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Dear Dr. Cameron: Here’s why FOAM matters As Olympics approach, Zika looms large How an app could improve bystander CPR Burned out? Take a gap year to work abroad EMERGENCY PHYSICIANS INTERNATIONAL



IFEM’S NEXT STEPS Incoming IFEM president Lee Wallis sets his sights on greater W.H.O. collaboration and on seeing the Federation become more inclusive of non physicians. page 16



“We have a great opportunity to refocus and to expand from specialists in emergency medicine to providers of emergency care.” prof. lee wallis

AN 48 1.0 08/2015/A-E

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Universal Truths


recently traveled 42 hours from the US to Mandalay, Myanmar to attend the Myanmar Emergency Medicine Updates Symposium, organized and sponsored by the University of Medicine, Mandalay. Myanmar (formerly Burma) is in the very early stages of EM system development. The students and physicians here are bright, energetic, enthusiastic, and they are very interested in improving patient care and medical education, and in collaborating with “outside” EM entities. The first EM post-medical school training programs, preliminary certification and “grandfathering certification,” and an emergency physicians organization have all begun. That said, one of my strongest take-aways from this trip was observing how similar the struggles facing emergency medicine are in varied corners of the world. Take policy and administration, for instance. In Myanmar, there is a lack of appreciation for the true breadth and depth of the specialty by government officials and hospital and medical school administrators. There’s also a lack of understanding of the specialty and fear of its implementation by the other medical specialties. Sound familiar? Within the treatment setting, patients with multisystem or complex problems can receive fragmented care because of reliance on the multispecialty care delivery model, while others are routed to specific hospital specialists (some based in single specialty hospitals) based on presumptive chief complaint. Ambulance personnel have no medical training and just transport patients, and there is no defined trauma care specialty. Like so many other regions, Myanmar has funding and resource limitations (non-availability of some medications such as tPA and some lab tests such as venous carboxyhemoglobin, for example). Doctors working in the publiclyfunded health facilities leave their public health facility in the afternoon to go work at a private healthcare facility in the afternoon and evening (where they make most of their income). Finally, there is little or no EM training in medical schools, and there are few senior mentors for training in the specialty. It is almost startling to realize how many of the EM challenges and opportunities in a place like Myanmar mirror those in other countries. We are much more connected in these struggles than we may realize.



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

Dear Dr. Cameron: Here’s why FOAM matters As Olympics approach, Zika looms large Burned out? Take a gap year to work abroad How an app could improve bystander CPR EMERGENCY PHYSICIANS INTERNATIONAL



IFEM’S NEXT STEPS Incoming IFEM president Lee Wallis sets his sights on greater W.H.O. collaboration and on seeing the Federation become more inclusive of non physicians. page 16



“We have a great opportunity to refocus and to expand from specialists in emergency medicine to providers of emergency care.” prof. lee wallis

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

Emergency Physicians International is a product of Portmanteau Media LLC ©2016



SEPTEMBER 12th Winfocus World Congress on Ultrasound in Emergency and Critical Care 2016 // Ljubljana, Slovenia September 7-10, 2016

OCTOBER MAY 2016 First Welsh International Symposium on Emergency Medicine // Cardiff, Wales, UK May 16-17, 2016

3rd Intercontinental Emergency Medicine Congress // Antalya, Turkey May 19-22, 2016

JUNE EMCORE Melbourne 2016 // Melbourne, Australia June 4-5, 2016

17th International Conference on Emergency Medicine // Mexico City June 5-9, 2016

VI Inter-American Emergency Medicine Conference // Mendoza, Argentina June 8-10, 2016

18th International Conference on Emergency Medicine // Seoul, South Korea June 12-15, 2016 Hosted by The Korean Society of Emergency Medicine (KSEM)

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

10th European Congress on Emergency Medicine // Vienna, Austria October 1-5, 2016

American College of Emergency Physicians Scientific Assembly 2016 (ACEP 2016) // Las Vegas, Nevada, US


Field Reports 8 | Brazil 10 | Cameroon 12 | Iraq

Departments 14 | Tech A crowdsourcing app alerts trained bystanders to nearby cardiac arrests.

14 | IFEM Q&A

October 15-18, 2016

Incoming president, Lee Wallis, on his new vision for the Federation.


16 | Education

The 3rd African Conference on Emergency Medicine // Cairo, Egypt

17 | Interview

November 9-11, 2016

IV World Congress In Emergency Medicine // Riviera, Maya, Mexico November 16-19, 2016

33rd Annual Scientific Meeting of the Australasian College for Emergency Medicine // Queenstown, New Zealand November 20-24, 2016

The first free electronic EM textbook will be available worldwide this year. Dr. Manny Hernandez discusses ED facilities design in the ‘post-lean’ period.

21 | Work+Life Taking a mid-career gap year can jumpstart clinical skills and personal quality of life.

Reports 25 | African EMS Jason Friesen writes that African EMS will thrive only when built upon local solutions.

28 | Infectious Disease


Zika is here. Here’s what you need to know as the Olympics approach.

SriLanka 2016 (DevelopingEM) // Colombo, Sri Lanka

Hospitals are increasingly under siege, and a disaster plan is essential.

December 5-8, 2016

34 | Grand Rounds

30 | War Zones

Peter Cameron: should we as emergency physicians think about recovery?

June 16-19, 2016



Issue 19 // Emergency Physicians International


Re: Pundit-Based Medicine [EPI Issue #18, page 34]

FOAM Helps to Bridge the Knowledge Translation Gap authors: Damian Roland BMedSci BMBS MRCPCH PhD United Kingdom Dr. Seth Trueger MD, MPH USA Dr. Brent Thoma, MD MA FRCPC Canada Dr. Teresa Chan Canada


n his recent commentary “PunditBased Medicine,”1 (EPI, Fall 2015) Peter Cameron reminds the EM community to be skeptical of dogma in all forms, whether in print or online: The evidence-based medicine movement from 20 years ago promoted evidence above eminence. It seems that now our colleagues bypass reading the real evidence and go straight to the latest false prophet—usually in 140 characters. As professionals who practice evidencebased care and also use social media, we question Dr. Cameron’s assertions. We enjoy debate: it is a cornerstone of both the evidence-based movement and FOAM (Free Open Access Medical Edu-

cation). Evidence-based debate among clinicians and researchers bridge theory and practice. On social media, practitioners are able to interact with leading clinician-scientists such as Jeffrey Kline (@ KlineLab), Ian Stiell (@EMODaddy), and Rick Body (@richardbody). Moreover, the ever-mourned knowledge translation gap between researchers and clinicians is closing, at least partially due to “chatter online;” sharing research online significantly increases the reach of research.2 Health professionals have long used formal and informal communications for knowledge transfer. We propose that there is nothing unique about social media, other than that it accelerates communication.3 Every critique of social media can be applied to traditional knowledge exchange; countless physicians have modified practice because of a hastily-read journal publication, at the recommendation of a lecturer, or after a chat with a colleague over coffee. We agree that we need to be critical. Leading participants of the FOAM community have long registered concerns about poorly constructed and insufficiently evidenced online material, sparking debate and proposing strategies to improve the use (and production) of evidence.4–6 Many leading scholarly blogs are developing, and journal-style pre-publication peer review strategies (such as ALiEM.com7) and (formerly known as has created a “coached peer review process,”8,9 which was selected as a Top 5 What Works innovation at the 2015 International Conference in Residency Education.10 The ALiEM AIR certification and scoring system similarly holds

online resources to a high standard.11–13 In truth, there has been more literature published in the last two years on the quality appraisal of FOAM14–17 (ironically, none of this peer-reviewed work was cited by Dr. Cameron in his article) than there has been in centuries of widespread use of textbooks, lectures, and other secondary sources. Dr. Cameron asks: “How useful is all this information? If we had neglected the last 10 years of these ‘scientific advances,’ would we have lost any salvageable patients?” This nihilistic perspective suggests that decades of new evidence have yielded no benefit to patients. While the support for many innovative management strategies often wanes in light of subsequent evidence, let’s not throw out the baby with the bathwater. Many innovative practices have withstood scrutiny. Social media provides an excellent vehicle for knowledge translation. We are not aware of any notable cases of “authoritative” websites ignoring accepted evidence or misleading readers into inappropriate practice. At the edges, individuals may have attempted techniques or procedures still in a grey area clinically, but learning tacit knowledge from peers is nothing new. Evidence-based medicine has its limits; the contextualization and adaptation of evidence, guidelines, and rules are paramount. Many blogs focus on linking EBM commentary between clinicians and researchers; many have experimented with virtual journal clubs, which may be instrumental in engaging clinicians in new literature, and the development of critical analysis skills.18–21


LETTERS Dr. Cameron asks “whether any of the constant flow of information is useful? Would it matter if many of the advances were delayed by a few years until adequate assessment of cost and impact were undertaken?” Fads come and go, and as new evidence rolls out, sometimes the retrospectoscope suggests that delaying adoption “a few years” would have been wise. However, like all good journal articles, FOAM websites frequently cite the need for further study. We too bemoan the paucity of adequate cost and impact assessments. But when they are completed, the necessity for speed in disseminating results is all the more profound. Past studies have found that the duration of the KT gap is an astonishing 17 years.22 We must do better. The last decade and a half has seen sepsis management change remarkably. While the pendulum has swung back, would anyone consider 1999-era care acceptable? More specifi-

REFERENCES 1. Cameron P. Pundit-Based Medicine. Emergency Physicians International. 2. Hoang JK, et al. Using Social Media to Share Your Radiology Research: How Effective Is a Blog Post? J Am Coll Radiol. 2015;12(7):760-765. 3. Roland D, et al. Top 10 ways to reconcile social media and “traditional” education in emergency care. Emerg Med J. 2015;32(10):819-822. doi:10.1136/ emermed-2015-205024. 4. May N. When FOAM Doesn’t Wash. St. Emlyn’s website. http://stemlynsblog. org/when-foam-doesnt-wash/; http:// Published 2013. Accessed January 16, 2016. 5. Purdy E, et al. MEdIC Series | The Case of the FOAM Faux Pas. Academic Life in Emergency Medicine. http://www. Published 2015. Accessed January 16, 2016. 6. Chan T, et al. MEdIC Series | The Case the FOAM Faux Pas – Expert Review and Curated Commentary. Academic Life in Emergency Medicine. www.aliem. com/MEdIC-Series-The-Case-theFOAM-Faux-Pas-Expert-Review-andCurated-Commentary. Published 2015. Accessed January 16, 2016. 7. Thoma B, et al. Implementing peer review at an emergency medicine blog: bridging the gap between educa-


cally, did EGDT spread because of online discussion, or because of “definitive statements from appropriately qualified expert groups”? When PROMISE, ARISE, and ProCESS were released, the FOAM community helped digest and disseminate the results,23–27 reining in EGDT much faster than the speed of print. Papers discussing these three important works are only just now being put online, nearly a year after the first online analyses.28 We thank Dr. Cameron for raising his concerns; we all must read critically. Whether online or in print, we must hold our colleagues accountable and support our arguments with evidence. Dr. Cameron criticizes those who would quickly change practice due to social media, but fails to provide any evidence to back his claims. Educated skepticism should always be applied, even to our work. We urge all health professionals to continue the quest for truth. It is through these debates that we can better serve our patients.

tors and clinical experts. CJEM. 2015;17(2):188-191. 8. Chan T. Battle Hymn of the Tiger Editor: Introducing the Coached peer review for FOAM. (formerly 9. Sidalak D, et al. Coached Peer Review: Developing the Next Generation of Authors and Reviewers. Acad Med J Assoc Am Med Coll. 2016;In Press. 10. Introducing the Top 5 What Works Abstracts. ICRE Blog. Published 2015. Accessed January 16, 2016. 11. ALiEM Approved Instructional Resources (AIR Series). http:// Accessed January 11, 2016.

Dr. Peter Cameron Responds: I thank the correspondents for their well-constructed arguments regarding my observations on the impact of social media on clinical decision making. The basis for my editorial comments was purely anecdotal, because of frustration borne of talking to trainees quoting the latest online blog (often abbreviated to a few words) rather than reading the context around the subject. The immediacy of social media gives credence to opinions (from often eminent people) that should always be framed by the caution of collective experience.

15. Paterson QS, et al. The quality checklists for health professions blogs and podcasts. 2015:1-7.

sgem92-arise-up-arise-up-egdt-vsusual-care-for-sepsis/. Published 2014. Accessed January 16, 2016.

