Why isn’t the UN talking about acute care? MSF: Pediatric emergencies in Galgaduud Bahrain: Detained docs spark global outcry
EMERGENCY PHYSICIANS INTERNATIONAL
AFRICA issue ethiopia
An in-depth report from a developing health system
A Swede’s observations of an up-and-coming EM program
Issue 6 // november 2011
November 2011 // Emergency Physicians International
Obstacles & Opportunity
fter what had seemed like years of relative neglect, emergency medicine has taken great strides forward in Africa over the past several years. If you are reading this issue of Emergency Physicians International in Cape Town, at the “Emergency Medicine in the Developing World” conference, you are probably aware of some of these coordinated efforts to develop this pivotal medical specialty. If you’re reading EPI online, there are no shortage of ways to get involved in EM development work in Africa. Recent African EM developments to highlight include the formation of the African Federation for Emergency Medicine (AFEM) as well as the publication of the federation’s new peerreviewed journal, the African Journal of Emergency Medicine (www.afjem.org). There are new EM residency training programs in Tunisia, Ghana, Tanzania, Madagascar, South Africa, and Kenya (among others), and there has been an increase in participation by African emergency physicians at international EM conferences. In addition, there is a growing African presence in the International Federation for Emergency Medicine (IFEM), with the Emergency Medicine Association of South Africa and the Tunisian Society for Emergency Medicine being “Full” members of IFEM, the Madagascar Association of Urgent Medicine and Reanimation Anesthetists being an “Affiliate” member, and AFEM being an “Ex-officio” member. As Terry Mulligan, Lee Wallis and others have pointed out in prior presentations and publications, many African countries are undergoing significant demographic and epidemiologic changes which make having quality emergency care delivery systems all the more necessary. Multiple factors, including urbanization of populations, increased road traffic, aging of populations, and greater occurrence of armed conflict and violence have contributed to an increased incidence of trauma and cardiopulmonary illness. Not only are these concerns well cared for by emergency care specialists, but they have been experienced around the world, making a global dialogue on EM development highly relevant and practical. In Africa, acute care issues have actually outpaced HIV, malaria, and the other infectious diseases – which have received perhaps disproportionate attention and financing – as a public health threat. It has only been recently that the World Health Organization (WHO) has woken up to the need to promote and develop better trauma care as a health system priority for developing countries. Similarly, it wasn’t until this Fall that the United Nations held a highlevel meeting that brought focus and attention to the increasing problem of non-communicable diseases, which account for over 63% of deaths in the world today. The world is taking note that there has been a shift in global morbidity and mortality, and emergency medicine is a key part of the answer. EM can act as a safety net for these skyrocketing health issues like heart disease and trauma, and it can do so efficiently and effectively.THE There is huge potential for emergency medicine to improve public health throughoutAFRICA the ISSUE African continent, and I encourage you to become involved, if you are not already. Providing training materials, participating in training development programs, hosting exchange African medical students and EM residents and physicians, are some of the ways you can contribute. Hope to meet you at this Cape Town conference!
C. James Holliman, MD, FACEP, FIFEM editorial director
In Africa, acute care issues have actually outpaced HIV, malaria, and the other infectious diseases – which have received perhaps disproportionate attention and financing – as a public health threat. It has only been recently that the World Health Organization (WHO) has woken up to the need to promote and develop better trauma care as a health system priority for developing countries.
Why isn’t the UN talking about acute care? MSF: Emergent medical needs in Galgaduud Bahrain: Detained docs spark global outcry
EMERGENCY PHYSICIANS INTERNATIONAL
AFRICA issue ethiopia
An in-depth report from a troubled healthcare system
A Swede’s observations of an up-and-coming EM program
conference program for “Emergency Medicine in the Developing World” starts on back cover
cover illustration by tracey jolliffe
About EPI With a quarterly print and digital distribution and an online network of more than 1,200 members, EPI is the new hub connecting global emergency care, sparking dialogue and creating a space for new collaborations. Find copies of the print magazine at international EM conferences around the world, or read it online at www.epijournal.com
Letter from the publisher
his issue of EPI is dedicated to emergency medicine development on the continent of Africa. But which Africa? The second largest continent comprises 54 sovereign states and more than a billion people – among whom are spoken around two thousand languages. Think emergency medicine is complicated where you live? Try living in Chad and writing your discharge instructions in four dialects of Kanuri. Africa’s emergency medical establishment is nearly as diverse as its geography and linguistics, yet there are common themes that bind it together. Namely, Africa has become a place that inspires innovative medical collaborations rarely seen elsewhere. In 2006, Canadians, Americans and Ethiopians established a CME training seminar in Ethiopia that has since become an annual symposium (read our in-depth report on Ethiopian developments on page 17). Likewise, the MUHAS residency in Tanzania is supported by a unique consortium of five institutions from Cape Town to California (read the Tanzania Source report on page 14). And nowhere is this spirit of collaboration more evident than in South Africa’s Adopt-a-Delegate program. The concept, which pairs African emergency care workers who may have difficulty attending a regional EM conference with a financial sponsor, was initiated at the second “EM in the Developing World” conference in South Africa. The first year saw 13 delegates apply and receive sponsorship; the second year saw that number more than double. Sponsored delegates receive more than financial assistance, says program founder Steven Bruijns. They are able to build and maintain a professional relationship with their sponsor long after the conference is over, giving new emergency physicians important confidence and critical contacts. While most emergency care systems in Africa are still in their early stages of development, African emergency medicine is teaching the world a thing or two about creative, multi-national collaboration. So whether you work in New Zealand, New Guinea or New York, get involved – there has never been a better time to roll up your sleeves and take part in emergency medicine development in Africa. Not sure where to start? Just say hello. Meet colleagues from all over Africa on the EPI Network (www.epijournal.com).
publisher Logan Plaster Logan@Plasterpub.com editorial director C. James Holliman, MD executive editors Peter Cameron, MD Terry Mulligan, do, mph Lee Wallis, MD Mark Plaster, MD associate editor LONNIE STOLTZFOOS regional corespondents Conrad buckle, md Marcio Rodrigues, MD Carlos Rissa, md Katrin Hruska, MD Subroto Das, md mohamed al-asfoor, md Jiraporn Sri-on, md editorial advisors ARIF Alper Cevik, MD Kate Douglass, MD Haywood hall, MD Chak-Wah Kam, MD Greg Larkin, MD Prof. Dongpill Lee Sam-Beom Lee, MD Gladys Lopez, MD Alberto Machado, MD Jorge otero, MD advertising Michelle rucks email@example.com 5 College Avenue Annapolis, MD 21401
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November 2011 // Emergency Physicians International
mark L. Plaster, md Rebecca r. Plaster
EVENT CALENDAR 12/11–11/12
12 months of international EM c o n f e r e n c e s
2nd International Conference on Preparedness and Responses to Emergencies and Disasters // Tel Aviv, Israel January 15 – 19, 2012 www.ipred.co.il
The 1st Global Network Conference on Emergency Medicine // Dubai, UAE Email papers to: email@example.com January 13 – 17, 2012 www.emergencymedicineme.com
The 16th Annual Scientific Assembly of the Israeli Association of EM // Tel Aviv, Israel
First International Congress of Pediatric Emergency Medicine // Leon Guanajuato, Mexico This congress will cover topics from controversies in pediatric resuscitation to pediatric airway management to the organization of emergency service. June 14 – 16, 2012 www.anmuep.org.mx
The 2012 International Conference on Emergency Medicine (ICEM) // Dublin, Ireland The theme of ICEM 2012 is ‘Bridging the Gap between Evidence and Practice’ and topics will include Disaster Medicine, Biomedical Research, Paediatric Emergency Medicine, Prehospital Care and Resuscitation among many others. June 27 – 30, 2012 www.icem2012.org
EuSEM 2012 // Antalya, Turkey The 7th European Congress on Emergency Medicine October 3 – 6, 2012 www.eusem.org
The American College of Emergency Physicians Scientific Assembly // Colorado, United States
Email for abstract submission: firstname.lastname@example.org March 13-14, 2012 www.kldltd.co.il
The annual meeting of the largest emergency medicine society in the world October 8 – 1, 2012 www.acep.org/sa
32nd International Symposium on Intensive Care and Emergency Medicine // Brussels, Belgium
Pan-Pacific Emergency Medicine Congress 2012 (PEMC 2012) // Seoul, Korea
March 20-23, 2012 www.intensive.org
The Inter-American Emergency Medicine Conference // Buenos Aires, Argentina This collaboration with the American Academy of Emergency Medicine (AAEM) consists of three days of lectures as well as a range of pre-conference workshops. May 16 – 18, 2012 International-em.org
The Korean Society of Emergency Medicine (KSEM) will host a joint meeting between the American Academy of Emergency Medicine (AAEM) and KSEM. October 23 – 26, 2012 www.pemc2012.org
3rd EurAsian Congress on Emergency Medicine // Antalya, Turkey Co-Organizers: Emergency Medicine Association of Turkey (EMAT), SUNYDownState, Singapore Society for Emergency Medicine (SSEM) September 19 – 22, 2012
In This Issue www.epijournal.com
03 | Editor’s Desk 08 | Relief Pediatric emergencies in Somalia 09 | Policy Terry Mulligan reports from the UN
Source 10 | Dispatches Who is doing development work in Africa? How can you get involved? 11 | Bahrain How the recent imprisonment of Bahraini physicians points to a critical disconnect between medical workers and national medical leadership. 12 | Turkey Government reform has brought positive change in the Eurasian medical establishment. 13 | Tanzania The East African nation’s first ED could become a center for EM education
Reports 14 | African EM Research SAEM’s Adam Levine reviews three practice-changing studies from across Africa 15 | A Swede in Botswana A Scandinavian EP working in Botswana witnesses firsthand the rise of evidence-based emergency medicine in southern Africa. 16 | EM Development in Ethiopia An in-depth dossier on EM development in one of Africa’s more troubled healthcare systems. 19 | IEM Fellowship Directory
L i s t yo u r n e x t i n t e r n at i o n a l e v e n t f o r f r e e o n t h e E P I N e t w o r k – www. e p i j o u r n a l .c o m 6
November 2011 // Emergency Physicians International
22 | Grand Rounds Peter Cameron on the problem with “efficient” emergency medicine
The 1st Global Network Conference on Emergency Medicine Dubai International Convention and Exhibition Centre, Dubai, UAE
13 â€“ 17 January 2012
Pre-Conference Workshops Friday 13th January Pre-Conference Courses WS 1 09:00 - 18:00
Saturday 14th January Pre-Conference Courses WS 4 Metabolic
WS 1 Ultrasound
Main Conference Sunday 15th January Conference Track 1 09:00 - 12:30 Intensive Care
Tuesday 17th January Conference
13:00 - 14:00 14:00 - 18:00
Monday 16th January Conference
Lunch Break Disaster Medicine
Lunch Break To Be Confirmed
Prof. Abdelouahab Bellou,
President of the European Society for Emergency Medicine Endorsed by:
Pediatric Emergencies in Galgaduud
u Malnutrition rates are very
high in large parts of south and central Somalia, but the ongoing conflict makes it difficult for international organizations like Doctors Without Borders/Médecins Sans Frontières (MSF) to operate at full capacity. Where MSF can work, our doctors face immense pressure due to the large numbers of people who need emergency assistance.
