Cuba Enters Global EM Conversation Amphetamine Abuse in Saudi Arabian EDs Healthcare at the World’s Largest Gathering Design: The Power of Observation Units EMERGENCY PHYSICIANS INTERNATIONAL
ISSUE 10
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SPRING 2013
. WWW.EPIJOURNAL.COM
LIFE FLIGHT When a devastating night club fire in southern Brazil killed and injured hundreds, emergency workers from nearby Porto Alegre took flight. Once the beds in Santa Maria were full, it took 92 trips by military aircraft to transport victims of the fire to Porto Alegre.
global snapshot – Readers from 25 countries share reimbursement challenges the med – A Mediterranean diet is among the most life-saving post-MI interventions
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EDITOR’S DESK
Season’s Meetings
T
here’s never been a more exciting time to be involved in international emergency medicine. As I penned this editorial to open the tenth edition of Emergency Physicians International, I walked through the list of exciting emergency medicine meetings and training events taking place around the world. There are literally too many to mention here, which is an incredibly exciting problem to have. The United States, the United Kingdom, Canada, and Australia will have their usual annual national conferences, with international EM becoming a more prominent component of each of these. One American conference to highlight is the 2013 Academic Emergency Medicine Consensus Conference called “Global Health and Emergency Care: A Research Agenda.” This will take place in conjunction with the Society for Academic Emergency Medicine Annual Meeting on May 15, in Atlanta, Georgia. The second unique U.S. based conference to highlight is the 10th Annual New York Symposium on International Emergency Medicine, which will take place August 7-8 in New York City. Already this year international EM conferences have taken place in Venezuela, Vietnam, Singapore, The Philippines, Denmark and Sweden. The next few months will bring emergency care providers together in Belgium, Manchester, Marseilles, Cuba, Tokyo, Cape Town, Hong Kong and Germany. Trying to keep up with this exploding list is enough to make your head spin – and wear out your passport. To help you keep track of who is gathering where, and when, check out our events calendar on page 6, or online at www.epijournal.com/events. The International Federation for Emergency Medicine (IFEM) has been busy as well, surging forward with a range of activities. IFEM’s leadership has been pleased to add on a few new member societies, including the Philippines, Costa Rica, Uzbekistan, Georgia, Ethiopia, Tanzania, Oman, Iraq, and Cuba. IFEM has developed and posted two useful landmark documents: “The Framework for Quality and Safety in the Emergency Department” and “The 2012 International Standards of Care for Children in Emergency Departments.” There are multiple IFEM task forces working on additional training documents and resources, so check back to epijournal.com and ifem.cc to find out the latest. To assist with these projects, IFEM is seeking expressions of interest for people to join its Pediatric EM Special Interest Group, Disaster Medicine Special Interest Group, Efficacy of Emergency Medicine Taskforce, Specialty Society Development Task Force, and its Categorisation and Rating of EM Websites Taskforce. If you’ve been wanting to get more involved in the logistics of international emergency medicine, now could be an excellent time to start. Bringing all of these new developments together is the ever-expanding EPI Network, which now boasts more than 1,900 physician members from more than 100 countries. If you haven’t yet, check out EPI online and you’ll find a wealth of information and opportunities. And if you know of an important international event or program I’ve not included here, then use the EPI network to publicize it. As you can see, there is quite a lot of activity going on this year in international EM and your opportunities to participate are almost unlimited!
C. James Holliman, MD, FACEP, FIFEM editorial director
The International Federation for Emergency Medicine (IFEM) has been busy as well, surging forward with a range of activities. IFEM’s leadership has been pleased to add on a few new member societies, including the Philippines, Costa Rica, Uzbekistan, Georgia, Ethiopia, Tanzania, Oman, Iraq, and Cuba.
Cuba Enters Global EM Conversation Amphetamine Abuse in Saudi Arabian EDs Healthcare at the World’s Largest Gathering Design: The Power of Observation Units EMERGENCY PHYSICIANS INTERNATIONAL
ISSUE 10
.
SPRING 2013
. WWW.EPIJOURNAL.COM
LIFE FLIGHT When a devastating night club fire in southern Brazil killed and injured hundreds, emergency workers from nearby Porto Alegre took flight. Once the beds in Santa Maria were full, it took 92 trips by military aircraft to transport victims of the fire to Porto Alegre.
global snapshot – Readers from 25 countries share reimbursement challenges the med – A Mediterranean diet is among the most life-saving post-MI interventions
ABOUT EPI With a quarterly print and digital distribution and an online network of more than 1,900 members, EPI is the essential hub connecting global emergency care, sparking dialogue and creating a space for new collaborations. Find copies of the print magazine at international EM conferences around the world, or read it online at www.epijournal.com
www.epijournal.com
3
LETTER FROM THE PUBLISHER
Into the Field
W
e left the Kumbh’s wide dusty avenue and made our way through an entryway of corrugated metal into the sector 4 health clinic. We stepped from the heat of the mid-morning sun into the pleasant in-patient tent and I quickly noticed two things. First, the beds were neatly made, each carefully topped with a red army blanket and marked with a numbered placard. Second, the room was empty save for one elderly woman with dehydration. The first observation left me optimistic; the second left me scratching my head. The Kumbh Mela, after all, isn’t just a Hindu festival held in northern India. It’s the largest human gathering on the planet. On any given day, there were literally millions of pilgrims coming to take a holy bath at the confluence of the Ganges and Yamuna rivers. Yet for all of these pilgrims there were merely 11 small health clinics. And this one was empty. Why? One of the outstanding things about emergency medicine is that it can never be confined within the walls of an emergency department or A&E. Whether it’s a traffic accident on the side of a road or a woman going into labor at a shopping mall, emergency physicians are trained to handle the unexpected, and they thrive within the unpredictable. This readiness makes EPs perfect for leading the healthcare at mass gatherings, so I wasn’t surprised when an EP friend from India invited me to join him at the Kumbh Mela. What could be more exciting to an emergency physician than tens of millions of people camping on the banks of a river chock full of E. coli? We traveled to the city of Allahabad for the festival with a team from Harvard’s FXB Center for Health and Human Rights. We went to study the festival’s healthcare infrastructure (full story on page 24), and to test a hypothesis. The team believed that even in a resource-poor setting, a simple iPad-based electronic medical record could be deployed, and that by doing so, a small team could bring life-saving syndromic surveillance where it had never existed before. The results were unprecedented. The dedicated team of local medical students were able to gather more than 40,000 data sets, arguably the largest healthcare data collection ever accomplished on a transient population. The results have the ability to improve resource allocation at future Kumbhs as well as at mass gatherings around the world, insuring that empty beds are well utilized, and that spikes in disease are identified before they reach epidemic proportions. This work is not traditional emergency medicine, but it is practical, innovative and life-saving healthcare and it represents the best of what emergency care systems thinking can bring to the world. Here’s to the next innovation, and to the emergency physician who will imagine it.