16. Lin M, et al. Quality indicators for blogs and podcasts used in medical education: modified Delphi consensus recommendations by an international cohort of health professions educators. Postgrad Med J. 2015;91(1080):546-550.

24. Body R. The ProMISe Study: EGDT RIP? St. Emlyn’s website.; the-final-nail-in-early-goal-directedtherapys-coffin/2015/03/24/. Published 2015. Accessed January 16, 2016.

17. Thoma B, et al. Emergency Medicine and Critical Care Blogs and Podcasts: Establishing an International Consensus on Quality. Ann Emerg Med. 2015. 18. Chan TM, et al. Ten Steps for Setting Up an Online Journal Club. J Contin Educ Health Prof. 2015;35(2):148-154. 19. Thangasamy IA, et al. International Urology Journal Club via Twitter: 12-Month Experience. Eur Urol. 2014;66(1):112-117.

12. Grock A, et al. ALiEM AIR Series Grading Tool. Academic Life in Emergency Medicine.

20. Oliphant R, et al. Early experience of a virtual journal club. Clin Teach. 2015:389-393.

13. Lin M, et al. Approved Instructional Resources (AIR) Series: A national initiative to identify quality emergency medicine blog and podcast content for resident education. J Grad Med Educ. 2016;8(2):In press.

21. Lin M, et al. Creating a Virtual Journal Club: A Community of Practice Using Multiple Social Media Strategies. J Grad Med Educ. 2015;7(3):481-482.

14. Paterson QS, et al. Quality Indicators for Medical Education Blog Posts and Podcasts: A Qualitative Analysis and Focus Group. In: Association of American Medical Colleges Medical Education Meeting. Chicago; 2014.

Issue 19 // Emergency Physicians International

22. Morris ZS, et al. The answer is 17 years, what is the question: understanding time lags in translational research. Jrsm. 2011;104(12):510-520. 23. Milne WK, et al. ARISE Up, ARISE Up (EGDT vs. Usual Care for Sepsis). The Skeptics Guide to Emergency Medicine.

25. Allen-Dicker J. The Final Nail in Early Goal Directed Therapy’s Coffin? Now @ NEJM. php/the-final-nail-in-early-goal-directedtherapys-coffin/2015/03/24/. Published 2015. Accessed January 16, 2016. 26. Boka K. NephMadness 2015: ProCESS ARISE ProMISe and the promise of Early Goal Directed Therapy. AJKD blog. nephmadness-2015-process-arisepromise-and-the-promise-of-earlygoal-directed-therapy/. Published 2015. Accessed January 16, 2016. 27. Mathieu S. Trial of Early, GoalDirected Resuscitation for Septic Shock. The Bottom Line. http://www.wessexics. com/The_Bottom_Line/Review/index. php?id=3665078336903245716. Published 2015. Accessed January 16, 2016. 28. Sharif S, Owen JJ, Upadhye S. The End of Early-Goal Directed Therapy? Am J Emerg Med. 2015:8-10. doi:10.1016/j. ajem.2015.10.039.

© Austrian National Tourist Office - Popp Hackner

General Organisation: MCO CONGRÈS - Information: Villa Gaby - 285 Corniche Kennedy - 13007 Marseille - France / Tel: +33 (0) 495 09 38 00


q The first emergency medicine (EM) residency program in Brazil was begun in Porto Alegre Brazil, in 1996. Porto Alegre is a city of approximately 1.5 million in the southernmost state of Rio Grande do Sul.


BRAZIL Just months after its medical and education officials approved EM as an official medical specialty for the first time, planned EM residency training programs already number in the dozens, including pediatric EM programs. by ross tannebaum, md

& ana paula freitas, md


n September 16, 2015, emergency medicine was officially recognized as a specialty in Brazil. At a joint meeting by the Brazilian Medical Association (Associação Médica Brasileira [AMB]), the Federal Council of Medicine (Conselho Federal de Medicina [CFM]) and the National Com8

mission of Medical Residencies (Comissão Nacional de Residência Médica [CNRM]), this triad of organizations formally recognized emergency medicine as an “official,” recognized specialty in Brazil. It was a great year for emergency medicine in Brazil! The first emergency medicine (EM) residency program in Brazil was begun in Porto Alegre Brazil, in 1996. Porto Alegre is a city of approximately 1.5 million in the southernmost state of Rio Grande do Sul. The residency program began as a two-year program with two residents per year and grew over time to a three-year program with six residents per year. The second EM residency program was started in 2008, in Fortaleza, a city of approximately 2.5 million in the northeastern state of Ceara. The Fortaleza program is also a three-year training program

Issue 19 // Emergency Physicians International

Brazil By the Numbers


204 million

Population (6th largest in the world)

1.89/ 1,000 Physician density

9.7% GDP

Health expenditures

with six residents per year. As of 2015, these were the only two existing EM residency training programs in a country of approximately 200 million people and in an area covering 3.3 million square miles of territory. Prior to 2015, lack of official recognition of the specialty meant both lack of funding and political opposition among academic physicians to formation of EM training programs. The two programs now in existence are the only successful attempts from at least ten serious endeavors known by the authors. Now that the specialty is recognized, there are between 10–20 new EM residency programs throughout the country in the planning stages, with several staged to start with new residents in summer 2016. These EM training programs are sorely needed. In most of Brazil, emergency departments are staffed by physicians without training in EM. These physicians comprise an eclectic mix of full-time and parttime time emergency physicians, some with essentially no postgraduate training, others with training in various specialties, and still others who “moonlight” in emergency rooms to supplement their income while building their practices and working other jobs. The quality and availability of medical care in Brazil is widely disparate. Among large regions of the country, and especially among the poor, available medical care would be considered substandard by American standards. At the other end of this spectrum, there is very sophisticated medical care available in many areas, especially in the more developed south, and especially so for patients with private medical insurance. In the latter situation, a person having a STEMI may get an angio-

plasty and stenting with all care being equivalent to the best hospitals in the US and Europe, but with one exception—the emergency physician first taking care of the STEMI patient may be a physician with no training straight out of medical school! If the number of applicants for the Hospital de Pronto Socorro (HPS) EM residency program are any indication, very promising trends are emerging for the employment outlook for trained emergency physicians in Brazil. Eighteen years ago, when the HPS EM residency program began, medical school graduates who applied generally could not obtain residency training in other fields, and there were few applicants for each year’s two positions. Now, entry to the program is extremely competitive, with 10–15 applicants for each residency’s six positions. EM resident graduates are highly sought after by local hospitals in the Porto Alegre, especially by the best known private hospitals in the area, and they are often contacted and courted by these hospitals during their last year of residency training. Pay scales for these trained emergency physicians in Porto Alegre have been rising steadily, and their incomes are now roughly on par with other primary care physicians. With predicted dynamic growth in EM training programs, it is anticipated that properly trained emergency physicians will be in great demand, as well as academic emergency physicians. The future of EM in Brazil now looks bright. Of course, with this great leap forward there will be challenges. One challenge will be to ensure quality and standardization of the curricula among the many new EM residency training programs now being developed. Another will

Brazil’s 24 New EM Residency Training Programs: National Commission of Medical Residencies (Comissão Nacional de Residência Médica ([CNRM]) and Ministry of Education (Ministério da Educação [MEC]) recently accredited 24 new EM residency training programs, including 12 three-year adult EM training programs and 12 one-year pediatric EM training programs. Here’s a rundown: State





Hospital Messejana








Fundação Hospital de C. Gaspar Vianna




Hospital Geral de Nova Iguaçú




Hospital De Clínicas de Porto Alegre HCPA




Hospital São Lucas de PUCRS




Santa Casa de Porto Alegre - UFCSPA








Instituto da Criança - USP




Santa Casa de Misericórdia de São Paulo




Hospital Santa Marcelina




Hospital Infantil Sabará




USP - Ribeirão Preto








Hospital de Clínicas de São Paulo - USP




Hospital Alemão Osvaldo Cruz




Hospital do Coração




Hospital Menino Jesus




Hospital Infantil Darcy Vargas



If the number of applicants for the Hospital de Pronto Socorro (HPS) EM residency program are any indication, very promising trends are emerging for the employment outlook for trained emergency physicians in Brazil.

List courtesy of ABRAMEDE

be development of a certification examination. Finally, there needs to be a clear process for recognition of experienced emergency physicians working in Brazil’s emergency departments who have not completed an EM residency. Presumably, there will be some type of grandfather clause for these physicians so that they and EM residency trained physicians may both be able to take a certification exam, similar to the process that occurred in the US in the 1980s. All of these challenges

are currently being discussed and debated at meetings of the Brazilian Association of Emergency Medicine (Associação Brasileira de Medicina de Emergência [ABRAMEDE]), and all the more so now that EM is a recognized specialty. For now, we owe our Brazilian EM colleagues a warm “PARABENS!” (Congratulations!) on a great step forward for emergency medical care in Brazil.



CAMEROON Although it faces some of the same trauma care challenges as its neighbors, EM is already an officially recognized specialty in Cameroon, and two new emergency centers have opened here recently. by shu olivier niba, with gerhard dashi


ameroon is a West African country with a population of approximately 22 million people and two official languages, English and French. The country is divided into ten regions, which are further divided as divisions and subdivisions. The health sector in Cameroon includes private and public health sectors. There are 5 referral hospitals, 70 general hospitals, 50 private hospitals, and a wide network of public and private health Medical Equipment

centers with a vast diversity of medical specialties. Emergency medicine has quickly developed over the last few years in Cameroon, from not being considered an independent specialty in the 1980s to a fully recognized and flourishing specialty today. Unfortunately, the current healthcare system does not meet the increasing needs of the public in Cameroon. Public spending on health was only 2% of GDP in 2012. Growing numbers of road traffic accidents and inadequate pre-hospital transportation systems, coupled with the limited number of trained hospital staff and appropriate equipment, can help explain the rising number of deaths from emergency situations. Sadly, Cameroon is a typical example of a developing African country with an under-developed prehospital system. The well-known “golden hour” of trauma specifies that patient outcomes are improved when patients are transported to a


The founding members of Cameroon Association of Medical Students Promoting Emergency Medicine (CAMSPEM). Front left to right: Ngwanwui Elaine Tasha (Treasure), Gwendoline Enda Ukum (board member), Khan Eugine Asobo (Secretary) Back left to right: Kughong Reuben Chia (Vice president), Shu Olivier Niba (President), Awemu Edmond (Board member)

South Africa


Density (per 1,000,000 pop.)


Density (per 1,000,000 pop.)






CT Scanner





PET Scanner





Nuclear medicine










Linear accelerator





Telecobalt unit (Cobalt-60)










* Density per 1,000,000 females aged from 50-69 old. † Cameroonian data reflect public and private institutions. ‡South African data reflect public institutions only. (WHO Global Atlas of Medical Devices, 2014)


Issue 19 // Emergency Physicians International

designated trauma center within 60 minutes of injury. In Cameroon, the average response time for EMS ranges from 35 minutes in major towns and cities to sometimes no response in the rural interior. This lack of reliability leads citizens to independently transport patients, family members, and friends to nearby health centers without ever calling 119, and may help explain the high degree of morbidity and mortality from prehospital emergencies in Cameroon. In an interview with Shu Olivier Niba, president of the Cameroon Association of Medical Students Promoting Emergency Medicine (CAMSPEM), Dr. Kwa Kidze described his department as congested and noisy at the best of times. Dr. Kwa is the EM district medical officer of the Ndop Subdivisional District Hospital in the Ngoketunjia Division. He and one EM nurse usually staff a department roughly 80 square meters that sees every-

thing from snake bites to road traffic crashes and burns. Reflecting the opinion of many others, Dr. Kaw also claimed that the lack of an adequate pre-hospital transport system, mandatory equipment, and even space are common problems faced by EDs throughout the country. Nevertheless, he acknowledges that the specialty is growing rapidly and generating much interest. At present, the Ministry of Higher Education, together with the Ministry of Public Health, is making efforts to train more EM physicians in the oldest state medical school, the Faculty of Medicine and Biomedical Sciences of the University of Yaoundé. Two new emergency centers, Centre d’Urgence de Yaoundé and Centre d’Urgence de Douala, have also opened, and both have quickly become leading institutions in the country. International organizations and foreign countries have also contributed by providing aid to Cameroon’s health system in general, and to EDs in particular. One example is the $40 million of equipment recently provided by the US government to Centre d’Urgence de Yaoundé. The development of EM student groups throughout the country also reflects a desire for better training of future emergency physicians, for the advancement of the specialty, and for public education and support. As a result, these student groups focus on educating communities in providing basic first aid while calling for new professional training programs and facilities. While much work remains to be done, the rapid expansion of EM in Cameroon in recent years likely foreshadows a promising future for the specialty and for patient care.


