption and administrative benefit of being able to dedoor of many EDs, and it is thought to be esformalization of triage termine casemix funding according to triage. sential for safe practice and smooth patient Resource usage closely follows urgency catby EDs resulted in better flow by many ED clinicians. egory. It was also useful as a means of getting outcomes for emergency The question I would like to pose is: has some structure around clinical quality indipatients? the adoption and formalization of triage by cators for waiting times. Waiting 20 minutes EDs resulted in better outcomes for emerwith a major trauma is very different than gency patients? In the early days of emerwaiting 20 minutes for a cut finger. gency medicine, working in the ED may well In modern emergency systems, there are now clinical pathways have seemed like a disaster situation with inadequate resources and for many emergencies where we effectively stream from the field surges in demand that could not be managed in a systematic way. to the operating room, trauma room, catheter lab, or CT scanner So some form of damage limitation process may have seemed sen(eg, for stroke). Including a triage process at the door of the ED can sible. In first world systems of care for emergency patients, does the only slow this process. At the other end of the spectrum of time urparadigm of an on-field disaster fit with the sophistication of the gency, there are many patients with minor conditions who could be medicine we are trying to deliver in the 21st century? definitively managed within minutes of arrival by an appropriately The formalization of triage as a process supposedly dates back to trained nurse or physicians assistant, if they could be safely streamed the Napoleonic wars, where doctors were overwhelmed by incomto a dedicated area. A formal triage process can only delay this, and ing casualties and had to make tough decisions regarding salvageadds another hurdle to the patient receiving the care that they came ability. This concept has been adopted and embellished by disaster for. medicine groups who have taught the world the importance of clasThe middle group of patients, who don’t fit defined clinical pathsifying a large number of casualties to ensure the greatest good for ways and are not clearly resuscitation or ambulatory/fast track, are the greatest number. Casualties are quickly color coded with triage usually classified as Cat 2,3,4 in the various triage systems. These tags according to red (immediate life threat), yellow (urgent), and compose the majority of sick patients and represent the greatest risk green (walking wounded), with black reserved for those thought to to the ED. The triage systems attempt to arbitrarily tease out whethbe dead or unsalvageable. The logic behind using this classification er these patients should be seen within 10 minutes to an hour. The on the battle field or in a disaster situation has some merit, but even triage nurse systematically asks questions in attempt to avoid unsafe in this context attitudes are changing, with rapid evacuation now practice (such as an AMI or subarachnoid hemorrhage) waiting in the ultimate goal. It is very difficult to determine the extent and salthe waiting area for a prolonged period, potentially resulting in unvageability of injuries on the field, and it is likely that more lives necessary complications. The problem with this approach is that would be saved by all casualties being evacuated quickly.
Over the last decade, after reviewing emergency systems in many countries, I have realized how little attention doctors place on the entrance and reception areas of their EDs.
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In modern emergency systems, there are now clinical pathways for many emergencies where we effectively stream from the field to the operating room, trauma room, catheter lab, or CT scanner (eg, for stroke). Including a triage process at the door of the ED can only slow this process.
what is really required is rapid initial assessment by a doctor, to quickly rule out the “red flags,” begin investigations, and ensure that essential initial treatments, such as analgesia and antibiotics, are given. Many patients with incipient septic shock, AMI, and stroke present with vague symptoms. Triage only delays the symptomatic management and definitive treatment of this ill-defined group. So who benefits from triage? The patients certainly don’t— they get left in the waiting room with no analgesia or other symptomatic relief, and receive delayed management of simple conditions. In fact, in many EDs there is almost a punitive element to triage for the patients, in that a Cat 5 “should wait” as they are “non-urgent.” Some doctors may like triage because it makes for an easier shift, in that workload is more orderly and rapid decisions regarding treatment priorities can be delayed. The nurses in those systems with triage like it because it means they have some control over processing and patient flow. However, the inherent delays caused by the triage process, especially before triage, are not necessarily acknowledged as they are not easily measured. If there is no triage, how does one create order from the potential chaos of an ED? Many EDs have introduced “streaming” to ensure that patients are seen by the appropriate person in the appropriate area in the fastest time. This means that if a patient fits a clinical pathway, such as major trauma activation, stroke, septic shock, or STEMI, then they are taken to those areas and teams are activated. Ambulatory patients without red flags are streamed to fast track areas where they are seen immediately by nurse practitioners or equivalent. The “cubicle” patients are assessed in a rapid initial assessment area, and initial symptomatic treatments, investigations, and agreed clinical pathways are initiated. In the “streaming” model there are no real delays for initial assessment and life-threatening emergencies. Patients are happier because they are seen quickly and symptomatic treatment is started early. What does triage add to this? Surely it is time to stop this form of disaster management and develop 21st century emergency systems of care. Dr. Peter Cameron is the immediate past president of the International Federation for Emergency Medicine (IFEM)
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