Logan Plaster Publisher
editorial director C. JAMES HOLLIMAN, MD executive editors PETER CAMERON, MD TERRY MULLIGAN, DO, MPH LEE WALLIS, MD MARK PLASTER, MD publisher LOGAN PLASTER logan@epijournal.com On Twitter @EPIJournal editorial interns DR. RASHMI SHARMA REBECCA CORDER PEREL BERAL 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 ALBERTO MACHADO, MD JORGE OTERO, MD print advertising LOGAN PLASTER logan@epijournal.com
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Spring 2013 // Emergency Physicians International
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5
EVENT CALENDAR 05/13–10/13
ACEM Winter Symposium 2013 // Broome, Australia
SIX MONTHS OF INTERNATIONAL EM CONFERENCES
MAY
The First European Congress on Pediatric Resuscitation and EM // Ghent, Belgium May 2 – 3, 2013 www.prem2013.be
The Second Global Network Conference on Emergency Medicine // Dubai, UAE May 2-6, 2013 www.emergencymedicineme.com
SAEM Annual Meeting // Atlanta, Georgia, USA May 15-19, 2013 www.saem.org
VII Argentine Congress of Emergency Medicine - SAE 2013 // Buenos Aires, Argentina May 23-24, 2013 www.emergencias.org.ar
18th World Congress on Disaster and Emergency Medicine // Manchester, UK May 28 – 31, 2013 www.wcdem2013.org
JUNE
CAEP 2013 // Vancouver, Canada June 1-5, 2013 www.caep.ca
7th Dutch North Sea EM Congress // Egmond aan Zee, Netherlands June 6-7, 2013 www.interactieopleidingen.nl/egmond
SEMES 25th National Conference // Santiago de Compostela, Spain June 12-14, 2013 www.semes.org
June 14-16, 2013 www.acemwintersymposium.com.au
AUGUST
4th Brazilian Congress of Emergency Medicine // Curitiba - Paraná, Brazil August 20–24, 2013 www.abramede.com.br/5781/congresso
SEPTEMBER
Mediterranean Emergency Medicine Conference // Marseilles, France
www.epijournal.com
03 | Editor’s Letter 04 | Publisher’s Letter
Source 8 | Dispatches What reimbursement challenges have EPs faced in your country?
September 7 – 11, 2013 www.memc2013.org
10 | Cuba: Coming together
DevelopingEM 2013 // Havana, Cuba
14 | India: Taking strides
September 19–22, 2013 www.developingem.com/program
CEM Scientific Conference 2013 // London, UK September 24–26, 2013 www.collemergencymed.ac.uk
The Leipzig Interdiscplinary for Emergency and Critical Care (LIFEMED) // Leipzig, Germany September 27–29, 2013 www.dgina.de
OCTOBER
12 | Liberia: Quick study
15 | Sudan: Uphill battle
Departments 16 | Research Non-Operative Treatment of Acute Appendicitis
18 | By The Numbers Post MI? Give Discharge Instructions That Will Actually Save Lives
19 | Curious Cases Working in an ED in Afghanistan, an infection can turn vicious in an instant.
Turkey Emergency Medicine Congress // Eskisehir, Turkey
Reports
October 2–6, 2013 www.tatd.org.tr/etkinlik/2013/TATKON
20 | Journal Scan
ACEP Scientific Assembly // Seattle, USA
22 | Drugs in the Middle East
October 14 – 17, 2013 www.acep.org
Irish Association for EM Annual Meeting // Letterkenny, Ireland October 17–19, 2013 www.iaem.ie
A new review by the Global Emergency Medicine Literature Review Group Amphetamine Abuse a Growing Reality in Saudi Emergency Departments
24 | Mass Gatherings Caring for Millions at the Kumbh Mela, the world’s largest Pop-Up Metropolis
28 | ED Design
7th Asian Conference on EM // Tokyo, Japan
When retooling your ED, consider the power of a few simple observation units
October 23–25, 2013 www2.convention.co.jp/acem2013/index.html
31 | Fire in Brazil
LIST YOUR NEXT INTERNATIONAL EVENT FOR FREE ON THE EPI NETWORK – WWW.EPIJOURNAL.COM/EVENTS 6
IN THIS ISSUE
Spring 2013 // Emergency Physicians International
Regional EMS rally after tragic night club blaze in Santa Maria
34 | Grand Rounds Dr. Peter Cameron tests IFEM’s Quality Framework in Qatar
SOURCE FIRSTHAND REPORTS OF EM DEVELOPMENT AROUND THE GLOBE
E.M. PEARLS from the ANTILLES The Cuban Society of Intensive and Emergency Medicine was founded in 2008 and has 1,405 members Report on page 10
DISPATCHES 8 CUBA 10 LIBERIA 12 INDIA 14 SUDAN 15
www.epijournal.com
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SOURCE // DISPATCHES READER-SUBMITTED UPDATES FROM THE FOUR CORNERS
08 20 21
24
15 07
25
22 14 16
12 19
06
18
10 03 23 09
05
11 04
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Q. What are some of the reimbursement challenges that you’ve faced in emergency care? ______________________
01 AMERICAN SAMOA Emergency physicians are hospital employees and get paid based on training, experience, and years of service. Work in the ED is the only location where overtime shifts are compensated above normal payroll. Being a US territory, we are held to a “US level of care,” but we only get 25% of the funding. EM and medicine in general is at least 75% dependent on medicare/medicaid funding and matching contributions from the American Samoan Government (traditionally mismanaged and diverted to other projects) ______________________
02 AUSTRALIA We have a single payer system and a
8
set pay-grade system at the consultant level. However, there are numerous shortages and many EPs work as locums and VMOs and make extraordinary amounts of money (1-2 million a year [AUS]). This encourages people not to contract and to remain on locum terms. ---------------Our challenge is getting recognition for the work we do. We have no private billing ergo the government gets no income from us; we cost them money. Therefore they dislike us. ______________________
03 BAHRAIN We are faced with a system of work schedules not consistent with rest of the world and a poor basic salary. We have 8 hour shifts 5 days a week and the allowances for evening and night shift are not worthwhile. We have to
Spring 2013 // Emergency Physicians International
work extra shifts to increase the pay. So emergency doctors might work 24-26 shifts to increase their pay. There is no risk allowance.
policies are too costly.
______________________
COSTA RICA The problem is that most of the ER docs work at public hospitals ---------------Have to work many hours (+70/week) to get a decent salary, and there are no incentives for doing a better job. Plus, we can’t bill for procedures or studies done.
04 BRAZIL As we are not a specialty we don’t have reimbursement per procedure or productivity. We don’t make more money if you work better or see more patients, or have better outcomes. ---------------EM is not a regulated specialty and so there are too many doctors of different specialties competing for jobs. ______________________
05 COLOMBIA Bank debts are too high, and health
______________________
06
______________________
07 FRANCE There are no reimbursement challenges because the majority of us belong to public hospitals. The incomes are modest, but they regularly fill the bank accounts.
---------------Extremely low salary and lack of recognition as a speciality by other specialities. ---------------We don’t have many qualified EPs. Thus, industry and administrations of various hospitals skeptical of recruiting trained EPs. Most of the EPs are young; according to the industry, good doctors are older. Thus the reimbursement offered is less. ---------------Most doctors still prefer to have their ‘own’ small nursing home instead of working in a hospital set-up. This is more so in rural areas, small towns. Reasons include, better autonomy, more power and control, better recognition, better income etc. ______________________
10 01 02
13
______________________
08 ICELAND Working for the state, the question is inappropriate, I have a standard salary which I cannot change. Our reimbursement is low when compared with other workforce in my country considering working hours, stress etc. Compared to other physicians our pay is modest as we are among the best paid doctors, but only because of working hours and many shifts. ______________________
09 INDIA EM is still in its infancy, so the demand is high, hence everybody is getting a good salary ---------------Hospital Management wants to run emergency as medical post office. As a result, there is cost cutting in the ED budget.