’m in charge of the pediatric department, where I deal with newborns and children up to the age of 14. Our main focus at the moment is the large number of malnourished children coming to us. The children we’re treating are severely sick. [Today] it’s only 3pm and we’ve already admitted 70 children. These are children who are so ill that they can’t even take medicine on their own. In our outpatient department, we are receiving a lot of patients. Before the droughts, less than 20 percent of our patients were malnourished, but now the number is closer to 50 percent. With malnourishment, come all manner of other diseases. Many of these children are suffering from watery diarrhea and pneumonia. We’re also seeing other problems and complications such as measles and renal and heart problems. For children whose condition is critical and a second medical opinion is necessary, we use telemedicine technology to connect with a pediatric specialist based in Nairobi. We have been holding real-time medical consultations between Guri El and Nairobi since last December. So far the results have been positive. A lot of the children we’re treating are very young, of breastfeeding age. Breast milk contains vital antibodies that babies need to fight off infection, and without it, they’re left defenceless. But we’re in a situation where mothers themselves have nothing to eat and, as a result, are not producing milk. This means children aren’t being breastfed and are left vulnerable. We’re seeing the results of this on a daily basis. Let me tell you about one patient we’re currently treating: Sevenyear-old Bishaaro was brought to us in a very bad state. She was weak and had ulcers all across her body, which were all infected. She also
November 2011 // Emergency Physicians International
Dr. Faiza Adan Abdirahman is the medical doctor in charge of the pediatric department at Istarlin hospital in Galgaduud, where MSF has been working since January 2006. She spoke by phone on August 30: had liver problems, was severely anemic and, after we ran some tests, we found she also had kala azar, which is a tropical disease transmitted by sandflies that is deadly if left untreated. We started treating her immediately, giving her medicine and a blood transfusion. But then she started bleeding from her nose and her mouth. She lost so much blood that we had to give her a second blood transfusion. Bishaaro is getting better now and her bleeding stopped. We all have high hopes that she’ll recover fully and go home soon. We’re facing a lot of challenges here at the moment, so many, in fact, that we’d probably be here all day if I listed them all. We have parents who are opting for traditional medicine when their children fall ill, with traditional doctors burning and cutting the children’s skin in an attempt to heal them. These wounds get infected and, as these children’s defences haven’t fully developed, they either die or come to us in terrible shape with all sorts of infections. We have parents taking away their children before they complete their treatment, and then returning them to us when their condition has deteriorated even further. Most of all, space is the biggest issue. We’re currently treating the largest number of patients at the hospital since I’ve been working here, and space is at a premium. We are over capacity and are constantly working out ways of keeping malnourished patients apart from those suffering from TB or measles. Putting them together is simply not an option. Despite all these major challenges, lives are being saved and we are able to assist these children, many of whom would have died.
Space is the biggest issue. We are over capacity and are constantly working out ways of keeping malnourished patients apart from those suffering from TB or measles. Putting them together is simply not an option.
The prognosis is grim. According to the WHO, deaths from NCDs will increase by 17% in the next decade.” -ban ki-moon
What about emergency medicine, trauma and acute care?
U.N. Puts NCDs On the Map Positive effort by United Nations to curb noncommunicable diseases falls short of setting targets and fails to address global emergency medicine development issues. by terry mulligan, md
n September 19-20, 2011, the United Nations held a global summit that took an important step towards addressing non-communicable diseases (NCDs) such as cancer, heart disease, lung disease and diabetes. The summit was devoted to curbing, preventing, recognizing and treating these often-preventable problems that cause 63% of deaths worldwide. The two-day general assembly meeting, attended by more than 30 heads of state and at least 100 other senior ministers and experts, adopted a declaration calling for a multipronged campaign by governments, industry and civil society. The plans address the need to curb the risk factors behind four major groups of NCDs – cardiovascular diseases, cancers, chronic respiratory diseases and diabetes – by the year 2013. Secretary-General Ban Ki-moon noted that over a quarter of all people who die from NCDs succumb in the prime of their lives, the vast majority of them in developing countries. The overall annual death toll from NCDs is estimated at 36 million worldwide. “Cancer, diabetes, and heart diseases are no
longer the diseases of the wealthy,” said Ban Ki-moon. “Today, they hamper the people and the economies of the poorest populations even more than infectious diseases. This represents a public health emergency in slow motion. “The prognosis is grim,” he continued. “According to the World Health Organization (WHO), deaths from NCDs will increase by 17 per cent in the next decade. In Africa, that number will jump by 24 percent.” Noting that “the rising prevalence, morbidity and mortality” of NCDs can be largely prevented and controlled through collective and multi-sectoral action by all member states and other relevant stakeholders, the NCD declaration highlights the need for universal national health coverage and strengthened international cooperation to provide technical assistance and capacity-building to developing countries. “This will be a massive effort, but I am convinced we can succeed,” Secretary-General Ban Ki-moon told the opening session of the landmark summit, only the second ever to deal with health (the first was HIV/AIDS in 2001).
This historic meeting brought together many national and international organizations. Most prominent was the NCD Alliance (ncdalliance.org), an organization of four international federations uniting a network of over 2000 organizations. These four organizations, namely the International Diabetes Foundation, the World Heart Federation, the Union for International Cancer Control, and the International Union Against Tuberculosis and Lung Disease, represent the four main NCDs outlined in the World Health Organization’s 2008-2013 Action Plan for NCDs – cardiovascular disease, diabetes, cancer, and chronic respiratory disease. These conditions share common risk factors (including tobacco use, physical inactivity and unhealthy diets) and also share common solutions, which provide a mutual platform for collaboration and joint advocacy. Absent from the UN meeting were any major national or international organizations representing trauma and injury, or emergency medicine. Largely unnoticed in Europe and North America, trauma has become a rapidly expanding epidemic in the world’s low and middle-income countries. Every 5 seconds someone in the world dies as a result of an injury. In fact, injuries kill about 5.8 million people each year, more than malaria, tuberculosis and HIV/AIDS combined. Tens of millions more suffer injuries that lead to hospitalization, emergency treatment or other care. Among the causes of injury are acts of violence, traffic accidents, burns, drowning, falls and poisoning. Currently, trauma from road-traffic accidents alone is the 6th most common cause of death in middle-income countries, and 9th in the world. Many countries are experiencing a rapid fiscal growth and with it expansion of their infrastructures. The increase in personal wealth means, for many, a graduation from foot or bicycle transport to motorcycles and automobiles. Sadly, this is also reflected in a commensurate increase in road-traffic injury rates. The WHO estimates that by 2030 trauma from traffic accidents alone will be the 3rd most common cause worldwide of both mortality and disability (as measured in disability-adjusted life years, or DALYs), and the majority of these accidents will happen in lower/ middle-income countries, precisely those areas with the least developed emergency care and trauma systems. Although a declaration adopted at the UN Summit laid out the economic and social importance of eradicating chronic disease, it fell short in two ways. It failed to address trauma systems and emergency care systems, and it did not provide concrete targets. Instead, the political declaration included suggestions, such as promoting healthier diets, tobacco-free workplaces, access to cancer screening programs, and breast-feeding for about six months from birth. In addition, further attention needs to be paid to trauma morbidity and mortality, to the establishment of trauma and emergency care systems, and to the role of emergency medicine and acute care as the safety net for acute and chronic presentations of non-communicable diseases and communicable diseases from all categories. While major benefits will result from attention to primary prevention of the vertically integrated five major areas of NCDs, global health policy makers need to also focus on secondary prevention of NCDs by a horizontally integrated emergency medicine and acute care systems. www.epijournal.com
Teaching in the following locations: JFK Hospital Redemption and Phebe hospitals in Liberia; Korlebu in Ghana; Addis Abada. I’m the ACEP lead ambassador to Ghana and Liberia. Kathryn Challoner USA
If you are currently involved in EM development in Africa, where are you involved? What work are you doing?
SOURCE // DISPATCHES READER-SUBMITTED UPDATES FROM THE EPI NETWORK Pending project in Gabon with U.S. military Robert Suter USA
If you have worked in EM development in Africa in the past, briefly describe a project in which you took part.
Participated in a faithbased group that goes 4 times a year and runs a clinic in Ethiopia. Clinic is set up with few EPs, ophthalmology and optometrist, dentistry and pediatrics. Jose Muniz Puerto rico
I am involved in EM developement in Nigeria. I started the first EMS in the country and started the first CPR training for health care providers in 1992. This led me to bring in AHA programs in 2003 and became the ITC coordinator. I have trained over 4000 doctors and nurses in BLS, ACLS, and PALS. Nnamdi Nwauwa NIGERIA
I’ve worked in East Africa (Rwanda) before, know the healthcare system, and speaks English and French. Dan Brun Petersen denmark
Worked with Global Emergency Care Skills, a non-profit voluntary organisation that has run five training programmes in East Africa, from Nairobi’s Mater Hospital to Lusaka University Teaching Hospital in Zambia and the Queen Elizabeth University Hospital in Blantyre, Malawi. The most recent course was held in Muhimbili University Hospital in Dar Es Salaam, Tanzania. Jean O’Sullivan ireland
My big interest is flow and triage. From what I hear, poor people still die in the waiting rooms because there often is no triage and the stronger/richer gets ahead of the cue. Triage tools could be translated and developed to suit the environment. Stefan Bodetoft SWEDEN
If you would be interested in working in EM development in Africa, where would you be interested in plugging in, and in what capacity?
Providing advisory and consultancy services for development and organisation of emergency care services and education. V. Anantharaman SINGAPORE
Happy to go most places in sub Saharan Africa, especially: Madagascar, Zambia, Zimbabwe, South Africa, Gabon, Rwanda, Tanzania, Malawi, DRC, Ethiopia. Justin Venable NEW ZEALAND
Mozambique, Southerrn/East Africa developing emergency services/ womans health UK
International Emergency Department Leadership Institute 24-28 October, 2011 Boston, Massachusetts, USA As the number of interdisciplinary emergency departments grows internationally, where can ED leaders acquire the administrative skills they need to build and sustain successful emergency departments? The International Emergency Department Leadership Institute (IEDLI) was created by Harvard Medical School faculty and other international experts in order to provide ED leaders with the skills and knowledge they need to successfully operate emergency departments in any part of the world. In this one-week course of over 35 hours of interactive lectures and workshops, leaders will explore strategies to: • Establish the ED’s role within the hospital • Improve efficiency and control costs • Decrease overcrowding • Develop quality improvement programs • Educate and motivate ED doctors and nurses • Develop an emergency medicine training program • Form a strong administrative structure This program is designed for doctors, nurses and administrators.
November 2011 // Emergency Physicians International
International Emergency Department Leadership Institute
Save the date: IEDLI 2012 October 22-26 Leuven, Belgium www.IEDLI.org The International Emergency Department Leadership Institute is a collaboration between Harvard Medical Faculty Physicians at BIDMC and Brigham and Women’s Hospital.
How the recent imprisonment of Bahraini physicians points to a critical disconnect between medical workers and national medical leadership by dr. mohamed al-asfoor
n September, twenty Bahraini doctors, nurses and paramedics were sentenced before a military court to up to 15 years in prison. These sentences, which were immediately decried by the global human rights community, came after six months of unlawful imprisonment and many well-documented abuses. “It is unlike anything that I have seen in my 20 years of investigating human rights and violations of medical neutrality,” said Richard Sollom of Physicians for Human Rights (PHR) in an interview with CNN. “The type of abuses that are actually occurring are serial, are so horrific and so wide spread and systematic.” Charges against the doctors included possession of unlicensed weapons, inciting the overthrow of the government, provoking sectarian hatred and forceful occupation of a public building, officials said. Prosecutors have alleged that, at the height of the protests earlier this year, the accused medical personnel refused to help patients at Salmaniya Medical Complex, the main hospital in the capital city, Manama. But the international community has seen these statements as the attempts of the Bahraini government to abuse power and circumvent the justice system. “These are simply ludicrous charges against civilian professionals who were working to save lives amid very trying circumstances,” said Philip Luther of Amnesty International As a specialist in emergency and disaster medicine who worked at Salmaniya Medical Complex (SMC) for more than 13 years, I’ve known many of those physicians, nurses and paramedics who witnessed these events first hand. I listened as one doctor described how he was abducted by armed, masked and unidentified military and police personnel
from the operating theater without any arrest permit. He was dragged barefoot, handcuffed to the back, blindfolded, in front of his colleagues and staff. The armed abductors broke in to his office where they started torturing him and confiscating his computer and belongings. Then they dragged him throughout the corridors of the hospital, and to the overnight stay doctors’ hostel looking for other colleagues to be arrested. I also heard from a medic who described how he was tortured physically and abused verbally. All were blindfolded and handcuffed. They were interrogated and continually threatened with death and sexual assault. They were not allowed to contact their families or their lawyers nor were they offered any lawyer from the police side. But these false imprisonments and abuses of power are only part of the story – the part that makes international headlines. They also tell of deep, systemic problems relating to emergency and disaster management in this small yet important country in the Persian Gulf. Before we get to the mistakes made by the medical establishment, we have to step back to last February, to the massive series of protests that, according to CNN, may have amassed as many as 600,000 people. People came out into the streets, united at first in a desire for reforms. But when some peaceful protesters were killed, the crowds swelled and the desire changed to a complete change of power. What followed was a massive crackdown on protesters by the government, resulting in more than 40 deaths and hundreds of injuries. Thousands were dismissed from work. The professional societies were shut off, and their presidents were or still arrested and sentenced to long term of imprisonment. The Bahrain Medical Society and the Bahrain Teachers Society were first to suffer.