Cameroon by the numbers

23 million Population

250 Languages spoken

13.4% Proportion of all deaths from HIV/AIDS

~ Physician Density

.08/1000 0.08 physicians per 1,000 population

DevelopingEM Emergency & Critical Care Conference with a Conscience December 5-8, 2016 DevelopingEM is a new direction in medical education, combining cutting edge training in critical care medicine, with a focus on providing a meaningful contribution to medical professionals in developing regions through an inclusive & philanthropic approach. DevelopingEM is a not for profit conference organising agency specialising in providing a practical & clinical approach to the delivery of emergency medicine & critical care education to senior practitioners - in the fields of emergency medicine, intensive & critical care medicine, anaesthetics, & prehospital & retrieval medicine.

Join us in 2016 - Columbo



IRAQ A bi-national coalition of surgeons and physicians are teaming with a local organization to bring surgical and trauma care training to local doctors in northern Iraq. by lisa moreno-walton, md, ms


here are more refugees and displaced persons in the world today than ever previously recorded. Thirty-eight million people were forcibly displaced within their own countries in 2014, an increase from 33.3 million in 2013, according to the Norwegian Refugee Council’s Internal Displacement Monitoring Centre. To put these figures into perspective, 30,000 people a day are newly 12

uprooted from their homes because of violence or fear of violence. Currently, there are 60 million refugees and internally displaced persons (IDPs) worldwide, half of whom are children, according to the UNHCR. If this were the population of a country, it would be the world’s 24th largest country by population. The majority of IDP’s (63%) are displaced within five countries: Syria, Colombia, the Democratic Republic of the Congo, Nigeria, and Sudan. In Syria alone, 7.6 million people are displaced internally and an additional 3.88 million people live as refugees in the surrounding region, many in the northern provinces of Iraq, and a United Nations commission estimates that over half of the estimated needs of Syrian refu-

Issue 19 // Emergency Physicians International

p Sunset at Sharya Camp, one of four refugee and 17 internallydisplaced person (IDP) camps in Duhok Province. With its proximity to several regions that are controlled by the Islamic State, Duhok Province, in Kurdistan, northern Iraq, has received over 850,000 displaced persons and refugees.

gees are unmet. While disaster relief organizations have traditionally met the medical needs of war-torn countries, this is becoming increasingly difficult in Syria and northern Iraq, and some organizations, including Médecins Sans Frontières (MSF), have been forced to scale back or abandon some medical aid missions owing to unacceptable security risks. In June 2015, health care teams were withdrawn from Tikrit, Iraq, about 140 kilometers northwest of Baghdad. Health care teams in Iraqi cities were subsequently withdrawn from Hawijah, in July; Sinjar, in August; Heet, in October; and from Duhok, in Kurdistan, in November, leaving the Duhok Directorate of Health responsible for the care of 2.2 million individuals living in Duhok Province and the liberated areas of the Mosul Governorate. The host community in Duhok consists of 1.4 million people. An additional population of 854,000 people, composed of 745,000 IDPs and 109,000 refugees, are living in and around four refugee and 17 IDP camps, with another camp currently under construction. The population growth in the area is staggering, with 62,761 births over the past year, many of them in the camps, and only 5,007 deaths. Yet the area remains resource poor. There are only 1,820 hospital beds, and 4.4 physicians per 10,000 people, as compared to 24.5 in the US. Emergency Medicine as a specialty does not exist in Iraq. Surgeons with limited experience in medical, pediatric, and obstetrical emergencies staff the surgery hospital emer-

Clockwise from top left: the triage area at the Sharya Camp clinic, where over 300 are seen daily; teaching transplant surgery at Sharya Camp; a nurse dispatcher at the 1-2-2 ambulance service; nurses and the clinic manager (center) at Sharya camp.

gency departments, and internists with limited experience in trauma, pediatric and obstetrical emergencies staff the medical hospital emergency departments. Patients are left to determine whether they have a medical or a surgical problem, and they self-triage to the appropriate facility. The military forces do not commission physicians, and the doctors most often sent to the front lines are recent medical school graduates who, without the benefit of internship or residency training, are serving their country in some of the

most dangerous conditions that can be found in the world today. I have been making trips to the northern provinces of Iraq for the past several years as part of a team of doctors supported by the Americas Hepato-Pancreato-Biliary Association, Operation Hope, and the Kurdistan Regional Government Prime Minister Foundation. The focus of our work is on training young physicians in the management of trauma and critical care, training experienced physicians in transplant surgery and advanced laparoscopy,

and teaching medical students the skills they will need to serve in rural clinics and on the battlefield after graduation. The next edition of Emergency Physicians International will feature an in-depth discussion of this work in the Kurdistan provinces of northern Iraq.

Dr. Lisa Moreno-Walton is a professor of emergency medicine at Louisiana State University Health Sciences CenterNew Orleans, and secretarytreasurer of the Board of Directors of the American Academy of Emergency Medicine.



A New App Aims to Improve Effectiveness of Bystander CPR A Canadian crowdsourcing tool, powered by mobile apps, alerts CPR-trained bystanders to the location of any active cardiac arrests nearby, along with available nearby AEDs.

PulsePoint screenshot shows a cardiac arrest (grey heart icon) in proximity to user location (blue circle). Nearby AEDs are also shown (orange AED icon). Icons placed for illustration purposes only; street names removed to protect privacy.

by peter wang & evan russell


ut-of-hospital cardiac arrest (OHCA) is a significant public health concern. There are 45,000 cases of cardiac arrests in Canada every year, and epidemiological estimates places the global incidence at 95.9 per 100,000 person-years. Experts have long recognized the importance and benefit of early recognition of cardiac arrest and interventions by bystanders. Public education has thus focused on early recognition of cardiac arrest, emergency medical services (EMS) activation, cardiopulmonary resuscitation (CPR) delivery, and use of an automated external defibrillator (AED). Collectively, this is part of the longstanding “chain of survival” approach to cardiac arrest, through which bystanders can play a significant role. From point of arrest, each minute of delay without CPR and defibrillation reduces the probability of survival by 7%–10%. Unfortunately, in persons with OHCA, only 15%–30% receive bystander CPR, and only 3% receive defibrillation with publically accessible AEDs. Improving both trained bystander response time and rate can therefore play a crucial role in improving outcomes of individuals who have an OHCA. Enter: PulsePoint. PulsePoint ( is a crowdsourced tool that empowers CPR-trained bystanders to locate and provide CPR before the arrival of EMS. There are two apps (PulsePoint: CPR Respond app and its companion PulsePoint: AED app) that may be downloaded for free on both iOS and Android devices. The CPR Respond app alerts CPR-trained mobile phone users to cardiac arrests in close proximity based on their GPS locations. The companion AED app allows public users of the app to identify and update locations of AEDs in their community. This information is verified by local authorities then updated in the CPR Respond app so that first responders can quickly locate nearby AEDs in an emergency. The first step in implementing PulsePoint in a community is through collaboration with the local EMS (i.e. police, fire, ambulance). The system integration of PulsePoint allows local emergency 14

Issue 19 // Emergency Physicians International

call centers to send location details of cardiac arrest emergencies to app users. No crowdsourcing effort is complete without the “crowd,” so a crucial next step is a strong community campaign to generate public interest and to encourage CPR-trained citizens to download and register themselves on the app. When the local emergency call center receives a call for a suspected or confirmed cardiac arrest in a public location, they can identify registered CPR-trained persons nearby by using the GPS and mapping features of the app, and alert them via an app notification. The app also displays any publically accessible AEDs in the vicinity. When the EMS arrives, the alert is turned off so that users know that professional responders are on-site. Local implementation in Kingston (Canada) Dr. Steven Brooks, an emergency physician and clinician-scientist at Queen’s University and Kingston General Hospital in Kingston, Canada, was the first to bring the PulsePoint app to a Canadian city, in March 2015. This was done in collaboration with Kingston Fire and Rescue, Kingston General Hospital, Queen’s University, the Heart and Stroke Foundation, and Bell Canada. More than 2,000 people signed up within two weeks of launch. In the past year in Kingston, there were more than 80 calls for possible cardiac arrests in a public space, with an average of eight PulsePoint users notified per call. More data are being gathered and will be analyzed to further clarify the benefits and limitations in the use of PulsePoint in Kingston.

The first step in implementing PulsePoint in a community is through collaboration with the local EMS. The system integration of PulsePoint allows local emergency call centers to send location details of cardiac arrest emergencies to app users. No crowdsourcing effort is complete without the “crowd,” so a crucial next step is a strong community campaign to generate public interest and to encourage CPR-trained citizens to download and register themselves on the app.

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Future directions The existence of PulsePoint and similar initiatives is changing the landscape in which trained and willing bystanders can respond to OHCAs. In Stockholm, Sweden, a similar crowdsourcing system, that uses text messages and computer generated calls, found that the incidence of bystander-initiated CPR increased when these notifications were directed at nearby bystanders (62% vs 48%, 95% CI = 6 to 21, P<0.001). Moreover, the potential benefits of crowdsourcing technologies are reflected in the newly-released 2015 recommendations from the International Liaison Committee on Resuscitation (ILCOR), which recommended for the first time the use of social media technologies that recruit CPR-trained bystanders to nearby cardiac arrests. Clearly, more research on the potential benefits and limitations of PulsePoint and similar technologies will be necessary to inform stakeholders and policy makers. Acknowledgement We thank Dr. S. Brooks for providing us with his insights and materials for this article, which would not have happened otherwise without his help and dedicated work in bringing PulsePoint to Canada. References available online at

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Lee Wallis Takes the Helm as Global EM Enters New Waters In 2016, the International Federation for Emergency Medicine will inaugurate Professor Lee Wallis, its first president from an African nation. Wallis is keen to use his term to help IFEM work more collaboratively with the World Health Organization, and make the federation more inclusive of non-physician emergency care workers.

interview by logan plaster

EPI: What new opportunities do you see for IFEM over the next year or two? LEE WALLIS: We are working on a new strategic direction, which I proposed. I can speak about it, although it’s not yet IFEM policy. For 25 years, IFEM has done a very good job of what it does: serving highly specialized emergency physicians (EPs). But I think that misses the vast majority of emergency care on the globe. Even in the US, where most emergency patients are seen by EPs, family physicians, nurses and PAs do a lot, particularly in rural areas. IFEM currently doesn’t capture any of that. So if we’re going to remain meaningful, given the lack of emergency care development in most of the world and given who provides emergency care in most of the world, we have to change our focus. We have a great opportunity to refocus and to expand from specialists in emergency medicine to providers of emergency care. And that’s what I proposed to the executive of IFEM: either that we focus on all doctors providing emergency care or we focus on all providers of emergency care, of which the majority won’t be doctors. We still need to debate that, and even I haven’t decided personally on that question. Broadening our scope could afford us a great opportunity. Last January, WHO Geneva appointed their first ever lead for emergency care, Teri Reynolds. She’s a superstar. She’s been in the post for a year, and she wants us, IFEM, as an organization to be at the top table with her, directing global strategy and advising on roll-out and scale-up and direction and all of those sort of things. The problem is that, at the moment, everything about us is geared 16

Issue 19 // Emergency Physicians International

only toward EPs, which limits our appeal for a broader global reach, and which is part of the reason why I think we need to make the change. There’s an opportunity here to be at the top table with the WHO, which makes us really meaningful, but we need to change our focus to do that. EPI: So this shift would take IFEM from being quite exclusive to being highly inclusive.

Prof. Lee Wallis is the head of emergency medicine in South Africa’s Western Cape Government.