IRAQ Emergency medicine is a difficult branch of medicine and full of problems and no one will appreciate the effort of emergency doctors, in addition it is not the branch that will make you economically rich in my country! ---------------Our challenges is an obligatory work system and frequent changes of members in the team.
increase pay despite being very well trained and highly experienced. As ED dept head I get no extra compensation. ______________________
14 PALESTINE We have a lack of well trained emergency physicians, a shortage of health staff and a shortage in physical resources ______________________
15 RUSSIA Low social status and a large workload ______________________
16 SAUDI ARABIA No reimbursement for procedures. We have fixed monthly salary. ______________________
17 SOUTH AFRICA No specialist billing for EM in private practice ---------------Competition from western and middle east countries with higher rates
______________________
21 THE NETHERLANDS Our challenge is underpayment. ______________________
22 TURKEY Several years ago the prime minister (to win votes for his party) declared that all ED visits would be ‘free’ for patients. After 6 months, abuse of this became obvious and a copayment was then made a requirement for those determined (after exam) to be ‘nonemergent’. The government became swamped in bills (this strategy became too expensive for them). Just recently they changed their criteria to ‘only paying for life-threatening’ problems. ______________________
23 UAE Delayed payments are a routine in UAE and one can’t do any thing about it as law is biased in favour of locals. ______________________
24
MALAYSIA We lack facilities and important drugs for acute care.
SOUTH KOREA We have very low insurance reimbursement.
UNITED KINGDOM Our challenge is payment for off-hours and on call work. ---------------No recognition of work intensity in ED. No significant effort to address payment for out of hours work.
______________________
______________________
______________________
______________________
11
12 MEXICO Big differences in salaries if you work in a private vs. public hospital. And even among public hospitals (municipal, state hospital or federal hospital) -------------It takes up to three months to get paid ______________________
13 NEW ZEALAND It is a socialized system, so I do not charge. -----In New Zealand, there is a 12 step pay scale. I’m at the top with no way to
______________________
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19 SUDAN Government gives priority for defence, as army and police takes around 85% of our budget. Education and health come last. ______________________
20 SWEDEN For junior doctors, salaries are quite low (65,000 USD/year as a first year resident at my hospital) and the salary development is not that good. Regarding that emergency medicine is shift work, I think compensation is an important issue.
25 USA Mandatory patient evaluation of many non-paying patients. -------------Large percentage of patients who are uninsured and have no means to pay anything -------------While compensation for emergency physicians in the USA is very high compared to EPs in most other countries, it remains very low compared to other specialists in the USA.
l
SOURCE
A Cuban pharmacy. Cuba has well-developed pharmaceutical and biotechnology sectors. Between 80% and 90% of Cuban pharmaceuticals are manufactured domestically.
11.3 Million Population 1:20,000 Ratio of EM Specialists per capita
CUBA
Despite the lowest public healthcare expenditure in the Americas, Cuba has strong public health indicators and one EM specialist for every 20,000 Cubans. by haywood hall, md
I
never smoke cigars, but in Old Havana I somehow found myself drinking rum with a Cuban between my teeth. I was traveling with a few companions, taking in the sights and sounds of this tap root of the Americas. Cuba is a living museum of impeccably maintained American cars from the 1950s. There is live music on every corner, creating a pulse of Afro-Caribbean rhythms. In addition to its music and classic cars, Cuba has a healthcare system that has caught plenty of attention beyond its shores. According to the lead article in the New England Journal of Medicine ( January 24, 2013), Cuba has a completely different, but generally successful, model of healthcare based on prevention. Of course, it is not without its flaws. The average life expectancy in Cuba is 78 years, equal to that of the United States. The per capita expenditure in the US is about $7,500 USD. In Cuba, that
10
figure is $431 USD. Most of Cuba’s public health indicators are first world. It is easy to assume that in a system with such a focus on prevention, there may be little emphasis in emergency care or specialty care. I was quite surprised to find that a friend of mine from Jamaica had a CABG in Cuba, which only cost him the equivalent of $3,000 USD. The advances in emergency medicine in Cuba are equally impressive. Cuba has recently submitted its application to become a full member of the International Federation for Emergency Medicine (IFEM). Cuba has 574 EMIntensivists on the island , serving 11 million people. That is about one EM specialist per 20,000 people. In Mexico, the country with the largest number of EM specialists in Latin America, that ratio is closer to 1:40,000. (As a reference, the ratio is about 1:10,000 in the United States). All of Cuba’s EM specialists complete a 3-year residency program in
Spring 2013 // Emergency Physicians International
10.6% Total expenditure on health as a percentage of GDP $431 USD Total expenditure of health per capita 28 Number of Registered Cuban pharmaceutical manufacturers (2010)
Sources: World Health Organization; Espicom
a primary care area and then complete an additional 3 years of specialty training in emergency and intensive care. This 6-year training period (twice as long as the typical US or Mexican residency program) takes place in 20 residency programs throughout the island. Under the leadership of MSc. Dr. Pedro Luis Veliz Martinez, The Cuban Society of Intensive and Emergency Medicine was founded in 2008 and counts 1,405 members, including nurses and paramedics. In Cuba the EM specialty grew informally out of an intensivist tradition and spread radially outward to earlier stages of emergency care within the healthcare network, particularly with the introduction of ventilators during the polio epidemic in the 1950s and 1960s. These portable pressure-driven ventilators were later used for drowning victims. In the mid 1960s, Cuban anesthesiologists started the specialty of intensive care more formally at the National Institute of Cardiology and Cardiovascular Surgery, where they managed complicated post-op patients. Cuba established the first pediatric ICU in all of Latin America in 1967, and Pediatric Intensivists were established as a specialty. The adult intensive care specialty was established in 1973 after Cuban anesthesiologists received training in Spain, and ICUs and CCUs were established. From 1974 to 1981, acute multispecialty clinics were established across the island with trained ICU nurses. What is considered the first Cuban textbook in emergency medicine, “Standards of Intensive Care” was also published by Dr. Rabell Hernandez in 1976. In 1981, fueled by an outbreak of Dengue fever, there was an expansion of fully equipped polyvalent clinics with mechanical ventilation equipment, monitors, medicines, and other disposable materials purchased abroad. In addition, training of specialists and nurses (typically one year) was accelerated to provide personnel dedicated to working full time on these units. With the restructuring of the healthcare system in the 1980s these polyvalent clinics became more emergency medicine capable over the following years, some morphing into full emergency departments. This created a need for improved patient transport between the clinics and the emergency departments and hospitals.