Life expectancy Men: 73 Women: 76
probability of dying before age 1 9 per 1,000 live births
Total expenditure on health per capita $1,557 (international dollars, 2009)
Total expenditure on health as percent of GDP
The medical body found itself trapped between escaping protesters from tear gas, ballets guns and live ammunitions, seeking shelters in the main hospital premises and car park area and a government wishing to end any means of protests quickly, no matter how harsh it can be with complete media and news blockage. At this point, the health ministry began making a series of mistakes that were indicative of a lack of disaster planning and qualified disaster personnel. The first mistake was that the minister of health denied the emergent state of the situation. As he reported to the media about few casualties (around 7), the hospital was flooded with literally hundreds – as many as 700 casualties reported within a short period. Many casualties were from tear gas, ballets guns and rubber bullets as well as live ammunitions-related injuries. Also at some point ambulances were prevented from going out to reach outside emergency calls. This resulted in the frustration of the medical staff and caused a worsening of the already bad situation. The medical staff felt betrayed by a minister whom they expected to provide support. I was personally informed by in-hospital physicians and nurses who were desperate, overwhelmed and unable to cope with situation, even days after. The second mistake was that the media started a campaign against doctors and other medics, characterizing them by their sects and ethnicity. This directly created fear in some patients and prevented medical staff from carrying out their duties. This move of using sectarian language to divide people only exacerbated the chaos in the country, and resulted in the birth of the strongly progovernment party. The third major mistake was the military occupation of the only secondary and tertiary government hospital. This act, which was clearly filmed and reported by many news channels, brings us back to the initial story. The occupation is what led to the arrest and abduction of injured patients and their doctors, nurses and paramedics. There were reports of torture and the deprivation of human rights. The doctors and other staff were prevented from leaving or entering the hospital for some time, essentially held hostage on their wards. Checkpoints were set in each ward. I still recall my conversation www.epijournal.com
over the phone with one of the doctors who seemed terrified at the time the army entered the hospital. He was slapped and pushed and his room was searched by police dogs. Some of the individual physicians concerned have detailed their testimonies on their own words in the web site www.doctorsinchains.org. The website was originally set up by MedWorm which is a medical website that has decided to support a campaign for Bahrain doctors. It is now run by a group of medical professionals from across different countries outside of Bahrain, who all feel the need to speak out in solidarity against the way these doctors have been treated. How did a series of well-intentioned protests end up with government occupied hospitals? The problems are deeply rooted in Bahrain and they are an accumulation of mistakes and corruptions, with no simple answer. The health authority and the government are the ones who should have to answer for all of this. The bottom line from a disaster preparedness standpoint is that if you are not prepared with a plan, a mass medical emergency can quickly go from manageable to being an unmitigated disaster. Thanks in part to pressure from the international community, there will be a retrial for the detained medics. But the process is still unclear and no one really knows exactly how or where it will take place. On October 23, before a civilian court, the public prosecutor asked the court to drop all confessions taken from the twenty medics, saying they were taken under torture. Whatever the result of this retrial, the health care situation in Bahrain will remain fragile and vulnerable. Many doctors have been dismissed from work while others left the country and applied for asylum abroad. These days the situation is still far from quiet in Bahrain; nightly protests take place in the villages, cities and the periphery of the capital. Protesters are injured daily but remain unable to go to hospitals for fear of detention, given the militarized state of the hospitals. Instead, most are treated in home clinics. For a positive resolution, there will need to be a clear article in the constitution regarding the right of all patients and injured to have unrestricted access to emergency medical care and there will need to be a clear and effective disaster plan. Doctors should never be prevented from their work in treating patients. This all is achievable through freedom and real democracy, and will ultimately benefit all people.
Recent government interest has led to an expansion of family practice and improved highway safety. by arif alper cevic, md
Traffic in Istanbul. Vast improvements in highway infrastructure have significantly decreased the number of motor vehicle accident deaths in Turkey.
November 2011 // Emergency Physicians International
ince 2002, one of the major subjects of the Turkish government has been the implementation of a more individualized health care system. In surveys, the public constantly mentions health as the government’s most important success. The new system enjoys such strong public support that it may help the leading party to garner at least 50% of the vote in Turkey’s 2011 election. There are very few countries that have done what Turkey has in terms of healthcare, and it has a direct relationship to voting. During the past eight years, the government has essentially moved toward a personoriented, equally-shared healthcare system. The government ended restrictions on the pharmaceutical markets, allowed the public to use their state benefits at private and university hospitals, and has provided “Green Cards” guaranteeing free treatment to more than 9 million low earners. The national network of family doctors has expanded to the point that there is now one for every 3,500 citizens. The family doctors are catching conditions like diabetes and obesity earlier, treating minor problems, and referring only more serious cases to hospitals. This helps to ensure that patients are treated more cheaply than hospitals, according to a government budget watchdog’s 2009 report. In addition to streamlining general health care management, an initiative to formalize emergency department management was declared in 2009, effectively strengthening the emergency medicine (EM) specialty
compared to its previous status. It is believed that a party leader was motivated to make these changes after he was transferred from hospital to hospital following a car accident in the late 1980s. The same leader is also an anti-smoking advocate, and cigarettes are banned from restaurants and bars. National highway regulations were also revised, improving highway capacity and infrastructure in all regions with strict speed and safety enforcements. It is difficult to evaluate the short-term effects of cigarette regulations, but highway regulation has significantly decreased the number of deaths from traffic accidents. All of these strategies have had a positive cumulative effect on Turkey’s health, success that should be shared with other countries. Because of its geographical location, collaborating with neighboring countries on healthcare infrastructure is an important potential initiative for Turkey. Although medical tourists can enjoy high quality specialty care in Turkey, sharing successful healthcare strategies with neighbors and old Ottoman nations will require real effort and non-governmental organization (NGO) support. Today, there are 450 EM specialists and 700 trainees in EM residency programs in Turkey. These numbers are insufficient for staffing its EM departments (>1,200) but they symbolize a turning point for Turkish EM. Two big national specialty NGOs, EMAT and EPAT, are working to improve EM. Over the pat 16 years EMAT has been the leading organization of Turkish EM since the specialty officially existed, especially with regards to forging friendships and collaborating with other international NGOs. EMAT has helped clarify the EM needs of Turkey and guided the processes involved. There is still much room for development. EMAT recently became a member of the Asian Society for Emergency Medicine. Collaborating with Asian Countries and learning from their experiences will surely create great benefit for Turkish EM, and will provide an opportunity for Turkey to share the success of its own health strategies in EM.
The East African nation’s first emergency department could become a center for EM education by renatus tarimo
he United Republic of Tanzania is an East African country with a population of 43 million people, more than 70% of whom live in rural areas. The Tanzanian public health system is a pyramidal referral system with a broad base of dispensaries that refer up through heath centers, district and regional hospitals, and ultimately to tertiary urban-based consultant hospitals. Muhimbili National Hospital is one of four such referral hospitals, and is located in Dar es Salaam, Tanzania’s largest city. Prior to 2010, patients arriving at Muhimbili were received in a casualty area staffed with rotating personnel with no dedicated emergency care training. Initial resuscitation and stabilization were often delayed and treatment was inconsistent as there were no formal protocols to direct management. Specialist medical or surgical interventions were also delayed and there was high mortality among critically ill patients. In 2010, in a joint effort of the Tanzania Ministry of Health and Social Welfare, Muhimbili National Hospital, and the Abbott Fund-Tanzania, a dedicated full-service emergency department (ED) was opened at Muhimbili National Hospital and is the first
& teri reynolds
ED in Tanzania. Facilities include treatment and resuscitation rooms with critical care capacity including cardiac monitoring and ventilator support. In the first 12 months of operation the department served over 35,000 patients with an average of 100 patients per day. Patients are mostly referred from other hospitals, but may also be “referred” by the police, as in the case of acute trauma. The number one patient condition at the ED overall is trauma, and respiratory illnesses are the most common medical complaint seen. The approximate admission rate is 78 percent. The key to the department’s success so far has been the dedication to specialized training and growing the department’s own training capacity. Throughout the planning and early operations of the department, board-certified emergency physicians from abroad acted as technical advisors, providing training and advice on operations. The advisors supported the establishment of treatment protocols and a training curriculum for the department, and created a supportive teaching environment in the ED. Currently, visiting nurse mentors specialized in emergency medicine, senior emergency residents, and emergency medicine faculty, provide clinical teaching throughout
Muhimbili registrar Magdalena Mbeyale intubates a trauma patient. Trauma is the top reason for a visit to the Muhimbili National Hospital emergency department.
Live in rural areas
Life expectancy Men: 53 Women: 58
Probability of dying under age 5 108 per 1,000 live births
Total expenditure on health per capita $68 (international dollars, 2009)
Total expenditure on health as percent of GDP
the year on a monthly rotating basis. Local ED personnel are now beginning to take over this training, as new generations of providers arrive. The academic field of emergency medicine is new to Tanzania and East Africa. The ED was opened with dedicated nurse and registrar physician staffing, as there were no emergency specialists in Tanzania. Less than a year later, in order to ensure the sustainability of emergency medicine in Tanzania, the first emergency medicine residency in Tanzania was established at the affiliated Muhimbili University of Health and Allied Sciences (MUHAS) and based in the ED. The first class of eight residents began in October 2010 and is expected to complete the 3-year program in 2013. The seven residents of the class of 2014 began in October 2011. The residency is run by MUHAS and the clinical teaching is supported by a unique academic consortium of five institutions, the University of Cape Town South Africa, the University of California San Francisco, Carolinas Medical Center, the University of Chicago and the University of Maryland. The academic consortium members collaborate to provide materials to support the MUHAS curriculum, and provide clinical faculty to support the residency program. Crucial to the success of the project has been engagement throughout with the Tanzanian Ministry of Health, who have embraced the ED and integrated it into larger national plans for the dissemination of emergency care. Trainees within the ED have established the Emergency Medicine Association of Tanzania (EMAT), a professional organization for emergency providers of all cadres. EMAT has been ratified by the Ministry of Health and this organization has allowed emergency personnel to participate in activities such as national and international sporting events, international meetings, and public health outreach programs. EMAT’s current projects include the development of dedicated, regionallyappropriate basic and advanced emergency care training programs for a variety of clinic, hospital and pre-hospital providers. In 2012, the ED and the residency will continue working to advocate for the development of emergency care in Tanzania, as well as to integrate with other African emergency care initiatives. Main areas of focus within the ED are standardizing care and training in the department and conducting research to establish best practices. www.epijournal.com
R Report Global Lit Review
Abstracts from Africa by Adam C. Levine, MD, MPH on behalf of the Global Medical Literature Review Group
South Africa_Validation of weight estimation by age and length based methods in the Western Cape, South Africa
research we hope to see more of in developing countries in that it is cost-effective, easily implementable, and can have widespread impact.