WALLIS: Yes, and I think that is where IFEM needs to be. Whether we’re there in six months or in six years is not clear. It may be too big a step to take right now, and that will be okay because we already recognize that IFEM member societies don’t have to be composed strictly of EPs, but we do still have these requirements like having an EM residency. So I think we may need to take smaller steps, like looking at doctor groups. The end point has to be that multidisciplinary groups are represented, as opposed to focusing on specialist doctors only. EPI: What might be lost as a result of IFEM taking such an expanded approach to its membership? WALLIS: We’d lose this commonality where we all speak the same language. Right now we all understand each other’s background, and that allows us to relate more easily to each other. We understand whether you’re from Argentina or Armenia, if you’re an EP you’ve had pretty much the same background and training and you speak a common language and your problems are probably the same. Whereas if you’re a mid level provider in a rural district hospital, you’ve got a different set of problems—you still have clinical patients to see, but you’ve got a different set of problems. With that greater diversity of backgrounds and practice, we’ll widen our influence and relevance, but communication, networking, and pitching and executing policies may no longer be as fluid or straightforward as it is now. We’ve already seen this in the African Federation of Emergency Medicine (AFEM). It’s harder to agree on things and get the level right when you’re looking at specialist doctors and general doctors and nurses and clinical officers and EMTs. It’s difficult to find the right level that suits everyone. Instead of producing one set of materials for a certain area, we’d have to produce five sets aimed at different targets. But that’s okay, as long as we understand that that’s what we’re taking on. It’s more work. It’s harder to do. But it’s further reaching in what it does. People who have been in the organization for a decent amount of time may genuinely not believe it’s the right thing to do, or may

If [IFEM is] going to remain meaningful, given the lack of emergency care development in most of the world and given who provides emergency care in most of the world, we have to change our focus. We have a great opportunity to refocus and to expand from specialists in emergency medicine to providers of emergency care.

only say it’s the right thing to do but harbor serious reservations. So, I think we’ve got some selling to do. It’s a fairly significant change, and I’d be disappointed if everyone rolled over and said, “Absolutely.” EPI: How do you think your experiences working with middle and low-income countries as the head of AFEM prepared you for the role of IFEM President? WALLIS: There are a small number of residency programs across Africa producing small numbers of graduates. Everything else in emergency care systems are underdeveloped. They haven’t had resources pumped into them. In most places there is no one at the Ministry to think about emergency care or what’s been advancing over the last few years. Because there was this huge vacuum, particularly with so many low-income countries, AFEM very quickly because the go-to for the continent. Because I have the flexibility in my job, I’ve been very lucky to travel a lot, and I’ve been on the ground in a lot of countries with the people who are working in them now, and helping them find medium-term approaches to development problems or questions they have. With the parallel work that I’ve been able to do with Teri Reynolds and the WHO, I’ve developed an understanding of health systems which I wouldn’t have had being an EP in an ED and only working clinically. So both my job as the head of EM for the provincial government here in South Africa, and my role in AFEM have allowed me to engage on the country and regional levels and to understand

systems in a way that I wouldn’t have been able to before. This also allows me to work with the existing structure in the societies; I think I can help IFEM leadership understand the realities, needs, and challenges of engaging with countries and with partners, and how we take the steps to help them build a system with us. EPI: Can you give an example of how your unique vantage point has already determined decisions or directions you’ve made? WALLIS: This is an example I use frequently. So, a country has appointed a person in the Ministry and there is a doctor who’s been driving emergency care in the academic hospital. They’ve been talking and the Health Minister has allocated some funds, and the question is, “Should we buy a Mercedes ambulances or we should we buy a Toyota? What do you think? We want ambulances on the road.” Meanwhile, the roads are impassable, traffic is gridlocked, there is no money for equipment or for a communications system that the patients can phone. If they do get an ambulance, when they arrive at the hospital there’s nothing for them. The first couple times I was approached I gave advice on which ambulances I thought were best. Then it only takes a few visits to countries and you see the same issues. Now my advice is, “Who cares? Don’t buy ambulances.” That’s the answer. Take that money, put it into the district level of your health system. Get emergency care right there, and let taxis do the transportation for a while until you’ve got enough money to buy. Get the basics right, get the community first aid, and get basic district hospital emergency care right. Everything else can follow from there. EPI: Many EPI readers will be attendees at ICEM and might be interested in knowing how to get more involved in the policy side of EM. What advice would you give to a young physician? WALLIS: Serve your own national organization first. Volunteer to get involved. Get into the committees, do some hard work, and deliver. People will notice. If you want to do that through IFEM, our committees are open. You can come to the committee meetings, sit in the back, and talk to the people in the committees and share your particular areas of interest. We’ll get you involved in the committees. Again, just sitting on the committee isn’t very helpful to anybody. So this is about working. So do something productive and you will be noticed. I think people often feel too shy. Everyone’s smart; it’s not that they don’t have the skills, but they might feel they don’t really fit in or that they don’t know the organization. But we’re all doing this as volunteers. We don’t have time to micromanage people. So if someone really wants to get in there, jump in and put your hand up and say “I’ll do it” and deliver the work.






Free Electronic EM Textbook Set for 2016 Release Now nearly two years in the making, and with over 100 international contributors and IFEM assistance, this project aims to be the first electronic EM textbook geared toward medical students. And it’s free.


p 114 contributors hail from nearly every continent, representing a diversity of emergency medicine experience.

by dr. arif alper cevik Creating a non-profit international e-book has not come without challenges. First of all, the lack of a dedicated secretariat or administrative staff, coupled with our own daily workload, meant that emergency medicine textbook resources for medical stubook editorial duties depended entirely on our available free time. dents can be difficult to come by; the majority of online This required a great deal of commitment from volunteers. In ador hardcopy clinical sources are too advanced for many dition, receiving contributions from different continents and relastudents in their various EM rotations through their tively different EM education backgrounds made standardization 3rd or 4th years. Many available resources are also too expensive difficult. That said, having so many different flavors from all around for medical students. Even Free Open Access Medical Education the world was one of the main goals of this goodwill project, along (FOAM) resources in the field of EM can be too advanced for with using collaboration and shared knowledge as a way of the students’ needs, too. Enter the iEmergency Medicine promoting and sharing EM with medical students all for Medical Students and Interns Project. This projOne around the globe. ect was first conceived in May 2014 with an aim of the interestThis project revealed many exciting and posito improve the learning experience of mediing things we realized tive opportunities, as well. First of all, knowcal students and interns during their EM during this process was that ing and collaborating with a number of EM rotation, demonstrate the enthusiasm in non of the available medical professionals from different continents is the global EM community, and encoure-books seem to have narration a priceless experience for us. In addition age them to choose EM as a career. for users. How I wish I could have to this, having a chance to learn and unIn October 2014, we announced the had Judith Tintinalli’s textbook, for derstand e-book technology was amazing. example, with narration while I project and then the International FederaOne of the interesting things we realized was a resident, listening to a tion for Emergency Medicine (IFEM) took chapter in my car on my way during this process was that non of the availon a supervising and collaborative role. Since to or from the hospital. able medical e-books seem to have narration then, we have secured approximately 114 confor users. How I wish I could have had Judith tributors to the textbook from all around the Tintinalli’s textbook, for example, with narration world, including North and South America, Euwhile I was a resident, listening to a chapter in my car rope, Asia, the Middle East, and Africa (Fig. 1). The on my way to or from the hospital. Therefore, we are planiEmergency Medicine for Medical Students and Interns Projning to complete native English language narration for all chapters ect will include 124 chapters, the majority of which are related to before or during early 2017. We think this will give students more IFEM’s medical student curricula. Although most of the textbook chances to “read” or listen to more chapters, and we think it will reflects the IFEM curriculum, curriculum from the Society for Acadefinitely improve learning. demic Emergency Medicine (SAEM) and individual contributors’ In addition to written material, the book will contain links, clinirecommendations were also considered when shaping the chapters cal videos, pictures and quizzes. But beyond these categories, there and have added a great deal of value to this project. are a limitless number of ways to get involved as a contributor. If Today, we are in the stage of scientific content review for all the you are interested in contributing in any way, it’s not too late: please chapters. We are expecting to publish the iBook in iTunes Univercontact us at sity and open it to the world of EM as a free iBook for medical students on or before September 1st, 2016.



Issue 19 // Emergency Physicians International


‘Post-Lean’ and the Future of ED Design As operational processes continue to evolve in growing numbers of emergency departments around the world, adjusting facilities design can become an obvious next step, albeit an extremely challenging one. Dr. Manny Hernandez shared his insights with us on how ED facilities design can both shape and respond to how its operations and processes are formed, and how telemedicine and personalized medicine could influence your ED design very soon.

interview by logan plaster

EPI: Where is emergency department (ED) design innovation coming from in 2016? DR. MANNY HERNANDEZ: When you think about design and innovation, there are a number of different categories that one can consider. I like to think of it from the perspective of process design, and how process and technology play into facility design. Certainly, the most advanced EDs in terms of design are in many of the more developed nations at this point. If you look at pure facility design, you tend to see the most innovation in ED design right now coming from North America and from Western Europe. Europe in particular is known as a region of the world that has very sophisticated design methodologies when it comes to physical environments, and there’s also been a strong willingness in that part of the world to really spend time thinking about and innovating in design in ways that other countries do not.

EPI: Which countries are really stepping out in terms of innovation? HERNANDEZ: I usually find that the greatest innovation—particularly architecturally—tends to come from the Scandinavian countries; Sweden, Norway, and Denmark tend to focus very much on design innovation as an integral part of solving a challenge. You tend to see facility design being less innovative in countries where decisions are being made solely on financial metrics.

EPI: Which design projects in Scandinavia have caught your eye? HERNANDEZ: The first one that comes to mind for me in Scandinavia is the Karolinska University Hospital, in Sweden. They have a number

of clinicians within their organization that are strong advocates for thinking very carefully about the design of the physical environment for healthcare. Another one that comes to mind is Akershus University Hospital, in Oslo. They built a new hospital, which is now about seven or eight years old, and when it opened it was the most technologically advanced hospital in the world. They spent a lot of time thinking about the interplay between technology and the physical environment, the workforce, and patient experiences, and designed from the ground up a solution that really focused on technology as an enabler of efficiency and quality within their institution. For example, I can think of two things that Akershus did that in my mind really helped to create better or more efficient environments. The first thing was in their clinical lab. The clinical lab in Akershus is a completely automated robotic laboratory. A human being never touches a laboratory specimen in that department unless there’s a problem with the specimen and it’s rejected by the automated line. In a typical clinical lab, you’ll often have a situation where the lab technicians will batch specimens—they’ll move a number of specimens through a process at the same time. At Akershus, every specimen that comes in is immediately processed. A robotic arm picks the specimen up out of the pneumatic tube. It logs the specimen in. If the specimen needs to be centrifuged, it places the specimen on the centrifuge. It then puts it on a robotic line that takes it through the analyzer, where are there humans manning the stations but not necessarily touching the actual specimens themselves. This results in what is probably the most efficient clinical lab in the world. Several hospitals, including Rush University Hospital, in Chicago, are also attempting to automate aspects of their supply chain. At Akershus, in particular, they use what are called automated guided vehicles (AGVs) throughout their entire hospital. They are driverless delivery modules that can deliver supplies, logistics, food—pretty much anything—from the point of origin to the point of need without having to have a human push those carts around. This creates a lower labor cost, which is important in markets where resource availability is an issue. It can also help with what’s called a just-in-time supply chain model, so that you need to keep fewer supplies in the department, which frees up space. The interesting thing about the AGV innovation is that while that works really well, particularly in areas where you’ve got a very high cost labor market, it’s an innovation that doesn’t make sense in an area of the world where labor is abundant and labor is low cost.

EPI: What other innovations in process design are you seeing in EM that are perhaps more globally-applicable? HERNANDEZ: The other innovation that we’re really beginning to see now in EM, and that I’m getting particularly excited about, is operational innovation and moving into what I would call almost a “postlean” world in the ED. In the 1990s and in the last decade, there’s been a lot of focus on lean, which I would define as applying a set of skills and tools to create a consistent, standardized a set of processes in the department that promote efficiency and outcomes. One of the things that we’ve learned in doing that is that “lean” as a tool works very well in systems where you want every input to be undergoing a similar process. We’ve begun to find that there are principles of “lean” that are very valuable in the ED, but there are things that we



can do that look beyond lean to help us become even more efficient. As a result, we’re evolving into a model of streaming and/or parallel processing, in which we focus more on function and focus less on place. Practically speaking, that means we focus more on eliminating the notion that every patient has to experience their process in the ED the same way. Rather, we’re tailoring that experience and tailoring the processes the patient needs to go through to match the patient’s true needs.