02
01
In 1997, the Integrated System of Emergency Medicine (SIUM) was formed by the Ministry of Public Health and organized and directed for several years by Dr. Alvaro Sosa Acosta, who was also the founder of ALACED, the regional EM organization in Latin America. This resulted in the professionalization of medical transport, institutionalization of EM in Cuba at all levels of care and the organization of the network of intensive care. Along with these developments came intermediate therapies as a form of continuous attention of serious patients; initiation of specialized intensive therapies dedicated to coronary diseases and stroke, as well as the organization of direction of structures to international, municipal, provincial, and national levels to achieve better planning and control of the material and human resources for the seriously ill. The International Congress of Emergency and Intensive Care Medicine (URGRAV) formed in 1999. In 2000, the specialty of Intensive and Emergency Medicine was officially established as a subspecialty, requiring 3 years of prior training in adult or pediatric medicine, but the one-year training programs also persisted, even for those with other specialty training. The first quarterly issue of the Cuban Journal of Intensive and Emergency Medicine was published in 2002, in electronic format, under the direction of Dr. Jaime Parellada Blanco. During the SARS scare of 2003, there was
01 Cuba’s
capital rotunda 02 Hospital Hermanos Ameijeiras, also known as The Havana Hospital
Article is adapted by Dr Haywood Hall FACEP, FIFEM, from the IFEM application submitted by Dr. Pedro Luis Veliz Martinez, President of The Cuban Society of Intensive and Emergency Medicine
an expansion of ICUs throughout the island in the polyvalent clinics and in hospitals. There was also intensive training throughout the system, further elevating the level of emergency care. In 2004 the specialty of Intensive and Emergency Nursing was established for nursing graduates, requiring three additional years of training with specializations in Adult, Pediatric and EMS. Five hundred ambulances were introduced in 2005, reinforcing pre-hospital emergency care. Since then a full EMS system has been developed, greatly affecting emergency care. Between 2004 and 2007, the Master of Science in Medical Emergency Primary Health Care was developed to train medical professionals and nursing graduates. The Cuban Society of Intensive Care Medicine and Emergency (SOCUMIE) was founded in 2008, and has been developed by Dr. Pedro Luis Veliz Martinez since its inception. This partnership brings together scientific professionals of various specialties related to emergency and intensive care in the country. The organization maintains a web site which offers regularly updated
scientific information to the pediatric and adult emergency intensivists in Cuba. Cuba’s transplant program is also operated from within this organization. We are all waiting for the economic embargo to finally be lifted, allowing a free interchange between the United States and Cuba. Cuba has been the tap root of Latin American civilization since Columbus landed, and the relationship has been pivotal for centuries. The mixture of Amerindian, Castilian, and African cultures has made itself felt in music, food, and politics. In the area of EM, there is surely much to learn from the development of our specialty in a low resource setting. The development of the specialty in the rest of the world is likely to be affected by Cuban EM. Cubans are proud of their heritage and rightly so. On our visit there were many stimulating conversations to be had, and the level of education seemed high. Whatever your world view happens to be, Cubans seem to love their doctors and their system of healthcare.
Now Accepting ‘Source’ Reports for EPI Issue #11 EPI’s ‘Source’ section is your chance to let the world know how emergency medicine is developing in your country. Share your latest projects, political updates and regional research. No previous writing experience necessary. Submit Source Reports by emailing Logan Plaster: Logan@EPIJournal.com
www.epijournal.com
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SOURCE
Trained citizen first responders must feel competent to help and confident that there will be no adverse legal consequences if they act.
LIBERIA
A small study in a Monrovia ED examines barriers to access, severity of patient population, and modes of transport for reaching the emergency department. by katheryn challoner, md
T
he baby that arrived convulsing had been brought to the emergency area by motorcycle. They’d traveled over an hour in the pouring rain. The triage blood sugar registered zero. The baby was septic, had malaria, and was profoundly malnourished. As we began emergency resuscitation, there was ongoing concern about the delay in treatment secondary to transport times. Liberia is a country emerging from 30 years of civil war. During that period much of the infrastructure was destroyed. Now, as re-building has begun, those dedicated to emergency care must begin to ask the hard questions: how can the EMS system be analyzed and developed given the country’s limited resources? My volunteer colleague and I decided to conduct a small preliminary pilot study. It was a survey of convenience, as our primary responsibility was the stabilization and care of all emergency patients arriving to JFK hospital in Monrovia, Liberia. Over a 2-week period, during which 62 patients arrived, we gathered the following data: • Age of patient (since babies and children would have to rely on family transport) • Whether the patient lived in Monrovia • Approximate time to reach the emergency at JFK Hospital • Mode of transport • Triage category given on arrival The triage category was a simple, easyto-apply system developed by JFK Hospital that classified patients as green, red or blue in order of severity (see table at right). The greatest limitation of this triage system was that it was not age specific, so blood pressure and pulse readings for babies and
12
infants were not very predictive. However, babies and infants arriving were inevitably very sick and received the correct triage assessment under this system. Another limitation to these data is that it was a convenience sample and we only obtained 62 responses. However, the purpose was to obtain an overall view of the difficulties and barriers encountered by patients in this third world setting in reaching emergency services and the general severity of patients arriving and modes of transport used. Owing to the small sample size some results were not significant, but the following interpretations could be inferred and were consistent with our experience (Tables 1–5). The most accessible mode of transportation available was taxis in Monrovia, but the length of time to locate an available taxi— and the transport time involved because of poor roads and crowded traffic—resulted in significant delays to reaching emergency care. Most families did not own cars. There is no EMS system and the 1–2 ambulances used belonged to private companies or corporations. Some ambulances were operated by non-profit entities operating in Monrovia. In an interview with the special assistant to the Minister of Health, other significant barriers to access became clear. In our original survey we had asked the patients their address or exact location within Monrovia. No one was really able to answer that question, and that part of the survey had to be eliminated. This was subsequently verified as there was no standardized address system within Monrovia. EMS services therefore would have difficulty responding to a call except to a street corner or a crossroads location.
Spring 2013 // Emergency Physicians International
Discussion
4 Million Population $49 USD Total expenditure of health per capita 78/1,000 Births Probability of Dying Under 5 39/100 population Cellular Phone Subscribers (2010) 43 Percentage of population under 15 years of age 770 Maternal Mortality Rate per 100,000 births (SD 430–1,500) Source: World Health Organization
Liberia, in their Health Sector needs assessment for 2008, identified the need of high impact intervention for basic health and nutrition. Especially crucial was the development of innovative and alternate strategies to accelerate the reduction of maternal, infant and under-5 mortality, and to increase the response to disease outbreaks, particularly in hard to reach and isolated areas. Challenges to implementation include a crisis in human resources for health, limited funds, high vulnerability of the population to communicable diseases, and bad road conditions1. From the WHO pre-hospital care systems report:2 • An effective pre-hospital care system should be simple, sustainable, practical, efficient and flexible. • Whenever possible, pre-hospital care should be integrated into a country’s existing healthcare, public health, and transportation infrastructure. • Any system should take into account local factors and resources. Given the reduced human resources in Liberia and an absence of emergency medical transport,4 the first approach might be to begin recruiting and training taxi drivers and other public service drivers in “first responder care.” These first responders can be taught to recognize an emergency, call for help, and to provide treatment and transport to the nearest hospital. It is very possible to identify particularly motivated and well-placed workers such as public servants, taxi drivers, or community leaders and train