Geduld H, Hodkinson PW, Wallis LA. Validation of weight estimation by age and length based methods in the Western Cape, South Africa population. Emerg Med J. 2010.
Kenya_A novel ED-based sexual assault centre in western Kenya
any different methods of weight estimation exist for pediatric resuscitation, including the Broselow tape, the Advanced Pediatric Life Support formula, the Best Guess, and the Luscombe and Owens formula. These formulas are frequently geographically or ethnically specific and therefore may vary in how well they predict weight depending on the region. In this study, the authors assessed which method is most accurate for their population of South African children. They prospectively enrolled patients between 1 and 10 years of age that presented to the Red Cross War Memorial Children’s Hospital in Cape Town. A Bland-Altman analysis was performed to compare the four different weight estimations. Outcome measures were fit - a predicted weight within 10% of the measured weight – and mean percentage error – how much the estimate deviated from the measured weight. They enrolled 2832 patients during a nine-month period. The Broselow tape emerged as the best estimator of their population (64.2% of estimates were within 10% of the measures weight and the mean percentage error was the smallest at 0.89%). This study answers a simple question that is a current focus of international EM research: Can we apply developed world tools to developing world populations? Geduld, et al. demonstrate that weight estimations can be applied to developing countries, but should be validated for the region. Strengths of the study include its large sample size and utilization of a generalizable measure of fit, which allows for easy comparison to age-matched controls in other studies conducted in the US, India, and Hong Kong. A desirable addition would have been a graph with the breakdown of ethnicity and socioeconomic status of the study population. This would have potentially allowed other African nations to apply the Western Cape data to their own population rather than conducting another study. In general, this study is exemplary of
Ranney M, Rennert-May E, Spitzer R, Chitai M.A., Mamlin S.E., Mabeya H. A novel ED-based sexual assault centre in western Kenya: description of patients and analysis of treatment patterns. Emergency Medicine J. 2010.
n sub-Saharan Africa, sexual assault and violence remains a major health issue. In this study, an EDbased sexual assault center was established to study the demographics of sexual assault in Western Kenya, and to assess whether newly established protocols could provide HIV prophylaxis, STI treatment and emergency contraception (EC) at rates similar to those in high-income countries. Thirteen months after implementing the new protocols, the Centre for Assault Recovery-Eldoret (CAR-E) conducted a retrospective study of the demographic, assault, and treatment characteristics of the patient population served. Over 300 patients were seen at the clinic, with 94% being female. Mean age was 15.9 years, with 50% under the age of 15. Overall, 89% of patients received testing for HIV, 80% for syphilis, and 73% for pregnancy. The study also found relatively high rates of STI prophylaxis (84%), HIV prophylaxis (63%) and EC (70%) for eligible patients treated at the center. Only 43% of the assaults were reported to the police, and only 44% of patients received counseling, which were both lower than expected. Sexual assault is common in sub-Saharan Africa, with Kenya being one of the few countries where sexual violence is against the law. This study shows that a community focused, ED-based sexual assault center is not only feasible, but can provide effective diagnosis and treatment for patients in a low-income country without the addition of significant external resources. Post-sexual assault counseling is likely to be the most difficult component of the CAR-E sexual assault assessment and treatment protocol to implement. This was the most resource-intensive component of their
protocol and implementation was limited by lack of availability of trained counselors, especially after hours. However, despite the low level of post-assault counseling or police reporting, the study highlights that with a little education and concentrated effort, effective diagnosis and treatment for victims of sexual violence can be provided in a resource-limited setting. -AL, SK
Kenya_Mortality and health among internally displaced persons Feikin DR, Adazu K, Obor D, Ogwang S, Vulule J, Hamel MJ, Laserson K. Mortality and health among internally displaced persons. Bulletin of the World Health Organization. 2010; 88(8):601-8.
eikin et al. conducted this cohort study among people displaced by the post-election violence in Kenya in 2008. The authors used demographic surveillance survey data to classify recent arrivals to the study area as internally displaced persons (IDPs). Morbidity and mortality between the local and IDP populations were compared. The authors found that IDP children < 5 years of age were 2.95 times more likely to be hospitalized than local children (RR, 95% CI: 2.44-3.58), but had equivalent mortality rates. They also found that almost twice as many of the deaths due to HIV that occurred among those age 5 years or older were IDPs compared to non-IDPs (53% versus 25-29%, p<0.001). The authors leveraged an existing demographic surveillance system to identify a population of IDPs and then compared them to the pre-existing local population. Although this method may have incorrectly identified as IDPs some recent arrivals who were not displaced by the post-election violence, this overestimation was likely small. The findings of this study are consistent with previous research that has shown that IDPs are often a vulnerable group – in this case evidenced by more severe presentation of childhood illness and disproportionate mortality due to HIV among individuals over age 5. Nevertheless, this study does give hope by showing that with appropriate treatment, excess mortality can be avoided among internally displaced children less than 5 years of age. -AL, KL
AL: Adam Levine, MD, MPH; SK: Sampsa Kiuru, MD; KL: Kevin Lunney, MD; EG: Elizabeth Goldberg, MD
November 2011 // Emergency Physicians International
R Report / Botswana Botswana
EM Takes Its Place in Gaborone A Scandinavian EP working in Botswana witnesses firsthand the rise of evidence-based emergency medicine in southern Africa. by Katrin Hruska, MD
ome things are the same everywhere. Airway comes first, then breathing, circulation, disability and exposure – the latter two sometimes replaced by “Don’t Ever Forget Glucose” and a laugh. I got to appreciate the universal nature of the EM alphabet first hand when I traveled from Sweden to Botswana to practice emergency medicine this year. More and more, we’re all beginning to speak the same language; and a common language sure facilitates communication. In Sweden, where the model has been for different specialties to handle their own emergencies, it has been hard to explain how one specialty could integrate that knowledge and increase the quality of care. As a result, as an emergency physician you are constantly explaining and defending the specialty. For a new perspective, I wanted to travel somewhere where emergency medicine was already established. I considered several countries, but somehow, I ended up working in Botswana, where the development of emergency medicine as a specialty has only just begun. Botswana is an upper middle income country, placed in the same economic class as Romania, Turkey and Argentina by the World Bank. Eighty percent of health expenditures are provided by the government and primary care is widely available. In the past, due to its population of less than two million, Botswana has sent students abroad for medical studies. Starting three years ago, however, the medical school in Botswana accepted its first students. Just like in Sweden, higher education is free. Here the students even get housing and a small allowance. One of the students I talked to was the youngest of ten siblings, and neither parent had been to university, which to me is an impressive indication that higher education is open to everyone. In Botswana a doctor is simply a doctor, or a medical officer (MO as they are called here). After a year of internship they are expected to be able to work wherever the government assigns them. There is, of course, some element of choice, but in the end it is up to the Ministry of Health to decide. Specialists have mostly been recruited from abroad and the few Batswana specialists have all trained abroad. That all is beginning to change. Emergency medicine is now one of six residency programs available in Botswana and three first year residents are training in the Princess Marina Hospital in Gaborone, the capital of Botswana. In some ways the emergency medicine pathway is easier in Botswana than in Sweden. In many Swedish university hospitals you have to do rotations in different clinics, such as gynecology, ENT and pediatrics, to cover the whole emergency department. There you will be supervised by the respective specialist, who rarely understands the scope of emergency medicine. To establish emergency medicine as a specialty
in Sweden (as well as in many European countries with similar systems) it does not suffice to increase the competence of the doctors in the emergency departments. All the emergency departments have to be reorganized, which of course involves transferring resources from other departments. That battle does not have to be fought here in Botswana where the MOs in the emergency department see the unsorted acutely ill patients of all ages. What they lack is specialists to oversee the care given to patients. Currently, there are three foreign emergency medicine specialists in Bostwana to train these future specialists. The curriculum is based on the South African curriculum and very similar to ones from Europe. The residents are taught evidence-based emergency medicine in the same manner as most of their colleagues around the world. Herein lies one of the great training challenges. There is precious little evidence currently available regarding common ED diagnoses in a black African population, particularly when a quarter of the adult population is HIV positive. The launch of the African Journal of Emergency Medicine this summer was a great step in creating this evidence. Emergency medicine is about more than producing competent emergency physicians, though. It is about developing systems where an adequate amount of time and resources is spent on each individual while making sure that urgent care is not withheld from any patient within the department. Time wasted on unnecessary interventions on one patient could end up harming another patient. This requires good management on the floor and teamwork from nurses and doctors. Creating that system in Botswana is not easy, partially because of cultural norms – doctors, nurses, even patients have an amazing acceptance for malfunctioning equipment and lacking supplies. The major challenge for our future colleagues here will be to establish patient processes that involve all levels of staff and ensure a systematic approach to all major patient categories. Each day that I practice here I am reminded of – and instructed by – the distinct cultural differences between Sweden and Botswana. In Botswana it is the disease that kills the patient, not the inadequate interventions by the doctor. No one here demands you prove that a common cold is not a pulmonary embolism or five minutes of chest discomfort a threatening acute coronary syndrome. It makes me realize just how much of our workup in Sweden merely serves to comfort either the doctor or the patient, and how our impatience brings these investigations to the emergency departments instead of the outpatient setting of primary care. We take full responsibility for the patients medical condition, leaving very little up to the patient, except to place the blame on us if we fail.
Batswana emergency nurses outside of the A&E department in Gaborone.
No one here demands you prove that a common cold is not a pulmonary embolism. . . It makes me realize just how much of our workup in Sweden merely serves to comfort either the doctor or the patient.
ID In-Depth / Ethiopia
Challenge, Progress & Possibilities An in-depth dossier on emergency medicine development in Ethiopia
by Fikre Germa, MD, FCFP; Tesfaye Bayleyegn, MD; Kidist Barolomios, MPH; Tsegazeab Kebede, MD; Jim Ducharme MD CM FRCP
he health care needs of Ethiopia are immense and complicated. This ancient country situated in the horn of Africa is home to over 80 million people (Table 1), most of whom are impoverished and live in rural settings. The population is growing rapidly and targeted to exceed 100+ million by 2020. Complicating matters further is the fact that the communicable diseases most associated with poverty have been superseded by diseases of urbanization and economic development, such as cardiovascular diseases and vehicular trauma. Ethiopia has one of the highest road traffic crashes and fatality rates in Africa. An estimated 60% of the crashes occur in Addis Ababa, the nations capital city of 3.5 million residents. There are about 8,400 road traffic crashes annually, resulting in 1,800 fatalities and $2.1 million in property loss annually. Pedestrians are the highest proportion (81.5 per cent) of people involved in traffic accidents, followed by vehicle occupants (15.2 per cent) and drivers (3.3 per cent). Most traffic accidents in Addis Ababa involve people from 15 to 45 years of age.
Pre-hospital and Hospital EM in Addis Ababa, Ethiopia Addis Ababa has no organized EMS system. Critically injured or ill patients arrive at poorly equipped and disorganized emergency units through the Addis Ababa Red Cross (AARC) or an informal network of private cars and taxis that transport patients to hospitals. Private hospital ambulances operate on a strictly fee-for-service basis. There is no air ambulance service. In addition, there is no citywide designated emergency phone (i.e., a single 9-1-1 dispatch system). Each agency involved in emergency response has its own emergency number comprised of three to six digits. AARC has 10 ambulances and provides services via a 9-9-2 number, however, they can only run four per day due to a limited municipal budget. The AARC ambulances are equipped with a bed and basic supplies but do not have life support equipment and the staff have only minimal medical training. There is no standardized training or certification of emergency medical technicians (EMTs), and there is no communication between ambulance staff and receiving hospitals. In addition, there are no national or regional
guidelines for triage, patient delivery decisions or prehospital treatment plans.