EPI: In other words, personalized medicine applied in an environment where typically there has been standardized medicine. HERNANDEZ: Right. You can see that play out from a facility perspective by rethinking the entire patient arrival experience, and moving away from traditional triage rooms and traditional waiting rooms and space for things like patient registration, and moving towards intake zones and care initiation zones and differentiating between patients who need a bed or a trolley and those patients who can remain upright in a chair. This also leads to another question more departments in the world are thinking about: Does every patient need to see a physician during the ED visit? For more than 30 years in the United States we have had advanced practice providers like nurse practitioners and physician assistants who care for patients in the ED. Other parts of the world are now beginning to look at that model and say: “If we have a limited number of physicians, are there other caregivers that we can rely on?” And bringing in those other caregivers can change the thinking about creating the spaces and environments needed in order to respond to them.

When working in cultures where male and female patients are segregated from one another, you have to think about design solutions that don’t require duplicating costly and expensive resources unnecessarily. So when it comes to things like diagnostic imaging, if a department’s volumes don’t support having an X-ray unit for men and an X-ray unit for women, then you have to figure out how to lay out those spaces in such a way that male and female patients can access the same unit and the same resources from different directions without ever being commingled.


Issue 19 // Emergency Physicians International

EPI: How is the reality of telemedicine changing the way your company designs hospital spaces? HERNANDEZ: The design solutions around telemedicine are partly based on whether you are a site that is seeing patients using telemedicine, or if you’re a site where the physicians and the other practitioners are actually delivering the telemedicine services. So on the patient experience side, it is about making sure that the rooms are laid out and sized to support the telemedicine technologies. Most of the technologies have become mobile, so you can wheel those pieces of equipment into the room and position them next to the patient. Some departments are beginning to explore wiring the telemedicine technologies into the room itself. Many EDs with training programs already videotape a resuscitation and use that as a teaching tool after the fact. Now it’s possible to utilize similar technologies so that you can have a physician watching the resuscitation managing the patient remotely, with the ability to zoom in and look at the patient, listen to the exam as it’s being completed, to move the camera over and look at the cardiac monitor and the blood pressure readings and the ventilator settings, and to actively assist in directing the resuscitation of that patient. This isn’t much different from how I operate as an attending working with residents now, where I stand at the foot of the bed or at the back of the room, just supervising. So that’s a very, very new innovation that is beginning to evolve. On the side where the clinicians are actually the ones delivering the telemedicine, the focus is to ensure that there is dedicated private space within the ED for them to do their work free of distraction. It almost starts to become similar to the way we’ve designed radiologist reading rooms in the past: larger rooms with ample technologies that allow the clinicians to really zoom in on what’s happening with that specific encounter.

EPI: Most physicians, when they read about this sort of ED design, think: “Well, that sounds nice. Maybe I should move to Sweden. But I have to deal with my emergency department, which is never going to change.” So maybe we could shift gears and talk about design solutions that are achievable at a local level without an entire overhaul? HERNANDEZ: Absolutely. I’ve had the opportunity to work with a number of resource constrained environments. When we’re working with resource constrained environments, we must always be very careful to not walk in and assume that we know the problem and assume that we have the answer, because the challenge is often more complex than we think, and the solution isn’t the one that we would think it is. I do see very resource constrained environments that are adding very advanced technologies into their EDs, and the first question that I always ask is: Well, that’s wonderful, but then what? What do you do with that information or that patient if you have an ED that’s attached to a hospital that doesn’t have an ICU, or a hospital that doesn’t even have ventilators? Or if you’re in an environment where the closest surgeon is three, four, five, six hours, even a day away? So the innovations that we create have to be tied to what is realistic and practical within a community and within a healthcare system.

The innovations that we create have to be tied to what is realistic and practical within a community and within a healthcare system. You can’t take North American solutions and drop them in India. You can’t take Chinese solutions and drop them in Europe. You can’t take Australian solutions and plunk down in Mexico. It’s just not going to work. The innovation begins with looking at the outcomes and looking at how you define value within your ED.

You can’t take North American solutions and drop them in India. You can’t take Chinese solutions and drop them in Europe. You can’t take Australian solutions and plunk down in Mexico. It’s just not going to work. The innovation begins with looking at the outcomes and looking at how you define value within your ED. For example, when working in cultures where male and female patients are segregated from one another, you have to think about design solutions that don’t require duplicating costly and expensive resources unnecessarily. So when it comes to things like diagnostic imaging, if a department’s volumes don’t support having an X-ray unit for men and an X-ray unit for women, then you have to figure out how to lay out those spaces in such a way that male and female patients can access the same unit and the same resources from different directions without ever being commingled. In environments where families and extended families are very actively engaged in the care delivery process, you have to think about designing spaces that can accommodate four, six, eight, ten people who are going to be coming and who expect to engage in and participate in the care delivery process. That certainly means bigger rooms for the patient. Sometimes it means thinking carefully about what is the family zone in a room and what is the staff zone in a room. It means having ample spaces for family members to wait comfortably while procedures are being done. It’s also important to innovate around what the scope of care is going to be in the ED. For example, we are having a lot of discussions around the world regarding the EDs role with observation patients. If the ED is going to be providing observation or short-stay services, then how should we rethink the spaces needed for those patients, because those spaces are different on some levels than how you would design a basic ED treatment station. For example, in a general ED treatment station, you wouldn’t necessarily consider designing those rooms to have bathrooms or toilets in the treatment station. But when you get into an observation environment where a patient may be spending 12, 24 or 36 hours in that space, you typically want to design those rooms to have amenities like a toilet. You may want to design those rooms to include amenities like a chair or a sofa that lies flat, so that if a family member wants or needs to spend the night, they can do so in the room. One of the other innovations I’ve seen that is really beginning to evolve is how we think about ED design for responding to mass casualties, whether resulting from an infectious condition like we had with

H1N1, or Ebola, or some of the other things that we were concerned about, like SARS in Asia almost a decade ago. We have to think differently about how we to create spaces to both accommodate these conditions and allow the ED to remain operational—where we are able to contain the potentially infectious patients from the general ED population without either population necessarily being delayed in receiving care. We have to be able to think about how to respond to the realities of a world where mass casualty incidents are becoming more frequent, and to really ensure that our departments do not become overwhelmed on the day when calamity strikes. So as we design we begin thinking about very flexible and adaptable solutions for that. One example that I can give you is a hospital that designed the dining room in their cafeteria in a way that all of the pillars had medical gases piped into them. So if they ever had a very large mass casualty incident, the staff dining room could actually become an overflow unit for patients, allowing them to roll trolleys in and immediately have access to things like oxygen and suction and to be able to bring in portable monitors, and to be able to use that space on a very short-term basis for patient care. These types of innovations are very uncommon because most organizations either don’t think about planning for those events, or they’re unable to invest in the costs that are required to do it. They also require a constant systems monitoring and running drills in those spaces. The hospital facilities department and the biomedical engineering department have to make sure that that equipment’s being maintained, inspected, and tested, and that everyone knows where the extra equipment is stored and how to access it. I’ve seen hospitals in the past that had all these extra mass casualty carts that sat locked in some administrator’s office, and when they’re needed at 2:00 AM no one can get to them because nobody has the key. That’s a very common and preventable mistake. Finally, the waiting rooms. When we think about waiting room space, we typically design very large and open spaces. A number of EDs that we work with now are designing separate spaces that they’re labeling the adult waiting room and the pediatric waiting room. Then, in case of a major outbreak of a communicable or infectious disease like H1N1, you can convert that pediatric waiting room very quickly from being one where you’re just putting children to one where you’re putting everyone who you suspect has the contagious condition that you’re trying to control, without mingling them with the general patient population.


The author’s daughter surveys the scenery during a family cycling outing in New Zealand. Taking a “gap year” can revitalize clinical skills and restore life and work priorities. Above, Dickson stands in the ambulance bay of Palmerston North Hospital, New Zealand, where he worked for 18 months.

Burned Out? Try Rebooting with a Year Abroad Is it ever too late to make radical lifestyle adjustments? A middle-aged American EP left his medical practice in Texas and moved his family for 18 months to practice medicine, life, and leisure—Kiwi style. Here’s what they learned.

by rob dickson, md


will always remember the fork in the road for me: my 50th birthday celebration and a poignant question from my 12-year-old daughter. While on a family holiday in Mexico with an emergency physician friend from Melbourne, we talked about his plans for the remainder of a three-week holiday to the US. Kate, my daughter, looked at me and said, “Dad, why can’t you have a job like Al’s?” At that moment it became quite clear to me that I could have a job like my friend’s. As an EP in Australia, it seemed Al had a good worklife balance, plenty of holiday time, protected non-clinical time, and staffing that made for a less stressful work environment than my 2.5–3.5 sick patients per hour in the US. My career and my family’s direction were forever changed in that moment of clarity. Within 12 months, I left my practice in Texas, where I was a partner, and took a 22

Issue 19 // Emergency Physicians International

position at the Mid Central District Health Board (DHB) in Palmerston North, New Zealand for 18 months. I would like to share a bit on how I got there and what I learned on my extended gap year. Why Make a Change? A gap year is a break in education common in many parts of the world. It typically entails a year of life experience prior to starting university, or a break during rigorous training programs, like in medicine. I am a product of the US medical education system. I attended medical school in San Antonio, Texas, and did an emergency medicine residency at Indiana University. Like so many other trainees, I went straight to my first attending job after residency in Indiana. During my training, the prospect of taking a gap year was never on the radar for me. I’d taken a circuitous course to my medical career, which began in my early thirties after a career in public service as a police officer and firefighter/paramedic in Dallas, Texas, and I was eager to get on with my new career. When I looked up again at age 50, I’d been hard at it as an attending emergency medicine specialist for 10 years. I was a much better and more experienced clinician by then, but I did not think I would fare well for another 10 years at the pace I was going. Like many of my ED colleagues, I was constantly asked to work miracles (we can sort out the most complex medical and social nightmares in a four-hour length of stay) with diminished resources, and increasing pressure from hospital administrators, regulators, and other clinicians. We have to make all this happen with no mistakes and are expected to achieve 95th percentile patient satisfaction scores. The work we do and the pressures of our practice—with limited control of our work environment—take a toll. After my epiphany (thank you, Kates), I went to work deciding how and when to make a move.

ity of resources and pressure to have everything sorted out prior to Where To Go? patients being admitted to hospital. There is an emphasis on cliniI investigated several options, including changing to jobs with a cal diagnosis, and I found it very refreshing to get back to using my slower pace here in the US, doing a fellowship, or working abroad. skills as a clinician and working in a system where this is an accepted I settled on an experience abroad. I’d always been interested in how standard. I was quite fond of telling our registrars (equivalent to resihealthcare systems in different countries compare with the US sysdents in the US system) that time is on our side, and we used repeat tem, and decided to search for a position in New Zealand. exams/observation in lieu of CT scans to sort out some of these paNew Zealand, a remote island gem in the South Pacific, seemed tients where the diagnosis was not quite clear. We certainly ordered to be the best fit for us. I had young children, ages 12 and 13, and a CT scans and other testing in NZ, but there is less pressure to use graduating senior heading off to university the year we left for NZ. I imaging or other expensive testing to rule in/out a diagnosis when really wanted an international experience for my younger children, observation and repeat exams will accomplish the same outcome. but was cognizant of the strain a move would put on them, and I My department in NZ has an annual census of 45,000 patients, wanted to choose a geographical location that was English-speaking and was staffed by eight senior medical officers known as consuland had a good educational track record. NZ has a population of 4.5 tants/attendings, and 16 junior medical officers of various million (smaller than greater Houston, Texas metro area), a levels of training. The ED at Palmerston North Hosgood public education system, and very friendly folks pital is an ACEM approved training site for EM to call neighbors. registrars. We also supervised junior medical The healthcare system in NZ is publiclyWant to work officers (RMOs) and training interns (first abroad? Check in with funded, and there is universal care available these following firms: year medical students). at no cost to all NZ citizens. The public It’s fair to say that NZ has its share of healthcare budget is divided between 20 Africa Health Placements frustrations just like any ED on the planDistrict Health Boards (DHBs) that et. You will not escape chronic pain paprovide care and hospital services for the Healthcare Recruiters International tients, personality disorders, snotty colcommunities they serve. All of the leagues, or administrative frustration. tors in the DHBs are employees and paid Our department was at times under rea set salary and benefits depending on International Medical Recruitment sourced, understaffed, and overwhelmed experience. There are no fees for service, with patient load and acuity, but, alas, that no patient satisfaction scores, and few if any Vista Staffing Solutions is our specialty! We are the ones who are exlawsuits in the public hospital system. NZ perts at sorting through a mountain of chief has a robust network of private General Praccomplaints in austere conditions with limited titioners who provide outpatient health care and data—and making decisions! I’m pleased to say you refer patients for inpatient services to the respective will find these same competencies in NZ departments. DHBs as needed. How to Get a Position? There are many routes to a physician job in NZ. Start with making connections. EM is a relatively small specialty worldwide, and that’s certainly true in NZ. There are 198 current fellows of the Australasian College of Emergency Medicine NZ (FACEMs). This qualification is similar to the American Board of Emergency Medicine standard and can be challenged by certified ED doctors from the US for reciprocal recognition. There are many US-trained EPs working in Australasia, and it doesn’t take much work to find a connection and start enquiring about opportunities. In my case, a classmate from my residency in Indiana had taken a position with the Mid Central District Health Board in Palmerston North and was happy to share his experience. I traveled to Palmerston North to interview and tour, and I got an ED consultant position at Mid Central starting in July 2014. Work Life Medicine is universal; it’s done the same way in Australasia and North America. We use the same sets of clinical decision rules, same diagnostic tests, and same therapies. The main difference is availabil-