TRIAGE LEVEL Temp BP P RR
-100
100-103
103+
90-160 70-90
<90/70 or >160/90
<70/50 or >220/120
<100
+100-120
>120
14-22
22-29
<6 – >30
95–100%
92–95%
<91%
LOC
Alert
Moderate
Unconscious
Pain
Comfortable
Moderate
Severe
SpO2
Table 2. Mode of Transportation by Age
Table 1. Living Location by Time to ED Live in Monrovia Yes
No
Mean (omitted outliers) Median Standard deviation (SD) [*omitted outliers]
Taxi
Car
Other
P-value= 0.013
AGE
TIME TO ED (MIN) Mean
Transportation
P-value = <0.001
<2 (n=19)
17 (89.5%)
0 (0%)
2 (10.5%)
151
2–10 (n=16)
9 (56.3%)
3 (18.7%)
4 (25.0%)
30
180
>10 (n=27)
12 (44.4%)
9 (33.3%)
6 (22.3%)
36.75
177.42
55.71 38.82
268.18
*omitted data included min = 1440 and 990 P-value based on mean (omitted outliers), performed by t-test
Patients who lived in Monrovia reported a significantly shorter traveling time to ED (38.8 min) than patients who did not live in Monrovia (P<0.001)
them to provide first aid skills, safe rescue, and transport. There would have to be some subsequent payment and recognition of these activities. As the data show, the most available form of transport in Monrovia are taxis, which represent nearly two-thirds of transport utilized, especially by the more critically ill patients <2 years of age. In 2002, Kumasi, Ghana pioneered a program designed to train taxi drivers in roadway casualties. They experienced improvements in the process of pre-hospital trauma care by building on existing, although informal, patterns of PHC transport.4,5 However, this study looked at initial trauma management interventions and not critical medical care. The majority of the critically ill arriving at our emergency area were young children. That might argue for a specialized concentration on initial pediatric life support given the serious consequences. In urban GuineaBissau, 20 of 125 acutely ill children died either on the way to the hospital or in the waiting room awaiting medical care.4,6 In Sierra Leone, a vehicle and a communication system led to a two-fold increase in utilization of emergency obstetric services and a 50% reduction of in case fatalities.4,7 A substantial number of Liberians carry cell phones, allowing them to call an emergency dispatch number for assistance and transport if an emergency medical condition was immediately recognized. This suggest a need for community training to recognize
Significant test performed by Fisher's Exact
Patients under the age of 2 were more likely to be transported by taxi to the ER (89.5%) than other age groups (P=0.013) Table 3. Mode of Transportation by Severity of Condition Transportation Taxi
Car
Other
Blue (n=26)
16 (61.5%)
5 (19.2%)
7 (26.9%)
Red (n=28)
19 (67.9%)
6 (21.4%)
2 (7.1%)
Green (n=8)
3 (37.5%)
0 (0%)
5 (62.5%)
P-value= 0.028
CONDITION
REFERENCES
Significant test performed by Fisher’s Exact
1. Liberia Health Sector Needs Assessment. 2008. World Health Organization. http:// www.who.int/hac/ donorinfo/liberia_ cap2008_eng.pdf
Patients who were transported by taxi were more likely to have a serious health condition (red or blue)
2. Sasser S, Varghese M, Kellermann A, Lormand JD. Prehospital trauma care systems. Geneva, World Health Organization, 2005. 3. Razzak JA, Kellermann AL. Emergency medical care in developing countries: is it worthwhile? Bull World Health Organ. 2002;80:900-905. 4. Tiska M, Adu-Ampofo M, Boakye G, Tuuli L, Mock CN. A model of prehospital trauma training for lay persons devised in Africa. Emerg Med J. 2004;21:237239. More refs on page 14
Table 4. Condition by Age Condition Blue
Red
Green
<2 (n=19)
11 (57.9%)
8 (42.1%)
0 (0%)
2-10 (n=16)
6 (37.5%)
8 (50.0%)
2 (12.5%)
>10 (n=27)
9 (33.3%)
12 (44.4%)
6 (22.2%)
P-value= 0.185
AGE
Significant test performed by Fisher’s Exact
A higher percentage of patients <2 years of age presented with more critical health condition, but the difference was not statistically significant. Table 5. Condition by Time to ER Condition Blue
Red
Green
mean
41.35
91.29
281.25
mean (omitted outliers)
41.35
58
105
30
35
105
33.39
71.74
130.97
P-value= 0.173
TIME TO ER (MIN)
median std.dev (omitted outliers)
*omitted data included min = 1440 and 990 p-value based on mean (omitted outliers), performed by t-test
Patients with less serious health condition reported a longer traveling time to the ER, but the difference was not statistically significant. www.epijournal.com
13
“One-naught-eight” is the most widespread number in India for comprehensive EMS. The program is a private-public partnership operating in 10 Indian states. LIBERIA (CONT’D)
emergency conditions in homes and communities. In Mexico, the training of mothers and first-aid providers led to care being sought more quickly, and deaths in children due to respiratory and diarrheal disease among children <1 year of age decreased by 43% and 39%, respectively. Among children <5 years of age, mortality caused by these conditions fell by 36% and 34%, respectively,4,8 Another concern would be freedom from liability for any help rendered. First responders must feel competent to help and confident that there will be no adverse consequences if they act. Certain non-profit groups recently began to require medical volunteers to carry malpractice insurance at JFK Hospital, meaning that certain laws indemnifying Good Samaritans from liability need to be passed. The need to improve access to emergency care in Monrovia, Liberia is great, but the opportunities for growth are clear. Several low cost rudimentary interventions have been implemented in other low resource countries with impressive outcomes. Many of these concepts could be trialed in Liberia should emergency care become a matter of greater concern for the Ministry of Health.
REFERENCES (CONT’D) 5. Mock CN, Tiska M, Adu-Ampofo M, Boakye G. Improvements in prehospital trauma care in an African country with no formal medical services. J Trauma. 2002;53:90-97. 6. Sodemann M, Jakobsen MS, Mølbak K, Alvarenga IC Jr, Aaby P. High mortality despite good care seeking behavior; a community study of childhood deaths in Guinea-Bissau. Bull World Health Organ. 1997;75:205-212. 7. Samai O, Senegeh P. Facilitating emergency obstetrical care through transportation and communication, Bo, Sierra Leone. Int J Gynaecol Obst. 1997;59 Suppl 2:S157-164. 8. Guiscafre H, Martinez H, Palafox M, et al. The impact of clinical training on integrated child health care in Mexico. Bull World Health Organ. 2001;79:434-441.
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1.2 Billion Population 11 Percentage of all deaths owing to Chronic Respiratory Disease 26 Percentage of all deaths owing to CVD and diabetes 10 Percentage of all deaths owing to Injury 72,718,000 Number of registered vehicles in India (2004) 27% Deaths by road accident occurring by 2- or 3-wheeler riders 71 percentage of all vehicles registered in India that are 2- or 3-wheelers
Sources: World Health Organization; Espicom
Spring 2013 // Emergency Physicians International
INDIA
Subspecialties are growing in India’s expanding EM community, particularly pediatric EM, ultrasound, EMS, and disaster medicine. by tamorish kole, md
E
mergency Medicine is essentially a new medical specialty in India and is being developed to meet the acute care needs of the Indian population, which are somewhat different from other parts of the world where EM is more established. In the United States, EM was only recognized as a medical specialty in 1979, which is much later than other US specialties. Similar to India today, American EM physicians had to develop their own unique curricula and training programs before being accepted as an integral part of hospital care. In India the recognition of the need for EM is increasing, as India has one the world’s highest rates of road traffic accidents. In “Epidemic of Accidental Deaths and Emergence of Emergency Medicine in India,” Hamza et al estimated that 1,050,000 deaths occur each year in India due to poor road conditions and dangerous driving habits. Furthermore, they state that most accident victims arrived at the hospital in an auto rickshaw or a private car. For those who
did arrive in an ambulance, they received no care en route that would benefit the patient. India has one of the highest prevalence rates of heart disease. In addition to pre-hospital care, the need for emergency resuscitation and treatment of stroke is essential. Not only are Indians predisposed to diseases that require immediate attention best provided in an emergency department but the natural surroundings also leave them at risk to snake bites and plant poisonings. The ED is usually the best place to provide treatment quickly, to stabilize the patient, and to make an admission decision. Currently, there are four kinds of EM training programs available in India (Figure 1). The need for strong EM training programs in India has never been greater, and yet they are few and far between. We desperately need more of these programs providing leadership, training opportunities, and helping Indian doctors grow this area of specialty care.