The Public/Private Divide Government-run hospitals in Addis Ababa do not have designated emergency departments. Rather, there is usually a “receiving area” where both scheduled and emergency patients are seen. The lack of a designated ER makes it difficult to provide dedicated emergency care with appropriate triage protocols, rapid diagnosis and timely treatment. In most hospitals, each major department provides “receiving area” coverage for patients with scheduled or emergency outpatient visits. Triage can be provided by a general practitioner and a health assistant or a nurse on duty. Triage is rarely practiced by persons with the ability to recognize the early signs of life or limb threatening illness, therefore those who could benefit most from early intervention are often forced to wait while those who do not require immediate care are seen first. Often the hospital’s laboratory and radiology departments are far from the ED and many do not have the capacity or personnel to provide quick turnaround of requested tests. In many hospitals, the responsibility of transporting patients to tests, providing bedside non-medical care, such as feeding and toileting patients, falls almost exclusively on the patients’ families. In almost all of the public and private clinics and hospitals in Ethiopia, facilities and equipment for administering emergency care are inadequate. Even in hospitals that have dedicated space and staff for receiving acute care patients, basic equipment and medications are lacking. The receiving areas of even the best-equipped and best staffed public hospitals lack the human and material resources to care for a person in distress – often efforts to support airway function, provide sedative and pain medications, or rapidly diagnose such patients are impeded. Most hospitals lack the ability to provide fundamental cardiac care because of the lack of basic equipment such as ECG machines, cardiac monitors or even oxygen. There are 28 private hospitals in Addis Ababa with a total capacity of 925 beds. The city’s private hospitals offer services on a fixed fee basis. Some of these hospitals have ambulance services for inter-hospital transfer and can also be used to transport patients to the hospital. Emergency care is often not even initiated without a down payment so investigative and therapeutic procedures are often withheld until payment is received. Patients who lack sufficient funds are directed to seek care at government hospitals. Many for-profit (and
November 2011 // Emergency Physicians International
Table 1: Selected demography and Health Indicators in Ethiopia Population
Health service coverage
Infant mortality rate
67 per 1000
Child mortality rate (<5yr)
124 per 1000
Maternal death rate
7 per 1000
Life expectancy at birth
Source: Ethiopian Ministry of Health6
Table 2A: Addis Ababa Emergency Medicine Training Workshops, 1998-2007 Year
Days of Training
No. of Participants
even not-for-profit private hospitals) feel they lack both the personnel and resources to provide “open door” emergency treatment.
The Need to Strengthen Ethiopia’s EM Education Prior to the early 90s initiative, Ethiopia had no systematic program in place to improve the knowledge and practice of health professionals working in the emergency unit. In 1993 initiatives to introduce the concept of contemporary emergency medicine were started. In 1996, the first shock/resuscitation room with two beds and basic life support equipment was established in the Black Lion Hospital (BLH) outpatient surgical department. In 1998, the Addis Ababa Health Bureau (AAHB), in cooperation with interested local staff and Israel’s emergency medicine association, held the first emergency medicine workshop in Addis Ababa for 20 doctors and 10 nurses (see table 2A) selected from Addis Ababa hospital outpatient departments (including
university, Army and police hospitals). Since then, there have been several workshops aimed at improving initial triage and treatment. In Ethiopia, in some hospitals, general practitioners, nurses and /or residents affiliated to the university manage the emergency units. Undergraduate and postgraduate physician, nurse and other health care provider training lacks EM content. Physician training related to emergency medicine focuses on making the right diagnosis — not the principles of triage and emergency management. This does not prepare Ethiopia’s doctors for emergency department care where the most pressing requirement is sorting sick patients, and making appropriate triage and treatment decisions.
What Has Been Achieved So Far — What Challenges Lie Ahead In 1993, work to develop an Ethiopian EM system got underway, thanks to the local emergency medicine advocacy and the international community. The advocacy group faced many challenges, from getting buy-in from health care professionals to the high turnover among EM policy makers to the lack of acute care space in hospitals. But despite the challenges, great progress were made from 1993 to 2007. The country’s medical community embraced the EM concept and built on the foundation started in 1993. In 2001, AAHB, in collaboration with the World Health Organization (WHO) partnered with the people involved in the EM initiatives, instituted a trauma registry system in the emergency departments of six hospitals in Addis Ababa documenting close to 10,000 injury related emergency visits in one year. Given that injuries account for a quarter of outpatient ED visits, the pilot data collection demonstrated the feasibility of establishing such a system in hospitals. For several years, the Ethiopia North American Health Professional Association (ENAHPA) has engaged in dialogue with all stakeholders helping to develop emergency medicine infrastructure. In 2006, ENAHPA and the Addis Ababa Health Bureau organized and hosted an international stakeholders meeting in Addis Ababa with the goal of improving emergency medicine. Representatives from a cross-section of Ethiopian society, from local women’s groups to the WHO to the Clinton Foundation, attended the meeting. In addition to allowing interested parties to define their priorities and assets for developing a viable emergency medicine system in Ethiopia, it laid the basis for future collaborations. Also in 2006, Canadian and American universities’ faculties of emergency medicine and volunteer academic staff launched CME sessions in collaboration with the Ethiopian Medical Association (EMA). Since then, there have been large annual symposia, including an international EM symposium which was organized by the EMA and hosted physicians from Canada, the United States, Uganda, South Africa and Ethiopia. To date, over 600 Ethiopian physicians and nurses have attended EM symposia focused on leadership, prehospital care, basic and advanced life support, and the evaluation and treatment of minor and major trauma. These events also provided opportunities for attend-
Clarity of Vision Ethiopia needs a clear vision, an overall strategy and an action plan for developing sustainable EM. The action plan must include: + Disaster planning and care, and strategies for developing strong public/private partnerships to integrate biomedical engineering and research and telemedicine evaluation and quality assurance + Developing a pre-hospital care policy + Identifying the leading agency + Mandating the assignment of a medical director for pre-hospital care. + Assess and upgrade existing resources (emergency rooms, ambulances and communication system). ees to increase their awareness of Ethiopia’s need for emergency medicine. In addition to these national level symposia, there have been multiple CME initiatives which have focused on the transfer of appropriate technologies and updates in scientific and medical advances. These efforts provided key building blocks to establish an EM infrastructure in Ethiopia, specifically: Increased awareness among the Federal Ministry of Health, leaders in medical education and safety agencies such as fire departments, the Addis Ababa Red Cross and others about the need for an Ethiopian Emergency Medicine infrastructure; A team of consultants were engaged in developing the National Injury & disability plan and strategy for the ministry of health in Ethiopia in which a working document was submitted to the Federal Ministry of Health for approval. The completion of physical modifications at a few hospitals to accommodate room for critical ill or injured patients in ER; Publication of what has been accomplished to share findings with EM professionals in other countries; Initiation of CME programs in emergency medicine; and Launching of an EM residency program in AAUMF.
1 2 3 4 5 6
Ongoing efforts include: High-level support from MOH: Multiple programs led by Ethiopia’s Ministry of Health to develop a national EM system under the auspices of a high-level task force that oversees and coordinates all of Ethiopia’s EM activities. Establishment of specialized training programs. Ethiopian physicians and other health care providers, physicians and hospitals from around the world (including Canada) have donated teaching materials and medical equipment. One result of these generous donations has been the establishment of an ultrasound-training program at St. Paul’s Hospital in Addis Ababa, Ethiopia. Engineers from Canada travelled to Ethiopia to install the equipment, troubleshoot and provide staff training.
+ New and renovated hospital architectural designs must be accessible to EM. + Reduce the brain drain of its physicians and other health care providers trained in Ethiopia and other African countries. + A sustainable EM system requires broad, longterm financing, in addition to the (most welcome) special project funding. + Ethiopia’s predominantly poor, rural population must have access to EM care. + Developing and sustaining an effective EM system requires the participation and involvement of Ethiopia’s communities and all of its citizens. + Developing/delivering EM education and training requires books, teaching and training modules and materials in Amharic, Ethiopia’s national language.
Public private partnership: The establishment of a local public-private partnership between St. Paul’s General Specialized Hospital and Ayder Referral Hospital which uses international support to train nurses in triage processes and protocols. Development of a paramedic-training program is underway, focusing on specific training and protocols, equipment, supplies and first responder skills.
Discussion Future planning is the essential first step in any emergency system development. All core stakeholders in Addis Ababa must unanimously agree on primary definitions, as well as on the ultimate desired goals to be attained. Ideally, this task group would be targeting goals for 5 and 10 years into the future. Once the definitions and goals have been established, all other stakeholders that may potentially be impacted should be included in the next round of discussions to allow adequate time for their systems and services to adapt to the changes the emergency medicine project will impact. Ideally these types of discussions and consensus agreements would occur before starting the system change process. There needs to be a general agreement about how EM will be defined and what its scope will be in Ethiopia. The Ethiopian model, while based on the same principles of emergency medicine utilized around the world, will have to be customized to its culture, its geography and its resources. No other national model should be simply “dropped into place”. The International Federation for Emergency Medicine (IFEM) has developed basic definitions for emergency medicine, emergency physician, emergency nurse, EMS, etc. Those definitions might act as a useful starting point for Ethiopia to define its own terms and scope. It is reasonable to recognize that some initiatives must take place while this vision and future plan is being developed. Also some steps already underway may require redirection or reconsideration. These include: 1) Integration of pre-hospital care system. All core stakeholders in pre-hospital response, specially the Addis Ababa Red Cross, fire and Emergency department, Police/traffic and hospital-based ambulance services should discuses and integrate their response efforts.
ID In-Depth / Ethiopia YOUR PATIENTS ARE ON THE CUTTING EDGE...ARE YOU?
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“ONE SIZE FITS ALL!” “BLOODLESS EXPLORATION THROUGH CAREFUL TOURNIQUET APPLICATION IS “CRITICAL” TO MINIMIZE RISK!” (ACEP’s Emergency and Primary Care of the hand).