Work-Life Balance This was a foreign concept for me, as I fear it is for many of my US colleagues. Kiwis have a different view on the work-life balance, and they enjoy their leisure time and holidays. The average annual paid time off for a consultant is 10 weeks. This, along with protected non-clinical time in most contracts, makes for a very attractive lifestyle that most US doctors find quite sustainable. When I spoke with our trainees in Palmerston North about the workload and lifestyle in the US, they were stunned that anyone would work under such adverse conditions. Doctors in NZ take time to sit down for dinner, a shock for those of us from the US who rarely take time for a bathroom break, and absolutely never leave the department for a meal break. Many of the trainees in NZ take time off during their specialty training to travel or take interesting jobs not directly related to their specialty. The juniors seem to be in less of a rush to complete their specialty training, and the contracts for junior doctors in NZ come with favorable amounts of paid holiday and dedicated CME time to support this.


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Issue 19 // Emergency Physicians International

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R report

// african ems

want to help african em? think local. One of the greatest threats to African emergency care development is an imported, Western understanding of the standard of care. If outsiders want to have a positive impact on African emergency medicine, we need to talk less, listen more, and focus on local talent and resources.

by jason friesen, mph, emt-p


ecent events in Africa have highlighted the continent’s ongoing and urgent need for improved emergency medical care. Examples—both positive and negative—include the Ebola crisis, several terrorist attacks, inaugural consensus statements from the African Federation for Emergency Medicine (AFEM), the U.N. Decade for Road Safety Action, and, perhaps most importantly, the sustainable development goals’ (SDGs) inclusion of injuries and maternal mortality as priority health concerns. The attention is welcome, for better or for worse, when

the routine disasters that emergency medical providers specialize in make it to the international news cycle, raising awareness and questions. One can’t help but hope that the billions of dollars spent on HIV/AIDS, malaria, and tuberculosis in Africa will one day be matched with funding to address routine emergency medical conditions. But how would Africa respond if such a thing were to come to pass? A Nigerian physician described in a New York Times opinion piece what may represent the prevailing sentiment: “We need to put in place systems to provide lifesaving care for accident victims [so they can] be moved to a fully equipped hospital — one with X-ray machines, CT scanners, a burn unit — within the space of 45 minutes. We need at least 10 of these proper hospitals [in Nigeria]. We need to improve our roads, and we need a high-quality ambulance system to drive on them. And we need paramedic schools…” He concluded the article by calling for an African response, with international support, adding: “It’s time the global public-health commu-

nity paid attention to Africa’s urgent need for emergency medical care.” But where the global public-health community joins Africa on the path to quality emergency care is exactly where things begin to get complicated. Chief Complaints In 2009, I started a nonprofit organization, Trek Medics International, to donate equipment and ambulances and offer prehospital emergency medical training in lowand middle-income countries. Over the past seven years, along with a growing community of emergency medical professionals in multiple countries, Trek Medics has given its undivided attention to the challenges of providing emergency medical care in resourcelimited settings. We have learned a great deal about local response, international support, and how attention from the global publichealth community gets translated into community programs. We have also learned that much of conventional wisdom falls flat when tested in the real world—that equipment, training, and ambulances have very little


R report

// african ems

to do with developing effective emergency medical systems, and that much of what Africa is being told of emergency medical care tends to overlook important details and ignores many difficult realities. What is the way forward, then, in helping African communities to dig deeper into what works and what doesn’t, or what’s needed and what isn’t? Initial Assessment There are undoubtedly myriad reasons why much of Africa has very limited access to even basic emergency medical care, but I believe the two biggest obstacles have been (1) uncoordinated communications and (2) poor roads. Acute emergency medical conditions are defined by their dependency on time for favorable outcomes, so if there is no way to reliably call for help when and where it’s needed then it doesn’t matter how well trained the medical personnel are or how well equipped the hospitals are. The same goes for well-stocked ambulances: if any communities are inaccessible by road, the ambulance is worthless. In Port-auPrince, Haiti, for example, 70% of its approximately 3.5 million residents cannot be reached by road. When the government of Brazil donated 35 new ambulances to Portau-Prince, the hidden but obvious implication was that over two-thirds of the population would be excluded from access to emergency medical care provided by those ambulances. Ironically, the communities that are best suited for Western-style, doorto-door ambulance response are also the demographic groups with the least need for emergency care—the affluent, who are both healthier and fewer in number. Differential Diagnosis The good news is that access to one of the most critical pieces of emergency care, telecommunications, is no longer a problem. Nearly every African has affordable access to mobile phones, and the Internet is not far behind. This gets Africa off the hook for becoming dependent on the over-priced and contextually inappropriate emergency communications systems offered by Westerners—technologies developed incrementally over 50 years and, until recently, relying almost exclusively on landlines and radios. 26

Beacon-trained bodaboda (motorcycletaxi) drivers assist in a local training simulation. [R] Firefighters and bodaboda drivers transport a victim of a motor vehicle crash.

That leaves roads as a major impediment to improving the quality and availability of emergency medical care for all Africans. But that shouldn’t be a showstopper—societies have been transporting the sick and injured for as long as there have been places where care and hospice are offered. The only reason ambulances are now deemed the preferred method of transporting the sick is because Western countries decided it was so—for themselves. In that vein, African countries need to be taking account of the unique social, cultural, and political factors that may inhibit the development of their own emergency medical care systems. An honest appraisal of the significant differences between the problems Western emergency medical systems were developed to solve, and those that African countries must solve today, should leave little question that Western emergency medical professionals with limited knowledge of emergency medical care outside their own contexts may not

Issue 19 // Emergency Physicians International

be the most reliable sources to consult. Most Westerners have never lived in communities where 24/7 emergency medical care isn’t available, leaving them with very little idea or appreciation of how their system got to where it is. In the U.S. there are more than 3,000 ways to organize an E.M.S. system, while in the U.K., Canada, Australia and most of Western Europe, there’s basically a single uniform national system. Is one better than the other? If Western systems are truly delivering the highest quality of emergency medical care possible, how could such variation be possible, let alone tolerable? The reason is because, as a rule, emergency medical systems have very little to do with medical care when they’re first conceived—the focus at the outset has always been on organizing and coordinating reliable access to ensure rapid transport to the hospital (which is where all that funding is really needed). If you solve that problem, the science, technology, and resources

will follow. There is a deeply local and nuanced evolution that emergency medicine undergoes in each new country where it is embraced. As one healthcare analyst, who sought treatment for the same injury in nearly ten countries, wrote, “each nation’s health care system is a reflection of its history, politics, economy, national values.” Minimal and Acceptable Standards of Care Perhaps the greatest threat to African emergency medical care is the Western perception of what constitutes a minimum standard of care. Outsiders are prone to make a lot of assumptions about what’s needed to improve the quality of emergency medical care in a foreign country, while also ignoring major problems that they’ve never had to deal with. For example, what good is an ACLS training program if the hospital doesn’t have oxygen? If the nurses can’t take blood pressures? If the vast majority of cardiac arrests are primarily out of hospital and rarely among the patient subset that benefits most from ACLS – bystander-witnessed, shockable rhythm? Nevertheless, ACLS is at the top of almost every emergency medical development laundry list. Would anyone suggest that countries across the globe spend very limited money and resources in an attempt to reach the gold standard of 8% positive outcomes for cardiopulmonary resuscitation? Vertically-funded programs that include an emergency component are another example of how Western perceptions can stifle African emergency care development. In programs addressing maternal child health, cholera, and even Ebola, for example, wellintentioned foreign epidemiologists and specialists from countries with reliable prehospital emergency response systems are brought in as subject matter experts and given the mandate to develop independent emergency response systems from scratch, focused solely on the targeted disease. In the rare case where the effort succeeds, the funding structures—which might demand that each initiative operate independently of one another—can often create further fragmentation, and, ultimately, political turf wars that ensure the system either stays

independent or dissolves. The true irony is that no Western experts would ever accept such a solution in their own community— they would never agree to call 911 for childbirth and 809-562-0567 for a car accident. There are, of course, very strong arguments for why a particular disease needs its own emergency infrastructure. But, in my experience, preventable fatalities caused by Ebola, cholera, or childbirth happen when communities don’t have an organized, reliable way to alert the community to send help and transport when it’s needed. It shouldn’t be surprising that such solutions evade many of the otherwise wellintentioned experts who devise these infrastructures. Emergency medical systems are not links in disease chains, they are public goods. Many Western emergency practitioners are offering emergency specialization when they really need to be looking at it from a public health standpoint, especially in places where access is severely limited. Universal Triage Western emergency medical systems certainly do have some principles worth teaching and emulating, but they are probably nowhere nearly as important and effective for Africans as what Africans can teach themselves. I can say this because Trek Medics has played a small role in the birth of a first-of-its-kind emergency medical system in Mwanza, Tanzania. The system is run by a diverse group of nearly 100 community members, all of whom have skin in the game: doctors, medical students, firefighters, traffic police, and bodaboda drivers—the demographic group most impacted by road traffic injuries and most well-positioned to help. In September 2015, we sent an Australian paramedic to Mwanza for three months to assist a local community-based organization, the Tanzania Rural Health Movement, in training relevant community members in first aid, scene management, and in the use of a text message-based dispatching software we created, called Beacon, which we’ve designed specifically for communities where advanced dispatching technologies are unaffordable or inappropriate. Our staff member undoubtedly brought a lot of value and

experience to the program, but he never made a single decision. Every decision was made by the local participants and was based on a common principle that was both simple and transformative: all communities in Tanzania have the same urgent needs for supplies, vehicles, and training. Instead of waiting for ambulances that likely aren’t coming soon, they pledged to use whatever they had to get the sick and injured people to the hospital. The system launched in December 2015, and within three days the first call came in for a rather severe motor vehicle collision, including an entrapped patient suffering bi-lateral lower extremity fractures. The bodaboda drivers arrived on the scene in less than ten minutes, followed closely by members of the fire department, who used rudimentary tools to extricate the patient successfully, and then accompanied him in the back of the police pickup truck to the hospital. They did all of this with nothing from outside the community, with the exception of a simple text-based alert system. Since then, the response system has been growing steadily through word of mouth, reaching patients farther and farther away from where it began, and using little more than a laptop and whatever phones the responders had in their pockets. This program is clear evidence to us that Africa doesn’t need to wait for the international community, and that Africans can now build their own systems to meet the performance standards of their Western counterparts, and for a fraction of the cost. The attitude of the Mwanzans is similar to an ancient African from Tunisia who knew a lot about moving injured and resources in austere conditions, and wrote, “We will either find a way or make one.” There is a belief that by being proactive with what they have, Tanzanians will stand out from the crowd and garner more support. So far, it’s working. Other African countries can do the same and start building systems now, with whatever they have, so that when the international community offers support, Africans will already know where and how it will be used best.