SUDAN
Fig 1. Available EM Training Programs in India Courses
Affiliation
# of residents per year (approx)
MD
Medical Council of India
30
MCEM
College of Emergency Medicine (UK)
40
Masters in Emergency Medicine
American Universities (George Washington, Hofstra, SUNY Upstate Medical University)
100
Others
SEMI; Autonomous Institutes such as CMC, Vellore
40
Despite a class of newly minted EPs, emergency medicine remains an embattled speciality. by dr. hussain gasim abdelgadir
// Subspecialization
Publications
Subspecialties are also growing in India’s EM community, particularly pediatric EM, ultrasound, EMS, and disaster medicine. EMS: The Health Sector Skill Council of the Indian government and the National Allied Health Sciences Initiative are planning to launch courses related to EMS. EMS law for India is the need of the hour. There is also a need to standardize thousands of EMTs who are already in state-run ambulances in various states Pediatric Emergency Medicine: PEM is being jointly developed by the Society for Emergency Medicine in India (SEMI) and the Society for Trauma and Emergency Pediatrics. A one-year fellowship in PEM is being conducted in four hospitals in India. Ultrasound in EM: EM ultrasound is gaining popularity faster than in any other subspecialty. There are very popular short courses on EM ultrasound, such as the All India Institute of Medical Sciences (AIIMS) Ultrasound and Trauma Life Support, and courses from SEMI and the World Congress on Ultrasound in Emergency & Critical Care. Disaster Medicine: Various natural and man-made disasters continue to strike India. Government and private institutions are therefore keen to impart education for capacity building. The National Disaster Management Authority (NDMA) has recently signed a memorandum of understanding with AIIMS to train doctors in ATLS in four vulnerable states in India. SEMI has set up a Disaster Medicine section that is actively involved in various emergency management exercises conducted by NDMA.
India now has the following EM/EMS related journals in circulation: • Journal of Trauma, Emergency and Shock (indexed) • EMS INDIA (indexed) • National Journal of Emergency Medicine, from SEMI (non-indexed)
Advocacy SEMI, now a full member of the International Federation for Emergency Medicine, is playing a pivotal role in national EM capacity building framework. Certain activities worthy of mention include: • Advocating for Good Samaritan law in India to develop bystander care • Advocating for the adoption of a single emergency number across India • Advocating for more training courses in emergency medicine • Collaborating with other Asian Countries to develop EMS network The enormous need of a more advanced emergency care system in India will eventually be a priority for policy makers. Over time, more and more healthcare professionals will join the EM specialties and help improve the overall care standards. This will also pave the way for future research and innovation in India. Dr. Tamorish Kole is the head of emergency services, Max Healthcare, and the president of the Society for Emergency Medicine in India (SEMI)
It’s very painful when you see that emergency services are ruled by people who are not interested in emergency medicine and know very little about it. Equally painful is the idea that to change anything in Sudan would require extreme political negotiations and maneuvering.
P
olitics play a major role in the management of emergency medicine in Sudan. Currently there are only four board-certified emergency physicians in the entire country, including myself. No emergency physicians have worked at Sudan’s government hospitals until recently, despite the obvious urgent need. My three colleagues and I were sent to Malaysia to receive training in emergency medicine. We finished the program in 2011 and returned to Sudan with the hope of improving emergency services and training new residents in our local residency program. This has been a struggle, however, and improvements have been very slow. Most of the people who are running emergency medicine have not welcomed us and consider us as a threat to their current positions. As a result of that tension, our emergency departments are run primarily by non-emergency physicians. The ABCD approach is the least significant priority in most emergency departments, and airway management is very poor. Some patients languish in the resuscitation room for days. I personally discharged a patient home who was diagnosed as a case of inferior MI after 5 days in the emergency department. (Thankfully, he had received streptokinase.) Another patient, with malaria complicated by ARDS, was intubated and extubated after staying 3 days in the resuscitation room. It’s very painful when you see that emergency services are ruled by people who are not interested in emergency medicine and know very little about it. Equally painful is the idea that to change anything in Sudan would require extreme political negotiations and maneuvering. So much for just being a doctor; now we have to become politicians. www.epijournal.com
15
RESEARCH
Non-Operative Treatment of Acute Appendicitis French surgical literature suggests the use of prolonged IV and PO antibiotics instead of surgery in the case of appendicitis. We review the literature. by paul r. fraley, md
A
pleasant, intelligent, fit 75-yearold lady presented with acute ruptured appendicitis to Carolinas Medical Center USA in March of 2012. She was not taken to the OR, but admitted and given appropriate IV antibiotics for a week in the hospital, followed by an additional ten days of PO antibiotics, much like a case of moderate diverticulitis. She recovered successfully and even reported hiking, horseback riding and traveling as usual. Six months later, on the 23rd of September, 2012, she presented to Aiken Regional Medical Center Emergency Department with acute appendicitis clinically, visualized by CT and confirmed in the operating suite. This woman presented with the chief complaint of right lower quadrant abdominal pain for 24 hours. Pain was epigastric and migratory the day before she decided to be driven by her husband to the hospital; and oddly subjective fever at onset of pain, resolved that first night. The next morning pain increased, “worse than when my appendix ruptured six months ago,” and localized to McBurney’s point. Walking exacerbated the pain. There was no back pain, nor genitourinary symptoms. She was anorexic but had no vomiting diarrhea nor complaint of constipation. Past history revealed medical hypothyroidism, hypertension, lipidemia, prior hip surgery, and a D&C. She has no cardiopulmonary nor cerebrovascular nor malignancy or diabetes historically. Meds were levothyroxine, a beta-blocker with hctz, pravastatin & an OTC multivitamin. There are NKDA.