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There are essentially no ambulances; the ambulances that are in place lack even basic equipment and trained personnel. Those who have completed training often leave. A well developed EMS system with a centralized dispatch system (for each region) and a well publicized and coordinated public education campaign are required. This system should start in all major cities at the same time if possible. This will require establishment of a well-structured maintenance base for the ambulances (and the equipment within), training of personnel and development of a coordinated public campaign. Oversight should be by a FMOH to ensure standardization, with municipal or regional personnel administering to their local needs. 2) Building of standardized emergency departments or modification of existing emergency rooms should have complied with the basic physical constructs of ED such as spacing, ergonomics, personnel and equipment proportional to anticipated needs over the following 5-10 years. No such active site yet exists in Ethiopia, which allows time for a standardized approach to be established. The current physical plant of Addis Ababa hospitals should not be considered a model to be emulated. Restructuring of hospital systems will be required as it is recognized that the large majority 3) Multiple ancillary services will have to be structured and available in the ED: social work to allow patients to be discharged with home support, community nurses who could arrange home care rather than admission, physiotherapists to assess patients requiring outpatient care, etc. 4) Sites to lead emergency medicine development should be identified. In the development of emergency medicine, a very distinct pattern became evident. Well-established bastions of medicine with well-deserved international reputations were often the least willing to embrace emergency medicine residency programs. Many felt that their current system was effective; others resisted because of specialists who refused to accept change. The primary reason however seemed to be the inertia of large medical centers to major change. Medicine is a naturally conservative domain; change only occurs with evidence that patient well being is not at risk. It has been shown that on average, implementation of new knowledge requires 10-12 years after proof of that new knowledge’s efficacy. It thus occurred that most of the new programs in emergency medicine opened in newer, more flexible universities and hospitals. It may well be easier to have the first full emergency medicine systems (EMS, emergency department, full hospital integration and residency program) set up in smaller, younger centres such as in Debub, Mekelle or Bahirdar Universities. In such new facilities there is more openness to change that is not inherent in longer established hospitals. Furthermore, the exhaustive changes required will be economically less prohibitive in a smaller region than in well-established universities; unanticipated errors or consequences that occur during the process could be rectified with less cost. When bigger centers start their programs, it will be with the experience of other, smaller sites so that implementation will occur with much less risk for error and with more experience than is currently happening. Peter W. Hodkinson has written about the urgent need to determine key strategies to help guide EM maturity in the developing world. These strategies must be practical, take into account existing health care systems and allow integration into these systems. There is clear evidence that well-established systems of emergency care can reduce morbidity and mortality from many common conditions in the developing world. To build on the progress that Ethiopia and its many partners have achieved, taking EM to the next level will take action in five critical areas:
CONTACT: PRECISION MEDICAL DEVICES (302) 778-2335 FOR MORE PRODUCT INFORMATION WWW.THETRING.COM 18 November 2011 // Emergency Physicians International
It is an exciting time for clinicians and other health care providers to be involved in fostering EM in Ethiopia through collaboration with local professionals to support CME initiatives and outcome-based research projects. Investing in medical student and resident exchanges is always enriching to everyone involved. In our highly interconnected world, everyone can benefit from transglobal conversations and idea exchange. Ethiopia and other nations that do not have mature continued on page 21
The IEM Fellowship Directory global IFEM Fellowship Focus: Global Contact: Peter Cameron, MD email@example.com. edu.au
australia/ new zealand Australasian College of Emergency Medicine (ACEM) Focus: Global, Australia, NZ & South Pacific Contact: Peter Cameron, MD firstname.lastname@example.org. edu.au and Gerard Oreilly email@example.com
canada University of Toronto / Canadian Association of Emergency Physicians (CAEP) Focus: Global, Africa Contact: Valerie Krym firstname.lastname@example.org
mexico PACE Global Fellowship Focus: Latin America Contact: Haywood Hall, MD Cinco de Mayo, # 11 San Miguel de Allende,Guanajuato Mexico Length: 1-2 years Salary: Competitive Shifts: Flexible Degree: Independent MPH encouraged Positions: 4 Deadline: January 15 ( (800) 770-6853 8 email@example.com : www.pacemd.org
The netherlands The NVSHA (Dutch Society for Emergency Medicine) Contact Dr. Pieter van Driel firstname.lastname@example.org Length: 1 to 2 years Number of positions: 1 or 2 Degrees: Subspecialty/Fellowship
Status in Dutch EM System Deadline: Rolling. Currently open only to Dutch EPs ( +31 624 11 3566 : nvsha.nl
south africa South Africa: Univ. Cape Town / Stellenbosch Univ. / EM Society of South Africa (EMSSA) Focus: Africa, South Africa Contact: Lee Wallis, MD email@example.com
The United States California
Harbor-UCLA/IMC Global Health Fellowship Focus: Iraq, Haiti, other Contact: Ross I. Donaldson, MD, MPH, Harbor-UCLA Medical Center Department of EM 1000 West Carson Street, Box 21 Torrance, CA 90509 Length: 1-2 years Salary: Very Competitive Shifts: 5 per month Degree: MPH, DTMH available Positions: 1-2 Deadline: November 1 ( (310) 222-3500 firstname.lastname@example.org :www.emedharbor.edu/ Global.html :internationalmedicalcorps.org Keck School of Medicine at USC Focus: Chile, Ghana, Mumbai, Thai-Myanmar border, British Guyana Contact: Billy Mallon, MD Department of EM 1200 North State Street Room 1011 Los Angeles, CA 90033 Fax: (323) 226-6454 Length: 1-2 years Salary: Competitive Shifts per week: 2 Degree: MPH, DTMH Positions: 1 Deadline: December 1 ( (323) 226-6667 8 email@example.com : www.cbooth.info
Loma Linda University Focus: Vietnam, China, and Kenya Contact: Debbie Washke, MD Department of EM 11234 Anderson St,. RM A108 Loma Linda, CA 92354 Fax: (909) 558-0121 Length: 1-2 years Salary: About $80,000 Degree: MPH with 2-year program Positions: 1 Deadline: March 1 ( (909) 824-4344 8 firstname.lastname@example.org Stanford International Emergency Medicine Fellowship Contact: S.V. Mahadevan and Matthew Strehlow Stanford University 701 Welch Rd. Bldg C Palo Alto, CA 94304 Fax: 650 723-0121 Length: 1-2 years Positions: 1-2 Salary: Please contact Hours per week: approx. 15 Degree: MPH possible for 2 yr candidate Deadline: ACEP Scientific Assembly ( (650) 723-0063 8 email@example.com : emed.stanford.edu/ fellowships/international.html UCLA-CIM International Medicine Fellowship Contact: Nicole Durden, UCLA Medical Center Dept. of EM 924 Westwood Blvd., Ste 300 Los Angeles, CA 90024 Length: 1-2 years Salary: Competitive Shifts: 5 per month Degree: MPH, PhD Positions: 1 Deadline: October 15 ( (310) 794-3086 firstname.lastname@example.org :http://cim.ucla.edu
Yale University School of Medicine Focus: Africa Contact: Simon Kotlyar, MD Department of EM 464 Congress Ave, Suite 260 New Haven, CT 06519-1315 Fax: 203-785-4580
Length: 2 years Positions: 1 Salary: PGY level, MSc tuition, travel stipend, excellent benefits Shifts/hours per week: 0.5 FTE Degree: MS, London School of Hygiene and Tropical Medicine Deadline: December 1 ( (203) 785-4058 email@example.com :medicine.yale.edu/ emergencymed/fellowships/ global/index.aspx
Christiana Care Health System Focus: Africa Contact: Susan E. Thompson, DO Christiana Care Health Systems Dept. of EM Administration 4755 Ogletown-Stanton Road Newark, DE 19718 Length: 1 – 2 years Shifts: Between two and three 8or 9-hour shifts/week Degree: MPH with 2-year program Deadline: November 15 ( (302) 733-3904 8susthompson@christianacare. org
George Washington University Focus: India, Malawi, Egypt, El Salvador, Ethiopia, Peru Contact: Kate Douglass, MD, MPH 2150 Pennsylvania Avenue, NW, 2B-417, Washington, DC 20037 Fax: (202) 741-2921 Length: 2 years (1 year possible under special circumstances) Salary: Highly competitive, MPH tuition and generous CME Degree: MPH Positions: 1-2 Deadline: November 15 ((202) 741-2954 firstname.lastname@example.org :www.gwemediem.com
University of Florida College of Medicine - Jacksonville Contact: Elizabeth DeVos MD, MPH Department of EM 655 W 8th St Jacksonville, FL 32209
The IEM Fellowship Directory Deadline: Check with department ((904) 244-4405 email@example.com
Emory University Contact: Scott Sasser, MD Department of EM 531 Asbury Circle - Annex Suite N - 340 Atlanta, GA 30322 Fax: 404-778-2630 Length: 2 years Positions: 1 Salary: Instructor Deadline: Check with department ((404) 778-5975 firstname.lastname@example.org Medical College of Georgia Focus: Peru, Bangkok Contact: Hartmut Gross, MD 1120 15th Street Augusta, Georgia 30912 Fax: (706) 721-7718 Length: 1 year Salary: Competitive salary, benefits, CME, int’l travel funds Shifts per month: half-time EM clinical faculty position Degree: None Positions: 1 ( (706) 721-4412 email@example.com :www.mcg.edu/ ems/residency/ internationalMedFellow.htm
Cook County Hospital Contact: Jamil Bayram, MD & Robert Simon, MD Cook County Hospital, Rush University Medical Center Dept. of EM 1653 W. Congress Parkway, 177 Murdock Chicago, IL 60612 Fax: (312) 942-4021 Length: 2 years (with MPH) Salary: Very competitive, benefits, tuition fees for the MPH, travel expenses and stipends Positions: 1- 2 Deadline: Open ( (312) 942-4978 8 firstname.lastname@example.org
Univ. of Illinois at Chicago Contact: Janet Lin, MD, MPH Department of EM, College of Medicine East Suite 469A 808 South Wood Street Chicago, IL 60612 Length: 2 years Salary: N/A Positions: 1-2 Deadline: Open ((312) 413-7393 email@example.com
Johns Hopkins University Contact: Alexander Vu, DO, MPH International Emergency Medicine Center for Public Health and Human Rights 5801 Smith Avenue, Suite 3220 Baltimore, MD 21212 Fax: (410) 502-8881 Length: 2 years Salary: Competitive Positions: 1-2 Degree: MPH Deadline: September 15 ((410) 735-6436 firstname.lastname@example.org University of Maryland Focus: China, Egypt, South Africa, Botswana, The Netherlands Contact: Veronica Pei, MD, MPH University of Maryland Department of Emergency Medicine 110 S. Paca Street, 6th Floor, Suite 200 Baltimore, MD 21201 Length: 2 years Salary: Competitive Positions: 1 Degree: MPH Deadline: Open ( Phone: (410)328-8025 email@example.com
Harvard University / Beth Israel Deaconess Medical Center Contact: Philip D. Anderson, MD Department of EM One Deaconess Road W/CC -2 Boston, MA 02215 Length: 2 years Salary: Competitive, benefits, CME benefits and MPH tuition Positions: One
November 2011 // Emergency Physicians International
Degree: MPH Deadline: December 1 ( (617) 754-2324 8 firstname.lastname@example.org Harvard University / Brigham and Women’s Hospital Focus: Various Contact: Stephanie Rosborough, MD, Department of EM 75 Francis Street Boston, MA 02115 Length: 2 years Positions: One Salary: Competitive with excellent benefits Shifts/Week: 1-2 Degree: MPH Deadline: November 20 ( (617) 732-5813 8 email@example.com : www.brighamandwomens. org/dihhp/iem
Regions Hospital Contact: Matthew Morgan, MD Regions Hospital Department of EM 640 Jackson St. St. Paul, MN 55104 Length: 2 years Degree: MS in development policy or certificate in tropical medicine ( (651) 254-3336 8matthew.w.morgan@ healthpartners.com :www.regionsem.org/ fellowships/internationalmedicine
Bellevue Hospital Center/ New York University School of Medicine Contact: Michael Mojica, MD Emergency Care Institute Room 345A, Bellevue Hospital Center 27th Street and First Avenue New York, NY 10016 Length: 1 - 2 years Salary: Competitive Positions: 1 ( (212) 562-8147 firstname.lastname@example.org Kings County Hospital/SUNY Downstate College of Medicine Contact: Christina Bloem, MD SUNY Downstate Medical Center
Department of EM 450 Clarkson Avenue Brooklyn, NY 11203 ( (718) 245-4790 8christina.bloem@downstate. edu New York - Presbyterian: The University Hospitals of Columbia and Cornell Focus: Africa (Uganda, Tanzania, Kenya, Sudan, Ghana, Malawi, Sierra Leone); India, Sri Lanka, Montenegro, Dominican Republic, Burma; WHO in Geneva Contact: Rachel T. Moresky, MD, MPH Columbia University Medical Center - Center for EM 622 West 168th Street PH 1-137 New York, NY 10032 Length: 2 years Salary: Competitive Positions: 2 Degree: MPH Deadline: November 1 ( (212) 304 5745 email@example.com : www.nypemergency.org/ fellowships North Shore - Long Island Jewish Health System Contact: Sassan Naderi, MD Dept. of EM 270-05 76th Ave New Hyde Park, NY 11040 Length: 1 year Positions: 1 - 2 Salary: $90,000 Hours per week: 18 Deadline: Rolling ( (718) 470-7501 8 firstname.lastname@example.org St. Luke’s Roosevelt Hospital Center - Global Health Fellowship Focus: HIV/TB/Tropical Contact: John D. Cahill, MD Dept. of EM 1111 Amsterdam Avenue New York, NY 10025 Length: 2 years Positions: 2 Salary: $87,000 Hours per week: 20 Degree: MPH optional Deadline: Rolling ( (212) 523-3330 8applications@
The IEM Fellowship Directory slredglobalhealth.com : www.slredglobalhealth.com University of Rochester Medical Center Contact: David H. Adler, MD Dept. of EM 601 Elmwood Avenue, Box 655 Rochester, NY 14642 Length: 2 years Salary: $80,000 - $100,000/year depending on clinical time; CME, benefits, 5k/year travel Positions: 1 Degree: MPH, clinical investigation, or medical management Deadline: April 15 ( (585) 463-2945 8david_adler@ :www.urmc.rochester.edu/ emergency-medicine/education/ international.cfm North carolina