R report

// infectious disease

as olympics approach, zika looms



by rebecca liggin and ashley bean

now cases throughout South and Central America and the Caribbean. Conventional thought is that the Zika virus was imported to the Americas by travelers to the 2014 FIFA World Cup in Brazil. These concerns have incited further debate about whether the upcoming Summer Olympics in Brazil will facilitate a more rapid spread of the disease. The International Olympic Committee has already recommended that pregnant athletes not attend the games this summer. On the upside, the Olympic games will be concentrated in Rio de Janeiro, which is undergoing a massive mosquito eradication effort, and they will be taking place during Rio’s winter when there are cooler temperatures and fewer mosquitos. However, millions of people will be traveling to Brazil for the Olympics and subsequent

round the globe, there is growing concern about the Zika epidemic. So far, in the continental US, we have primarily seen imported cases. This lack of host-to-host transmission so far is due primarily to cooler winter temperatures. However, given the rapid spread of the disease in recent months, we should expect to see locally acquired cases of Zika in the US this summer when the weather becomes warmer and mosquitos become more prevalent. The Zika virus is carried by Aedes aegypti mosquitoes. This mosquito is found in the continental US and can also spread yellow fever, dengue, and chikungunya. Prior to April 2015, Zika had not been seen in the Americas, but since that time it has spread northward rapidly from Brazil, and there are

How Zika Spread: An historical timeline (W.H.O.)

How are the real risks of Zika changing as mosquito season and the Summer Olympics approach?

Para-Olympics. Many visitors will not be limited to staying within Rio, and may journey throughout the country before returning home. Those returning to the US will arrive during prime mosquito season. If they carry the virus, they risk introducing it into the US mosquito population. Since most people infected with Zika have mild to no symptoms, they probably will not realize they are potentially infectious. As emergency physicians, the most common questions we get about Zika are, “What is the real risk of Zika?” and “What can we do to prevent it?” The risk of contracting Zika, of course, depends upon exposure to the mosquitos carrying the virus and upon the measures taken to combat mosquito bites. Currently, there is a low likelihood of contracting Zika within the continental US, and

Uganda United Republic of Tanzania


Central African Republic Senegal Pakistan Burkina Faso Cote D’ivoire Cameroon Sierra Leone Gabon Indonesia Malaysia Nigeria Costa Rica Cambodia




Issue 19 // Emergency Physicians International

YAP (Micronesia (Federal states of)) Gabon 2007–2009

the risk of developing a severe illness due to Zika infection is quite low, as it is typically a mild illness with fever, rash, joint pain, and conjunctivitis. There are, however, two major complications associated with Zika infection. A small number of people infected with Zika virus will develop Guillain–Barré syndrome (GBS), a disorder that causes progressive weakness and potential paralysis that can last weeks to months, and will in some cases require ventilatory support. Most patients recover with little or no deficits. The Zika virus is more concerning for pregnant women. Pregnant women infected with Zika develop the same mild illness, but the virus can cross the placenta into the fetus and cause fetal anomalies including microcephaly. As there is no treatment or vaccine currently available for Zika, the primary step in preventing the complications of Zika is to avoid infection. First and foremost, if you are pregnant or in a sexual relationship with someone who is pregnant, do not travel to a Zika-affected area. Zika cannot be transmitted by respiratory droplets, but it can be transmitted by sexual contact. (Zika may also be transmitted via blood and could also pose a threat for people who share IV needles.) The virus can be detected in the blood of infected persons for up to one week, although there does not appear to be a risk to future pregnancies. If you are pregnant and you must travel to an area of Zika transmission, reduce your chance of infec-

tion by preventing mosquito bites and by using condoms. Insect repellent is an important adjunct to preventing mosquito bites. It is important to understand that not all mosquito repellents are equal or effective. The CDC has a list of recommended mosquito repellents listed at repellent.html. The most effective mosquito sprays are those containing DEET, picaridin, or lemon eucalyptus oil. Although higher concentration or time-release formulations of DEET- and pircaridin-containing sprays will last longer, all mosquito repellents need to be applied frequently. If using lemon eucalyptus oil, you must cover all exposed skin since, unlike DEET, it has no repellent activity in areas where it has not been applied. You can also pretreat your clothing, tents, and sleeping sheets or bags with permethrin. Permethrin, a spray that can be applied to cloth, will last months and through multiple washings. It is safe for infants, young children, and pregnant women. Clothes with factory impregnated permethrin are available from several companies that specialize in outdoor clothing. Other precautions to help decrease the risk of contracting Zika include wearing pants and loose-fitting, long-sleeved shirts, and draining any areas of standing water that may act as a mosquito breeding grounds. Sleeping in screened or air-conditioned rooms and under a bed net treated with a long-acting insecticide may decrease

French Polynesia EASTER ISLAND (Chile) Cook Islands New Caledonia Malaysia Philippines Cambodia Indonesia Thailand

Brazil Vanuatu Fiji Colombia Cabo Verde Samoa Solomon islands

El Salvador Guatemala Mexico Paraguay Suriname Venezuela (Bolivarian Republic of)


Jan–Oct 2015

Nov, 2015

mosquito exposure. Again, remember that most people with a Zika infection have limited symptoms. Therefore, if you are returning from a Zika area, assume you have the virus for two weeks after your return and take precautions to prevent transmission via mosquitos or body fluids. One of the most important things to understand about Zika, dengue, and chikungunya is that they are all viruses that are spread by the same mosquito. On initial presentation, all of these diseases may look quite similar with fever, a rash, and arthralgias. The difference is that Zika, for the most part, is a mild disease that is dangerous only to pregnant women and the few who develop GBS. Chikungunya also has a low mortality, but the pain from the arthralgias can be devastating, can last for years, and can make young children very ill. Dengue can cause symptoms ranging from a mild illness to fatal illness, and is responsible for thousands of deaths each year worldwide. An epidemic in a country the size of the US could be devastating. Protecting yourself and your family from mosquitos—and educating your patients—is critical to decreasing serious illness during the warmer months ahead.

French Guiana Honduras Martinique Panama Puerto Rico

Bolivia (Plurinational State of) United States Virgin Islands Dominican Republic Costa Rica Guadeloupe Saint Martin Nicaragua Barbados Maldives Ecuador Guyana Jamaica Curaçao Samoa Haiti


Dec, 2015

Jan, 2016

Feb, 2016


R report

// war zones

Surmounting an Assault: Hospital Staging in Disaster, Structural Damage, and War Military attacks on hospitals have become all too frequent around the globe. Being prepared for them will help ensure your patients’ safety – and your own.

by keith a. raymond, md


ttacks on health care workers and facilities have increased in recent years. In October 2015, US aerial forces attacked the Médecins Sans Frontières (MSF) Trauma Center in Kunduz, Afghanistan, resulting in 42 deaths, including 24 patients and 14 members of MSF’s staff. Among the staff casualties were the hospital’s deputy medical director, an emergency room physician, an ICU doctor, and several nurses. Patients in the intensive care unit burned to death in their beds. The attack – which garnered widespread international condemnation – resulted in a rare apology, first from the US commander in Afghanistan and then from President Obama himself. Another MSF facility was bombed in Yemen in January, following the attack on two other Yemen hospitals in previous months. In its “Attacks on Health: Global Report,” released in May 2015, Human Rights Watch documents other instances of violence against health care workers and facilities. The HRW report shows that the 30

assaults predominate in 13 countries where regional conflict or civil war is underway — and, thus, where medical care is needed most (see map). The possibility of violence in or out of a war zone requires vigilance and preparedness on the part of emergency physicians. We must be aware of the dangers, protect ourselves against them, limit risk, and have an action plan in the event of emergency. We must ensure that our patients are taken care of even when we have to evacuate or move to temporary facilities. And we must “surmount”—a term from an old French word that means “to rise above or go beyond.” To muster through or carry on is what we do regardless of facility or patient status. Hospitals are protected under international humanitarian law, and may only be attacked if there is clear evidence of coordinated military activity within the facility outside its humanitarian function. Except in cases when troops come under heavy fire from a medical building, such an attack can be initiated after the personnel there are warned and have reasonable time to respond and/or evacuate. Unfortunately, laws are violated. In remote locations, the destruction of a healthcare facility means the difference between life and death for the people of the region as well as a loss of livelihood for hospital workers and their

Issue 19 // Emergency Physicians International

families. A soldier, sailor, or airman will risk everything in battle if they know they have a medical backstop. Denying the enemy a medical facility is a strategic, albeit illegal, target that affects their ability to recover during battlefield conflicts. It is a psy-op that attacks their will to fight. So hospitals and mobile surgical units can therefore become prime targets, despite the protections they receive under international law. Should you take up arms to defend your facility? If you’re in the military medical corps, the answer is yes, but as a civilian your duty remains with your patient. The Kunduz tragedy serves as an example of the challenges and situations that hospital staff face during and after an assault; it provides a training lesson for how you can prepare to surmount an assault on your own facility. MSF has always maintained neutrality, and not only insisted on its facilities as weapons-free zones but also that patients must remove all rank and identifying features on uniforms they wear on arrival. These are key policies to maintain in areas of conflict to avoid violence within

the facility itself and to ensure that military forces cannot claim that the hospital was harboring armed combatants engaged in military activity. A variation of this policy would be applicable when working in inner cities, where gang colors and other signifiers are worn. Without question, weapons should be made safe (unloading guns and putting them on safety), collected from patients, and turned over to authorities when possible. I recently disarmed an inpatient who kept a pistol under her hospital bed pillow. I left the weapon with the floor charge nurse, who put it with the patient’s other valuables until her discharge. It is inevitable that hospitals, clinics, and their personnel will be attacked in the future. As physicians, we must discourage military forces of all sides—whether government or paramilitary—from assaulting healthcare facilities and personnel. It’s important to register our outrage at such instances of violence, in order to ensure the safety and well-being of patients and ourselves. Considering that such assaults continue to happen, you may be called on to protect

yourself and your patients under a coordinated military attack. With that in mind, it’s essential to take the time to review your hospital’s disaster plan. What contingencies are in place in the event of an attack? How will healthcare and administrative functions be maintained if communication is compromised and parts of the hospital need to be evacuated? Who will be in charge? Does the disaster plan encompass a bomb or fallout shelter within the facility? Many hospitals are no longer single structures but multiple buildings on a campus, so certain staff and patients may need to evacuate from one building to another. Once hospital personnel and patients make safe passage to that hardened structure, it can serve as a disaster coordination center, in addition to serving as the fallout shelter. Such disaster coordination centers, besides being an emergency supplementary medical care center, can also house computers and multiple communication system redundancies to allow contact not only with personnel in the facility but also with fire, police, and disaster services on the outside. In Kunduz, the safe room was in the

basement of the hospital. Up to a week before the attack, members of the MSF staff were staying there when not on duty, as a result of conflict that had spread into the city and its Taliban’s takeover on September 28. MSF staffers were also told to stay at the hospital because of a possibility that insurgent groups might kidnap them. Such situations provide a valuable touchstone for operating in conflict zones: hospital administrators should be consistently evaluating the safety of the surroundings, determining whether or not staff should be allowed to leave the facility. Because of the instability in some regions where MSF operates, its staff must remain on-site at all times, except when leaving the area altogether. A central element of an evacuation plan is the movement of patients from threatened areas to safe rooms, or off-site, if there is security to protect an evacuation. Staff should move the most ambulatory first, followed by those needing assistance, and finally the bed-bound, starting with the most stable and then those with greater and greater medical demands. Ultimately, each hospital decides how to prioritize evacuees


R report

// war zones

based on what will get the greatest number of patients to safety as quickly as possible. Because of continued fighting between government and Taliban forces after the group’s takeover of Kunduz, the streets in the city were deadly. Mass casualty conditions ensued and the hospital census was soon in Code Black. By 10 pm on the day of the Taliban takeover, 137 wounded had been treated, 26 of which were children. On the 30th, there were over 60 Taliban combatants who were being treated in the hospital. The daily ED census surged from the low sixties to more than double that number. Gunshot wounds, head and abdominal trauma predominated. By October 1, patients were being transferred to MSF Chandara to manage the overflow. Surgical unit supplies were dwindling. When there is a crisis at a medical facility, it’s essential to have backup supplies available. The hospital’s basement, disaster coordination center or fallout shelter should be well-equipped with sleeping cots, surgical kits, lights and tables, pharmaceuticals and food. The supplies should be adequate to meet personnel and patient needs for up to two weeks or more. In Botswana, while overseeing the construction and staffing of a new hospital, I made sure the loading dock provided basement access. Central supply and the pharmacy stock room were situated above the basement with a dumb waiter to shift supplies as needed. The A&E was adjacent to these areas. We also made sure that a separate generator was available for basement operations. Our primary concern was not aerial attack but tribal conflicts that spilled over onto the hospital grounds, either from direct assault or from patient-topatient battle. While the basement was being upgraded in Kunduz, a US government official contacted MSF on October 1, and asked if Taliban were “holed up” in the facility. This was the veritable shot across the bow. On October 2, MSF, concerned for facility safety, placed two additional MSF flags on the roof of the hospital to verify the facility location and stress its neutrality. It had repeatedly given the GPS coordinates of the 32

A soldier, sailor, or airman will risk everything in battle if they know they have a medical backstop. Denying the enemy a medical facility is a strategic, albeit illegal, target that affects their ability to recover during battlefield conflicts. It is a psy-op that attacks their will to fight.