16
Physical Exam: Stoic, cautious ambulation, RLQ abdominal tenderness with positive Rovsing’s sign. CT without contrast was ordered prior to labs, and she was kept NPO. Radiology Imaging: “Significant inflammatory changes surround the cecum with the appendix swollen measuring up to 12 mm consistent with acute appendicitis ... with significant periappendiceal stranding... No complication such as abscess fluid collection or free air perforation.” Surgical Findings: “Laparoscopic appendectomy... General endotracheal... There was thickening of the small bowel and cecum ... with densely adherent appendix lying up against the ileum.” Post Operative Course: She was discharged the following day, and is doing well at home now on post op day #2. And she is doing well post-operatively long-term. Pathology Report: Acute Appendicitis
Discussion This patient being our first encounter with non-operative medical therapy for appendicitis in the United States, our South Carolina community hospital medical staff was fascinated enough to submit this case for discussion of the history and pros and cons of nonoperative vs. traditional conservative surgery for acute appendicitis. As a deputy ambassador representing the American College of Emergency Physicians International Section, and volunteering Medical Officer on the Operation Mobilization Ship Logos Hope in the Philippines earlier this year, I was privileged to meet the Chief of Surgery responsible for
Spring 2013 // Emergency Physicians International
training residents at Saint Lukes Medical Center in Manilla. This was the first time I learned of non-operative treatment for acute appendicitis. I was informed that his practice of prolonged IV and PO antibiotics instead of surgery was based on French surgical literature. The French Ministry of Health, Programme Hospitalier de Recherche clinique, published a Lancet article which states, “researchers have suggested that antibiotics could cure acute appendicitis. We assessed the efficacy of amoxicillin plus clavulanic acid by comparison with emergency appendectomy for treatment of patients with uncomplicated acute appendicitis.” Adults between the ages of 18 and 68 with uncomplicated acute appendicitis – as assessed by CT – were enrolled in six university hospitals in France. Of essentially 240 patients, about 120 were randomized to receive amoxicillin-clavulanate 3 grams daily (Unasyn for 8-15 days). The other 120 were allocated to undergo prompt appendectomy. Of 120 patients treated with Unasyn nonoperatively, 44 (one third) were taken to the operating room for appendectomy within the first year, 14 (about 10%) of these within the first month1. In another randomized clinical trial, this time published in the British Journal of Surgery, 202 patients were allocated to 24 hours IV antibiotics followed by ten days PO home antibiotics. Only half (52%) completed medical treatment; the other half had surgery. Of the nonoperative patients, 14% (15/106) developed acute appendicitis within sixteen months2. In an American study by Kaminski et al, 32,938 cases of appendicitis, all hospitalized, were assessed. Seven percent were abscessed, 18% had peritonitis, and 75% had uncomplicated appendicitis. Emergency appendectomy was done in 31,926, or 97% of patients. Three percent, or 1012 people, did not go to surgery, but were treated medically. Of these, 148 (15%) had interval appendectomy and another 39 people needed appendectomy within 4 years3. According to a meta-analysis on antibiotic therapy versus appendectomy for acute appendicitis published in the World Journal of Surgery in 2010, “Antibiotic treatment has been shown to be effective in treating selected patients with acute appendicitis, and three randomized controlled trials (RCTs) have compared the efficacy of antibiotic therapy alone with that of surgery for acute
REFERENCES 1. Vons C, Barry C et. al. Amoxicillin plus clavulanic acid verses appendicectomy for treatment of acute uncomplicated appendicitis: an open-label, non-inferiority, randomised controlled trial. Lancet. 2011;377(9777); 1573. 2. Hansson J, Korner U, et al. Randomized clinical trial of antibiotic therapy versus appendicectomy as primary treatment of acute appendicitis in unselected patients. Br J Surg. 2009;96(5): 473. 3. Kaminski A, Liu IL, et al. Routine interval appendectomy is not justified after initial nonoperative treatment of acute appendicitis. Arch Surg. 2005 Sep;140(9):897-901. 4. Varadhan KK, Humes DJ et. al. Antibiotic therapy versus appendectomy for acute appendicitis: a meta-analysis. World J Surg. 2010;34(2): 199. 5. Andersson RE, Petzold MG. Nonsurgical treatment of appendiceal abscess or phlegmon: a systematic review and metaanalysis. Ann Surg. 2007;246(5): 741.
appendicitis. The purpose of this meta-analysis of RCTs was to assess the outcomes with these two therapeutic modalities” in adults over 18 years old. Children and patients suspected of perforation or peritonitis preoperatively were excluded in these 3 RCTs. Of 350 patients treated with antibiotics only 200 remained asymptomatic after one year without re-hospitalization or surgery. 150 people received operative appendectomy or were re-admitted. Of these 150 patients, 38 who were re-hospitalized resolved their appendicitis with a second round of antibiotics without surgery and 112 underwent appendectomy4. While the authors of this meta-analysis did not personally experiment with non- operative medical treatment for their patients with appendicitis, their conclusion was, “This meta-analysis suggests that although antibiotics may be used as primary treatment for selected patients with suspected uncomplicated appendicitis, this is unlikely to supersede appendectomy at present. Selection bias and crossover to surgery in the Randomized Controlled Trials suggest that appendectomy is still the gold standard therapy for acute
appendicitis.” Up To Date in August 2012 references 78 articles on the subject of acute appendicitis in adults. Only four of these 78 articles studied nonoperative treatment, and three of these (sited here) were done outside the United States. Neither of the articles intentionally included nonsurgical medical therapy of perforated appendicitis. Uncomplicated appendicitis is distinct from perforated appendix. In the above French study, 18% (21 of 119) of patients with simple appendicitis by CT images were found to be perforated at surgery. During internship I was taught that with an adult’s inflamed appendix, 48% rupture in 48 hours. Swenson’s Text of Pediatric Surgery reported 85% of children with appendicitis were already perforated at the time of diagnosis. Abscess or phlegmon with appendiceal mass, and free (vs localized) peritonitis are further distinctions. This perhaps was a factor in the decision not to operate on our patient, when she originally presented. Delayed or nonoperative therapy of walled off abscess or phlegmon of the perforated appendix is supported by literature.
In a Swedish study of nonsurgical treatment of appendiceal abscess, abscess occurrence was reported in 4% of 61 studies of case series of appendicitis. 20% required drainage. Risk of recurrent appendicitis in patients treated nonsurgically was 7%5.
Conclusion Up To Date concludes that “The great majority of patients with acute appendicitis are treated surgically and an appendectomy remains the gold standard of care. As illustrated in the following randomized trials, some patients respond to medical therapy with antibiotics alone but are at appreciable risk for recurrent disease.” John C. McDonald MD, former Chair of Surgery at Louisiana State University in Shreveport, made a comment appropriate to this discussion, and relevant to our patient. “Sometimes doctors use the term conservative inappropriately. Conservative therapy is not synonymous with non-surgical. There are times when conservative care is to operate.”
CAVEATS Carcinoid and other tumors of the appendix are not discussed. Appendiceal obstruction by parasites is not included in this discussion. Appendicitis in third trimester pregnancy also is not discussed. Endometriosis of the visceral peritoneum of the appendix, for example in a young lady at Manilla Doctors’ Hospital in 2007, can be a rare cause of appendicitis. Not all hospitals in Manilla treat appendicitis nonoperatively.
October 21-25, 2013 Baltimore, Maryland, USA The International Emergency Medicine Faculty Development and Teaching Course is a weeklong educational experience, in Baltimore, Maryland USA, that combines didactic sessions, group discussions, and interactive workshops. The course is designed specifically to meet the career development needs of international emergency medicine faculty. It is intended for physicians who seek to enhance their own development as faculty members, to improve their skills as medical educators, and to participate in the development of emergency medicine in their home countries. Our goal is to provide course participants with:
COURSE DIRECTORS
§ a framework for faculty development that will help you advance in your career and prepare you to make valuable contributions to your department and medical facility § cutting‐edge information that will dramatically improve your skills as a medical educator § short‐term and long‐term mentoring in a faculty development and medical education project § an established relationship with the course faculty for long‐term career enhancement
Our distinguished course instructors are all faculty at the University of Maryland School of Medicine and include the following instructors: Dr. Rob Rogers—Course Director & Assoc. Professor Dr. Amal Mattu—Course Co‐Director & Professor Dr. Terry Mulligan—Course Co‐Director & Assist. Professor Dr. Haney Mallemat—Course Co‐Director & Assist. Professor
REGISTRATION IS NOW OPEN! For more information, please visit our website at www.teach.umem.org and www.theteachingcourse.com www.epijournal.com
17
the NNT
Post MI? Give Discharge Instructions That Will Actually Save Lives The elegantly (and deliciously) simple Mediterranean diet is among the most life-saving post-MI interventions. Look beyond statins and bring on the olive oil!