Duke International EM Fellowship/Global Health Residency Program Focuses: East Africa, Casualty department epidemiology, trauma epidemiology research, validation of trauma scoring in resource limited settings Contact: Charles J. Gerardo, MD Duke University, DUMC 3096 Durham, NC, 27710 Length: 2 years Positions: 1 Salary: Competitive, including tuition for advanced degree Degree: MS in Global Health (MSc-GH) Deadline: September 24 ( 919-681-4458 8 email@example.com : www.dukeglobalhealth.org :globalhealth.duke.edu
University of Pittsburgh Contact: Allan B. Wolfson, MD Dept. of EM 230 McKee Place, Ste. 500 Pittsburgh, PA 15213 Length: 2 years Salary: Negotiable Shifts per week: Negotiable Degree: MPH offered from the University of Pittsburgh Graduate School of Public Health ( (412) 647-8265 firstname.lastname@example.org : affiliatedresidency. health.pitt.edu
Oregon Health & Science University - Global Health Fellowship Contact: Amy Marr, MD OHSU Dept. of EM 3181 SW Sam Jackson Park Road, CDW-EM Portland, OR, 97068 Length: 2 years Positions: 1-2 Salary: PGY level, CME allowance, benefits Shifts per week: 1 Degree: Master’s or certificate options (tuition support provided) Deadline: Rolling ( (503) 494-8220 8 email@example.com : www.emergencyresidency. com Pennsylvania
Rhode Island Rhode Island Hospital Focus: Liberia, Rwanda, Uganda, Kenya, and Haiti Contact: Lawrence Proano, MD University EM Foundation 593 Eddy Street, Providence, RI 02903
Length: 2 years Salary: $87,500 Positions: 1-2 Hours per Week: 16 Degree: MPH from Brown University ( (401) 444-5826 firstname.lastname@example.org
Vanderbilt University International EM Fellowship Focus: South America Contact: Seth Wright, MD Vanderbilt University 703 Oxford House Nashville, TN, 37232 Length: 1-2 years Positions: 2 Salary: $92,000 + excellent benefits, tuition, travel expenses Hours per week: 14.75 Degree: MPH, DTMH Deadline: Rolling ( (615) 936-0075 email@example.com : emergencymedicine. mc.vanderbilt.edu
texas Baylor College of Medicine / Texas Children’s Hospital Focus: Various Contact: Charles G. Macias, MD, MPH Texas Children’s Hospital 6621 Fannin, MC 1-1481 Houston, TX, 77030 Length: 4 years (pediatrics trained); 3 years (EM trained) with Board eligibility in PEM at completion Salary: PGY level Positions: 1 Hours per week: 32-40 Conferences/week: 4 hours, except PICU rotation Degrees: MPH, MEd, MS, MBA
Deadline: August 31 through ERAS (apply for PEM Fellowship) ( (832) 824-5468 8pwomack@ :texaschildrenshospital.org University of Texas Southwestern (DallasParkland) Focus: Mexico/Latin America. Others negotiable. Contact: Robert E. Suter, DO, MHA Div. Emergency Medicine UT Southwestern Medical Center at Dallas 5323 Harry Hines Boulevard CS2.122 Dallas, TX, 75390-8579 Length: 2 years Salary: Competitive Positions: 4 Hours: 56 clinical hours/month Degrees: MPH Deadline: December 1 ( (214) 648-3916 8robert.suter @utsouthwestern.edu
utah University of Utah Focus: Ghana, Thailand, India, Peru Contact: Erik Barton, MD, MS, MBA University of Utah Health Care 30 North 1900 East, Rm 1C26 Salt Lake City, UT 84132 Length: 1 to 2 years Salary: competitive Positions: 1 or 2 Shifts: 7 per month/54 hours Degrees: MPH Deadline: Rolling ( (801) 581-2417 firstname.lastname@example.org
In-Depth / Ethiopia continued from page 18
EM systems can be helped to develop the surveillance research infrastructure they need to deal with emerging infections and strengthen global health security. In a recent article in the Canadian Family Physicians Journal, titled “Motivating Action: Why Canadian Physicians Should Participate in Research, Education
and Patient Care in Developing Countries”22, Professor Peter A. Singer describes the scientific opportunities, compelling economic reasons, bio-security considerations, human capital and peace and development issues that are pragmatic, motivating factors for physician participation. As a new specialty, international emergency medi-
cine can make inroads to build capacity in Ethiopia. There is a great opportunity to transfer knowledge, provide research capacity, help with needs assessment and develop a model of relationship between academia, business and the international Ethiopian professional diaspora. Together, all can work closely and achieve mutual benefits. www.epijournal.com
with peter cameron, MD
The Problem with “Efficient” Medicine Doing the right thing for the patient often means slowing down care and assessing the big picture.
One day as I watched the relentless line of ambulance trolleys coming through the front door and the slow pace of patients leaving the emergency department, I reflected on exactly what I was trying to achieve in my chosen profession of emergency medicine.
Sometimes it feels like we are investigating and treating patients who have an inevitable outcome, in spite of our best endeavors. There is a conveyer belt of humanity that we “tinker” with as it passes through the emergency department. Many patients will recover, some will die, a small number require immediate life-saving interventions and some require relief of pain or discomfort. Significantly, there are some patients who would benefit from avoiding the ED altogether and don’t fit neatly into our disease and symptom based protocols. Does emergency medicine add value to the conveyer belt? Are we providing a service that helps society? There is increasing demand across emergency systems internationally and little chance of this changing in the foreseeable future. Projections from some regions predict that if present demand trends continue, more than 50% of GDP could be consumed by provision of healthcare by mid century. Clearly the main drivers for this inexorable demand must be identified and strategies developed to manage it. In emergency medicine, we have been held captive by the need to deliver more “efficient care”, in order to provide high level services within present budgetary constraints. Politicians and administrators have been more comfortable with the idea of improving “efficiency” as opposed to questioning the drivers of increased demand. There has been little dialogue with the community on what it expects from money spent on health care and what is the highest priority for health care spending. The closest to a debate occurred when “Obama death panels” were demonized in the popular press in the USA (the Obama administration suggested that some patients might be better off not receiving high technology/high cost care). As an emergency doctor I have real concerns regarding increased “efficiency” and the possible impairment of effective delivery of “good emergency care” in my ED. Using process mapping, lean thinking and various other organizational review techniques, many EDs have “improved efficiency”. For example, early ordering of X-Rays – even from triage, direct admission to wards for “obvious admissions”, immediate pain relief for patients presenting with pain. All of these procedures may ultimately result in faster transition through the ED. However, do such initiatives ultimately result in greater efficiencies in the health system? More importantly, do they improve the experience for patients and deliver lower costs across the whole episode of care? Elderly patients, with undifferentiated illness are particularly susceptible to disadvantage in the “efficient” emergency system model. For example, an elderly frail man inadvertently takes a double dose of sedative because his wife is out of the house, playing cards. This patient falls in his house, is heard by the neighbor, an ambulance is called and he is brought to the ED for assessment. It is night, the LMO is not available, the wife hasn’t yet returned from her outing, the patient is confused because of the tablets – and gets more con-
November 2011 // Emergency Physicians International
fused because he has been taken from his home. This patient can’t go home from the ED, so he is admitted quickly to the ward for his acute confusional state within a couple of hours of arrival (efficient). He has had blood tests, CT brain and X-rays (all normal). His disorientation and confusion worsens, he wanders at night, falls again and fractures his NOF and spends weeks in hospital, never truly returning to his premorbid state. The end result is nursing home or death. Variations on this story occur on a daily basis in hospitals around the globe. The measured care is extremely efficient, times are met, illnesses are treated, but the whole hospital episode is probably preventable. A further issue is the problem of determining a good outcome. Survival is not the most important outcome for many patients. For example, those patients (or their carers), with terminal illness, advanced dementia or debilitating illness, might regard death as preferable to being taken by ambulance to a hospital, especially when good nursing care and a comfortable environment can be provided in their residential care institution – or with support from their families. If a demented elderly patient in a nursing home falls and has a head injury in my country, it is highly likely that they will be taken by ambulance to hospital, in a cervical collar and assessed in the ED. The collar may be left on for hours to days, as the imaging and clinical situation are difficult to assess. They will receive a CT and sometimes even get admitted to hospital. The resultant discomfort to the patient, the futility of any surgical treatment, possible harm caused by immobilization and assessment and the distress of the relatives are rarely assessed in a balanced way. There seems little consensus amongst my emergency colleagues and even less amongst my inpatient colleagues about the best management plan for this situation. If the patient and family were fully informed of the advantages and disadvantages of conservative versus active management it is likely that most would chose to leave the patient in the residential care or community setting – provided there was adequate support. From the perspective of measured efficiency, the emergency system can whisk the patient quickly to hospital, get scans and into a medical ward within hours. Alternatively, an experienced clinician could assess the situation at a nursing home, discuss with relatives and usual doctor and keep the patient in their usual surroundings. Which is better for the patient? What is best for the system? As EPs, we have a duty to develop the emergency system to do what is right for the patient. We are in a position to inform the community and patients of relative risks and likely outcomes. Much of the “conveyer belt” of incoming patient load could be prevented by better community structures and more informed discussions with patients and relatives in the ED. Spending time developing community processes, links and educating the community is not seen as “efficient care”. Fully assessing patients and their complicated social/ psychological situations in the ED may look like “wasted time” from an ED process improvement model. However from a societal perspective it is essential for efficient use of the hospital system and to ensure appropriate use of scarce resources. Dr. Cameron is the president of the International Federation for Emergency Medicine (IFEM)
The Global Emergency Medicine Initiative: Building a Global Emergency Medicine Network for Comprehensive Acute Care Systems Development
The Need for Emergency Medicine and Acute Care Systems is a Global Crisis Emergency medicine and acute care systems are in demand in every country in the world, yet most systems are vastly under-staffed, under-resourced, under-funded and under-developed. The Global Emergency Medicine Initiative (GEMI) will address this need by creating a Global Emergency Medicine Network, which will link together and create the multilevel, multi-professional, multi-dimensional partnerships – EM societies, governments, NGOs, universities and private investors & corporations – that are necessary for comprehensive emergency medicine and acute care systems development. Through the Global EM Network, GEMI will focus on key areas of emergency medicine and acute care systems development in order to provide expertise and development in all aspects of EM and AC systems development:
u Education u Service u Research u Systems development
National and Independent Responses to Trends in EM EM and acute care systems are growing in over 50 countries. Over the past 40 years, emergency medicine specialists, EM societies, federations and emergency health professionals have assisted in establishing: u Training programs for EM physicians and specialists u Schools for emergency nursing, medics and paramedics u Professional societies for EM specialists u Disaster medicine and disaster management programs u Trauma systems and trauma training programs u Ambulance and pre-hospital systems u Injury and acute disease surveillance systems u Global and National research programs Developing Successful National and Independent Responses into a Global Cooperative. Emergency physicians and EM Societies who are engaged in EM development are now seeking to create larger, more comprehensive partnerships and networks in order to build more comprehensive EM and acute care systems on a national and regional scale.
“Cancer, diabetes, and heart diseases are no longer the diseases of the wealthy. Today, they hamper the people and the economies of the poorest populations even more than infectious diseases. This represents a public health emergency in slow motion.” -United Nations Secretary-General Ban Ki-moon, addressing the UN high-level meeting on NCD’s, Sept 19-20, 2011
The New Global Burden of Disease Non-communicable diseases are a giant wave approaching in global public health. For the first time in history, non-communicable diseases (NCDs) have surpassed traditional communicable diseases as the major global causes of death and disability. And not just in more developed nationsâ€“this has happened all over the world, in nearly every country.