Kunduz Trauma Center to various military and government authorities to ensure that the hospital would not be bombed. In regard to facility demarcation, the UN General Assembly passed a resolution in December 2014 urging member states to develop clear and universally recognized identifying markings for healthcare staff and installations. This is another element of the protocol to protect medical facilities from attack. Consider the identifying features on the roof of your hospital, are they adequate? Is a Red Cross or Red Crescent clearly displayed? Is there a highly visible electric sign identifying the facility as a hospital? Flags? While these seem basic, it is surprising how often such features are absent in developing-world facilities. Several hours before the attack on October 3, MSF Kunduz Trauma Center was in full swing. Outside it was quiet. Some reported it as too quiet. The flow of casualties had slowed, and, as in any ED, the staff was restocking and catching up. Two of the three operating rooms were in use. Suddenly, a series of airstrikes hit the main hospital building, leaving the rest of the buildings in the MSF compound comparatively untouched. Patients attempting to flee the hospital rather than seeking shelter in the

Issue 19 // Emergency Physicians International

basement were strafed with machine gun fire. Multiple explosions ripped through the facility. According to MSF, the ICU was hit first. The OR patients did not survive. MSF made multiple calls and sent numerous SMS messages during the attack to the US military, NATO, the UN, and Afghan authorities, but these were ineffectual in stopping the assault. Once the attack stopped, all MSF staff in Kunduz went to work, after attempting to locate colleagues. The ED was destroyed, so triage was set up in the administrative building, and it became the makeshift ED and OR combined. The MSF coordinator contacted the Ministry of Public Health Provincial Hospital and ambulances were dispatched to the hospital so patients could be transported elsewhere. Armed conflict continued in the city, and ambulances sustained bullet impacts while exiting the Kunduz facility’s front gate around 6 am. By 9:30 am, MSF Kunduz Trauma Center was closed, and international staff were evacuated to the airport. It remains closed to this day. It’s useful to note that not all hospital damage is due to war. Structural damage can occur from a hurricane or tornado strike—as when Hurricane Katrina made

landfall—or from an irate or drunk patient losing control of their vehicle and driving into the hospital, as I saw once when working in the Virgin Islands. In 2008, the UN took action to curb hospital and healthcare facility damage from natural disasters by directing the UN International Strategy for Disaster Reduction group to establish a Hospitals Safe from Disasters program. The plan involved creating and fielding teams to assess structural and nonstructural integrity of hospitals worldwide, and to make recommendations on construction that would reduce damage and destruction during catastrophic events (see figure 1). The guidelines in figure 1 provide reference points for architectural design. For example, had “T” walls been placed in front of the entire structure of the hospital adjacent to the parking area where I worked in the Virgin Islands (a hurricane area), instead of just in front of the ER waiting room windows, the driver would have been stopped before his vehicle penetrated the load bearing wall.

While a hurricane, earthquake or tornado is a more likely scenario in your medical center, a terror-based explosion or attack is no longer out of the question. Even when there is severe structural damage, physicians and nurses must still take care of the patients in their charge. Evacuating them and continuing to provide care is required until you are released by administrative or government authorities. Waiting for outside support by fire rescue or FEMA is not an option. Where do you establish triage, decontamination, and a makeshift ED if your hospital is unsafe? Your disaster plan may be robust in answering these questions and if so, recharge your memory. If it is not, or merely addresses the potential scenarios in broad strokes, it’s worth developing it now rather than at zero dark thirty in the middle of the chaos. Does your plan include a disaster coordination center, an internal shelter, or an external shelter within the operations plan? Do you know which medical centers in the region can take your patients if healthcare is curtailed or canceled on site, and who you can receive patients from

when those facilities fail? Communication is always cited in disaster drills as a shortcoming. Several hours into the November 2015 terror attacks in Paris, Jean-Paul Fontaine, head of ED at the city’s Hôpital Saint-Louis, called the Services d’Aide Médicale Urgente (SAMU), or medical emergency services unit for Paris. The organization had still not been updated on the attacks. His only reports came from patients and onlookers that had arrived from the scene. In order to strengthen communication, work with your team. Is there a phone call chain for Code Black staff callups? Do you have walkie-talkies when phone lines fail, and is there redundancy in the system as well as other forms of communication? Do you have a disaster coordination center, and, if so, who will man it? Knowing the what, when, and how of all these questions is critical. Your life and the lives of your patients will depend on it. A great resource for hospital evacuation planning:

Fig 1: An excerpt of guidelines from the Hospitals Safe from Disasters program: A. LOCATION


1. Building is not located in a hazardous area:

1. Building has a simple shape and is symmetrical along both the lateral and longitudinal axes (e.g. square or rectangle), making it resilient when subjected to stress such as that produced by an earthquake

a. Not at the edge of a slope b. Not near the foot of a mountain vulnerable to landslides c. Not near creeks, rivers or bodies of water that could erode its foundation d. Not on top of or in proximity to active fault lines (less than 10 meters away) e. Not in tsunami-prone areas f. Not in flood-prone areas g. Not within a typhoon zone h. Not in areas prone to storm surges 2. Building has appropriate provisions for addressing hazards related to location, such as rainwater drainage and dikes

2. Building structural members (foundation, columns, beams, floors, slabs, trusses) and non-structural members conform with requirements for strong winds (wind importance factor of 1.15) and earthquake (seismic importance factor of 1.25) 3. Glass walls, doors and windows resist basic wind speeds of 200 – 250 kph with regional application of secondary covers 4. Number of building floors (stories) less than five, especially in areas that are vulnerable to earthquake 5. Roof angle of 30°– 40° (optimum for withstanding wind forces) for buildings in typhoon-prone areas



An Eye On Outcomes Should we, as emergency physicians, think about long-term recovery?


After completing my most recent evening shift, I was glad to get home and feel that I probably hadn’t missed much in terms of difficult diagnoses, and hopefully I hadn’t inadvertently sent too many sick people home. Most of my patients had been very ill,

and I had admitted those cases under an inpatient unit. I had seen some fascinating cases, including a stab wound with no blood pressure, a dissecting abdominal aortic aneurysm in a 20-year-old presenting with gastro, a meningococcal meningitis, plus the usual cases of heart failure and chest pain.

Upon further reflection, I realized that once I had resuscitated each patient, performed the necessary procedures, and handed the case on to the inpatient unit, I quickly lost interest! As emergency physicians, we don’t hear much about what happens in the ward, and we know even less about what happens when the patient is discharged. We have no concept about the impact that any admission might have on the individual or their family, and the wider community. The next morning, I did my day job, which focuses mainly on research. One of the major areas of my research focuses on longterm outcomes following major trauma. This is where I get to see what happened to all the maimed people months and years down the track. Over a prolonged period, we have begun to understand a lot more about how people recover from injury and illness, and what influences recovery. When I started out in this area, I thought that the biggest determinant of outcome was the severity of the illness. As we looked into this, we found that the type of injury and severity of injury had less to do with the final outcome than other factors such as age, sex, socioeconomic circumstance, family support, and work status. In fact, for injured cases, severity of injury for major trauma cases was only a small component of the prediction model for the trajectory of recovery.1 Importantly, we found that supposedly “moderate” degrees of injury could take years to recover from. For example, although a patient may only spend a few days in hospital after a long bone fracture of the lower limb, their recovery may be a long and drawn out process. We then looked at other factors, such as the attitude of the pa34

Issue 19 // Emergency Physicians International

tient toward the injury, and how they think they might have contributed to the injury event. When patients think they were a victim and someone else was at fault, they did badly. When they thought that it was mostly due to their own stupidity or carelessness, they actually recovered more quickly. Importantly, the promise of compensation was found to delay recovery.2,3,4 Outcomes were even worse in a scenario where there was protracted delay in settlement due to legal feuds. It could be argued that the mere act of giving compensation could result in preventing or delaying recovery. There are some obvious reasons for this, especially for low income or unemployed people who have little incentive to return to work when they are paid for not working. However, the effect seems to go beyond malingering, and may possibly be correlated with real physical differences in degree of recovery. Although this work is most clearly related to injury, for which there is often an overt precipitating cause, the effects of attitude and social circumstance on speed of recovery probably relates to other serious illness as well; for example, someone suffering from cancer, where the cause might be work-related, or cases where chronic lung disease may be due to passive smoking. It is all very well to say that non-illness related factors such as attitude and socioeconomic status make a difference, but is there anything we as clinicians can do about it? First of all, statistically, we can identify patients at higher risk of poor or slow recovery. Secondly, if we believe the numbers that we are seeing (and the numbers are very strong), then early intervention may make a difference—but only if we can change the attitudes of patients during recovery. Is there any evidence that we, as clinicians, can change the attitude of patients? There is a lot of work happening in this area, although large-scale randomized trials are lacking. A number of studies have shown that coaching and peer support may have some influence. One particular fad is “mindfulness” (coaching people to understand that they should not focus on negative or unproductive thoughts but more on positive outcomes instead). In the case of patients who may have been “wronged,” either through injury or illness, letting go of the victim mentality may be very important.5 Patients can be helped to achieve this through counseling, meditation, group therapy, and other techniques. The idea that patients do worse when compensation or wrongdoing are involved, especially in cases involving a lawyer, is not new.6 The evidence is now overwhelming, however, that focusing on this aspect of their injury harms people’s recovery. So what has all this got to do with ED physicians? Should we be

thinking more about recovery and how we might influence the final outcome? As ED physicians, we see our job as being focused on patching people up and sending them on to hospital or community care. Maybe we should be focused more on the recovery aspect. Clearly, we have a very short time with the patient, compared with many other clinicians, but, as with most aspects of medicine, if we put our patients on the right “conveyer belt” to recovery, then there is a chance they will do well. As a start, this may include the language we use with patients, encouraging them to not blame others, not to seek compensation, to maintain positive attitudes to recovery. Arranging post-discharge follow-up, telephone support, coaching and so on, through a hospital/community liaison might also help. In resource-limited countries, maybe we could use post-discharge messaging and other more innovative solutions to assist with positive thought in the recovery phase. For example, we are now undertaking trials in India for rehabilitation following leg injury using texting, in order to assist in recovery from injury. Where does the ED physician’s responsibility end? Surely, we are just the patch up docs—“see and street,” right? I would argue, though, that part of the patching up involves putting the patient on a pathway to optimal recovery, and setting expectations around attitude, peer support and appropriate coaching—if it is evidence-based—is part of our job. We seem happy to arrange for blood pressure tablets post discharge in a well patient with moderately elevated blood pressure for an NNT of 1/700 treatment years. But when it comes to things that really matter, like speed of recovery from a serious illness, our attitude usually seems to be: not included in my pay grade! 1. Gabbe B, Simpson P , Harrison J, et al. Return to Work and Functional Outcomes After Major Trauma. Who Recovers, When, and How Well? Ann Surg. 2016;263:623–632. 2. Gabbe B, Cameron P, Williamson O, et al. The relationship between compensable status and long-term patient outcomes following orthopaedic trauma. Med J Aust. 2007;187:14-17. 3. Harris I, Mulford J, Solomon M, et al. Association between compensation status and outcome after surgery, a meta-analysis. JAMA. 2005;293:1644-1652. 4. Harris I, Murgatroyd D, Cameron I, et al. The effect of compensation on health care utilisation in a trauma cohort. Med J Aust. 2009;190:619–22. 5. Gabbe B, Simpson P, Cameron P, et al. Association between perception of fault for the crash and function, return to work and health status 1 year after road traffic injury: a registry based cohort study. BMJ Open. March 2016.

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6. Murgatroyd D, Casey P, Cameron I, Harris I. The Effect of Financial Compensation on Health Outcomes following Musculoskeletal Injury: Systematic Review. PLoS One. 2015;10(2): e0117597. Dr. Peter Cameron is the immediate past president of the International Federation for Emergency Medicine (IFEM)

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Issue 19 // Emergency Physicians International


EPI Issue 19  
EPI Issue 19  

Incoming president of the International Federation for Emergency Medicine (IFEM) speaks out on the Federations new directions. Plus, field r...