Trauma, cardiovascular disease, cancer, diabetes and lung disease now account for 63 percent of all deaths in the world. Why the monumental shift? The world is changing in unprecedented ways:
The Aging of the Population: Fewer deaths from increased life expectancy and decreased childhood mortality now allow people to survive to older ages, exposing them to different disease patterns. There is now also a greater percentage of people older than 60 than at any other time in history. In a few decades, the majority of older people will no longer live in the developed world, but instead will live in underdeveloped areas with less developed health care systems.
Global health policy makers are starting to recognize that emergency medicine systems will be the next major healthcare concentration along with primary care. The developing world is starting to recognize that treatment for noncommunicable diseases in a communicable disease setting is becoming increasingly expensive and inefficient.
Increased Urbanization: As of 2006, for the first time in recorded history, the majority of the worldâ€™s population lives in cities. This has never happened before. Urban life brings key changes in diet, exercise, work, lifestyle, and new disease patterns
Globalization of Trade and Marketing: There has been a progressive increase in unhealthy lifestyle patterns (tobacco use, diet, physical inactivity and the harmful use of alcohol), and new disease patterns with them.
DEATHS IN MILLIONS
According to WHO studies, the forces of demographic and epidemiologic shift have elevated non-communicable diseases to be the single largest cause of morbidity and mortality worldwide, now and increasingly into the future.
4 ACUTE RESPIRATORY INFECTIONS ROAD TRAFFIC ACCIDENTS PERINATAL HIV/AIDS TUBERCULOSIS MALARIA
2 0 2005
Q: What can meet this new NCD burden? A: Emergency Medicine and Acute Care Systems Development What makes this shift in morbidity and mortality so important? 20th Century healthcare initiatives focused on healthcare provision for communicable diseases in outpatient and inpatient settings. The greatest 21st Century healthcare burden will be healthcare provision for non-communicable diseases. The rise of NCDs have and will continue to affect all populations of all countries. NCDs are already the largest causes of death and disability in low- and middle-income countries; they are increasing more rapidly than previously expected and in precisely those areas with the least developed EM and acute care systems. “The prognosis is grim. NCDs hit the poor and vulnerable particularly hard, and drive them deeper into poverty. According to the WHO, deaths from NCDs will increase by 17 % in the next decade. In Africa, that number will jump by 24%”
What Is Emergency Medicine? “EM is a fully-developed medical specialty that focuses on recognition, stabilization and treatment of all emergency conditions for people of all ages. Sometimes called the ‘specialty of time,’ the full practice of EM involves education, training, practice, research and systems development. EM is a combination of proper medical education care and proper systems design and management, in order to deliver medical care to the people who need it most.”
mulligan , do , mph
cameron , md
40 35 While EM is still one of the youngest medical specialties in the world, it is an officially recognized medical specialty in over 50 countries, with the rate of specialty recognition accelerating in recent years .
The Number of Countries with Emergency Medicine
15 10 5
# of countries
president of the international federation for emergency medicine
Emergency medicine and acute care systems focus on bringing the right care to the right people at the right time. It combines specialized training with skills in health care triage, management and efficiency, to form a safety net of emergency medical preparedness and secondary prevention for entire populations, and results in lower NCD burden, greater access, greater quality and lower costs.
“EM development has universal appeal across the globe because it is the key to more efficient and accessible care in developed countries and in LMICs it is the key to basic healthcare that is a human right for every citizen.”
secretary general ban ki - moon
Without global strategic emergency medicine integration with existing healthcare facilities, the costs of healthcare provision for noncommunicable diseases on a communicable disease setting will grow exponentially.
How To Build Emergency Medicine & Acute Care Systems
STAGES OF EMERGENCY MEDICINE TERTIARY DEVELOPMENT STAGES STAGES OF
Emergency medicine and acute care systems development involves more than just medical training for health care professionals. It requires simultaneous and coordinated development in multiple disciplines and in multiple stages.
EMERGENCY Public Health Agendas MEDICINE TERTIARY National Health Policy DEVELOPMENT STAGES Health Agendas Legislative Structure Public National Health Policy
Ba s ic
Interest in IEM has also led to the development of IEM fellowships, subspecialty training programs and other educational projects for EPs and allied healthcare professionals. Formal and informal international / global EM fellowships and training programs now exist in at least five countries. Further, the International Federation for Emergency Medicine (IFEM) has emerged as the peak emergency medicine organization in the world, representing over 70 EM Societies from over 50 countries.
“International EM fellowships and training programs are designed as adjuncts to EM residencies and specialty training initiatives, which promote the clinical and nonclinical expertise that is needed for EM practice, and include training on how to support the creation, development and maturation of EM/acute care systems in other countries.”
t mulligan , chobgood , pcameron . emergency medicine australasia
(2011) 23, 525–529
IEM can be viewed as a natural extension of the systems-based nature of EM: it allows EPs and other health professionals who are involved in emergency medical care to learn from each other, and involves the educating and training of emergency care providers throughout the world in practice, education, research and systems development.
ute Ca re
er ge n
Economic & Finance Administratice & Management Systems
Em er Ca gen cy re Me Sy ste di ci m
ute Ca re
er ge n
Economic & Finance STAGES Administratice &PRIMARY Specialy Systems Academic Development Educational Systems Management Systems Patient-care Systems Training Programs for existing physicians and specialists Midwives, nursing, advanced health care workers Pre-hospital and First Responder Training for Medics, Fire, Police, Taxi
PRIMARY STAGES Ba s ic
Em er Ca gen cy re Me Sy ste di ci m
Over the past 20 years, many EM societies, departments and training programs have responded to this need for international EM development. The result has been the creation and growth of the field of international emergency medicine (IEM), which is concerned with the development of EM and acute care systems in countries and regions where EM is lacking and is needed.
Basic First Aid and Community Health Workers Basic Public Health Services
Specialy Systems Academic Development Educational Systems Patient-care Systems
Training Programs for existing physicians and specialists Midwives, nursing, advanced health care workers Pre-hospital and First Responder Training for Medics, Fire, Police, Taxi Basic First Aid and Community Health Workers Basic Public Health Services
This multi-level, multi-professional, multi-disciplinary and multi-institutional approach ensures successful medical development and health system strengthening, and ensures program longevity, sustainability, resilience and self-generation. -T. Mulligan & L. Wallis
Bringing together multiple partners to build emergency medicine International emergency medicine organizations understand the complex nature of emergency medicine and acute care systems. GEMI will construct the Global EM Network, which will provide expertise and assistance with all levels of EM and AC systems development. Many parties, organizations and individuals are currently working in international EM development all around the world: EM Societies and Federations, universities, NGOs, governments, corporations and private investors. GEMI was founded by members of these organizations, and brings together the multiple disciplines necessary to build EM systems: medicine, nursing, management, economists, legislators, health policy makers, public health experts, corporations and businesses and private investors. Bringing together the world’s experts at all levels of EM and AC education, research, service and systems development, GEMI will embody one unique organization that will build comprehensive EM systems on a national or regional scale.
The Global Emergency Medicine Initiative Supporting emergency medicine across the globe
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Establish the Global EM Network by bringing together the many partners playing a founding, directing role: interested Universities, governments, NGOs, professional societies, and private businesses.
e Emergency Med h t g icin yin f eN i n U et I: Foundations M EM Societies
Establish GEMI and local Global Health and EM Institutes to offer educational courses, certificates and degrees in all aspects of EM systems development:
Link existing Global Health and EM Institutes to establish local, national and international networks of GH institutes, to share resources, local knowledge and to multiply regional impact
Continue to expand to establish GEMI as the first, go-to organization for comprehensive EM education, research, service and systems development.
GEMI will rapidly become the leading provider of national and international emergency medicine and acute care training, consulting and service, and will emerge as the thought leader and the resource of first choice for anyone seeking comprehensive, lasting solutions for emergency medicine, acute care and other medical system needs.
How Will GEMI Build EM Systems? GEMI realizes that all change starts with education. GEMI will focus on EM systems development through the establishment of local Global Health and EM Institutes abroad, dedicated to teaching, research, service and systems development in all levels of EM development. Focusing on the “teach-the-teacher” philosophy, these local Global Health and EM Institutes will use a combination of on-site and on-line teaching modalities, including the best on-site teaching faculty and curricula, and the best available e-learning and distance education technologies. Courses, certificates and degrees will be available in all levels of the EM Development Pyramid—clinical and academic EM, EM administration and management, EM finance and economics, EM
legislation, and EM health policy and public health. Through these linked Institutes, GEMI will provide education, training, research and consultation in all aspects of EM and acute care systems development, including: Training for community health workers, mid-wives, nurses, paramedics and other health professionals Clinical and non-clinical emergency medicine training for medical students, residents/registrars, physicians and other health professionals Health administration and management in EM Patient Safety and quality improvement Health economics and finance for EM and AC systems Legislative and health law agendas for EM development Public health and health policy programs and agendas for EM development
GEMI: Global Success Requires Global Partnerships GEMI, the Global EM Network and partnerships of EM Societies, EM Federations, universities, NGOâ€™s, governments, corporations and other organizations will work to bring emergency medicine to the world on a global scale.
By helping to build EM and acute care systems around the world, GEMI will provide value for multiple global partners involved in health care:
GEMI will enable multi-lateral cooperation and synergies that will broaden the scope of current EM clinical, educational and research efforts, and will establish EM as the active agent for solutions for noncommunicable disease burden, EM and acute care systems development.
comprehensive research and international exchanges
Today, many global health policy makers are recognizing the need for EM and acute care systems. GEMI will be the first large organization that can build EM systems on national or transnational scales. By creating the Global EM Network, by building Global Health and EM Institutes, and by bringing together multiple partners from multiple disciplines, GEMI is the organization that will enable people all over the world to receive the emergency care they deserve.
uGovernments interested in global health diplomacy
uHealth care systems interested in health system strengthening
uUniversities interested in
uBusinesses looking for new
To get more information or to learn how you can partner with GEMI, visit www.globalemi.org, or send an email to email@example.com
markets for health care innovations, improvements and social entrepreneurship
uNGOs looking for capacity building, creating longevity and sustainability
Advisors & Supporters Terry Mulligan
University of Maryland, USA / Stellenbosch University
Uniformed Services University of the Health Sciences / George Washington University School of Medicine and Health Sciences, USA
University of Maryland, USA / Stellenbosch University, S.Africa
Rennes University / President, EuSEM
University of Cape Town / Stellenbosch University, S.Africa
Tawam Hospital, UAE / University of Maryland, USA
Brian Browne Abdel Bellou
Monash University, Australia / President, IFEM
Jeffrey Arnold, MD Santa Clara Valley Hospital, USA / California Emergency Physicians
Juliusz Jakubaszko MD, PhD Wroclaw University / President, Polish Society of EM
Arif Alper Cevik MD Eskisehir Osmangazi University Medical Center, Turkey / Emergency Medicine Association of Turkey
Tamara Thomas MD Loma Linda University, USA
Timothy Rainer MD Chinese University of Hong Kong Gerard Oâ€™Reilly MD Monash University, Australia
Kumar Alagappan MD North Shore Long Island Jewish Hospital, USA Sassan Naderi MD North Shore Long Island Jewish Hospital, USA
Colin Graham MD Chinese University of Hong Kong
David Hegstad OAO Mohn and Allen CPAs, USA
Manny Hernandez MD, MBA Cannon Design, USA
Matthew Gracie PNC Bank, USA
Maaret Castren MD, PhD Karolinska Institutet, Sweden
Robert Alexander Corporate Press, USA
Silvio Aguilera MD Buenos Aires, Argentina
Logan Plaster Publisher, Emergency Physicians International, USA
David Sheehan, JD Thomas and Libowitz Law Firm, USA
Learn how you can get involved with GEMI at www.globalemi.org, or email firstname.lastname@example.org
The 6th issue of Emergency Physicians International focuses on developments in emergency care on the continent of Africa.