David H. Newman, MD Author of Hippocrates’ Shadow: Secrets From The House Of Medicine
by david newman, md
E
mergency physicians are trained for heroic procedures. Emergency thoracotomy, cricothyrotomy, post-mortem c-section, Mediterranean diet counseling… we do it all. Oh. Don’t know that last one? For decades the heart diet headlines have been dominated by Ornish, Scarsdale, Atkins, and the like. But while they were making headlines, the Mediterranean diet has been making data. A few moderate quality trials for the headliners have suggested that they may be useful in mild to moderate short term weight loss, but none has achieved the holy grail—long term heart benefits. In 1994 the Lyon Diet Heart Study, a rigorous randomized trial performed in post-MI patients, showed that a Mediterranean diet reduced heart attacks and deaths. Moreover, the findings were confirmed in long term follow-up in 1999, and have now been replicated several times. Here’s the best and most shocking part: In studies that showed the life-saving superiority of a Mediterranean diet the comparator was a diet of reduced cholesterol and fat (the American Heart Association recommended diet). Try to imagine what happens, therefore, when a Mediterranean diet replaces the average American diet. And yet, even against an AHA diet the raw life-saving numbers for the Mediterranean diet are astounding, particularly next to interventions that are much better known and routinely trumpeted by doctors, lay people, and health authorities. The Number-Needed-to-Treat to prevent one
18
The number needed to treat (NNT) for a few of the best known cardiac interventions Intervention
NNT
To save one life with defibrillation for sudden cardiac arrest
2
To save one life with statin pills post-MI
100
To save one life with aspirin during STEMI
40
To save one life with reperfusion therapy during STEMI
40
To save one life with a Mediterranean Diet, post-MI
30
MI, i.e. the number of people who need to use this diet for five years in order to prevent one heart attack, is 18. And to save a life the number is 30. Compare that to the NNTs for a few of the best known cardiac interventions (figure 1). Admittedly, the diet loses to defibrillation—but then, so does everything else. And note that five years of a Mediterranean diet is three times more powerful than five years of taking a statin (without the statin side effects). These numbers mean that the Mediterranean diet is among the most powerful interventions ever studied for heart disease. Moreover, in a Spanish study published last month, the diet reduced cardiovascular outcomes even in people without heart problems. And again the raw numbers dwarf most other interventions for preventing a first cardiovascular event. How can we use these data in the ED? One of the more vexing rituals in EM is the anemic discharge instructions we give to our
Spring 2013 // Emergency Physicians International
patients after a negative cardiac work-up. ‘See your doctor if the chest pain continues and, um, come back if you drop dead.’ Perhaps it is time to start adding a new instruction, an active endeavor to avoid the problem that worries them most. Here’s what we can say: • Eat more fruits (3 servings a day) • Eat more vegetables (2 a day, including a salad). • Use olive oils abundantly, including for salad dressings and for cooking. • Eat less red meat and more white meat • Indulge in plenty of fish (3 a week). • Snack on legumes like nuts and beans. • Eat red sauces. • If you’re so inclined, enjoy a glass of wine with dinner. If you’re like me, this sounds more like an oceanside vacation than a health intervention. Or, perhaps, it’s a heroic discharge instruction that might save some lives.
//
Admittedly, the diet loses to defibrillation— but then, so does everything else.
CURIOUS CASES
The Morgan Lens for Emergency Ocular Irrigation Patient enters, eyes inflamed.
The Tiger’s Bite
The Morgan Lens is inserted.
In the austere environs of an Afghan military base, infections can turn vicious in an instant. by keith a. raymond, md
N
othing is more frightening then the growl of a tiger while moving through the bush. It is a primal fear that makes one stagger in the path. Tending to a tiger in a cage can be just as frightening. Cornered, it is unpredictable. If you survive an attack the mauling wound is horrendous, permanent, and disfiguring. In Afghanistan, the conditions are such that every wound will become infected. While Tigers are not indigenous, they are present nonetheless. On Military Bases in Helmand Province, maintaining health and hygiene requires constant vigilance. Most toilet facilities are outhouses, and bathing may require a one kilometer walk through the desert in the dark in the early morning. In Kandahar, the UN ISAF troops took over an old Russian Base and expanded it until a Human Waste Pool and Treatment Plant that was once on the outside of the base is now a lake in the middle of the base. As a result the inhabitants live in a cloud of E. coli mixed with unpaved road dust. So it is little wonder that a scrape festers, and a laceration requires oral antibiotics. In this environment, good diet and exercise are essential to boost immunity against a myriad of virus and bacteria. This keeps not only the fighting man or woman on duty, but also the contractor on station and mission
enabled. Hitting the gym is essential to maintain both physical and mental health, relieving stress but also straining muscles. When those muscles get sore, self-care is encouraged and a healing balm has fewer side effects than Ibuprofen. When the patient presents to the clinic for such complaints, they are usually given Blue Ice Gel or Tiger Balm as first aid One day, I received a call from a paramedic at a Forward Operating Base concerning a rapidly expanding ulcer on a young man’s thigh. Two days previously, the patient applied Tiger Balm to a sore vastus medialis after a workout at the gym. He then applied an occlusive dressing over the site where he placed the Tiger Balm. As a result he developed a chemical burn. Initial treatment with topical and oral antibiotics per the paramedic was ineffective, and I was contacted the next day. On seeing the wound, I switched treatment to a burn protocol but over the next day his condition worsened. It was clear that on the initial presentation the chemicals had been either removed or metabolized, but the burn process continued. Once the underlying muscle was exposed the following day, I ordered a medical evacuation to a burn center. The patient required wide debridement and skin grafts, and his job was forfeit due to the long period of recovery.
In less than 20 seconds irrigation is underway, and your hands are free to help elsewhere.
OnLy with the MOrgAn LenS:
• “Hands-free” ocular irrigation – frees staff • Effectively removes chemicals or non-embedded foreign bodies • 100% of solution treats the eye – no pooling • Eliminates blinking reflex • Patient may be transported without stopping irrigation • Patient rests comfortably with eyes closed Fast, comfortable, and effective— there’s a reason 95% of the hospitals in the USA use the Morgan Lens.
®
To find a distributor in your country, go to www.morganlens.com | 001 406 728 2522 ©2013 MorTan, Inc., PO Box 8719, Missoula, MT 59807 USA
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R report
// journal scan
Global Research Review by Gabrielle A. Jacquet, MD, MPH on behalf of the Global Emergency Medicine Literature Review Group
USA_Is the Simplified Motor Scale (SMS) as good as GCS?
GLOBAL_Managing pediatric procedural pain without medications
Thompson DO, Hurtado TR, Liao MM, Byyny RL, Gravitz C, Haukoos JS. Validation of the Simplified Motor Score in the out-of-hospital setting for prediction of outcomes after traumatic brain injury. Ann Emerg Med. 2011;58:417-25.
Pillai Riddell RR, Racine NM, Turcotte K, et al. Non-pharmacological management of infant and young child procedural pain. Cochrane Database Syst Rev. 2011;(10):CD006275.
T
I
his study is a secondary analysis of an urban trauma registry that sought to validate a previous finding that the out-of-hospital simplified motor score (SMS) was comparable to the Glasgow Coma Scale (GCS) to predict 4 outcomes of interest: emergency tracheal intubation, clinically meaningful brain injury, need for neurosurgical intervention, and mortality. The authors analyzed a trauma registry composed of all trauma patients over a 9-year period (January 1, 1999 to June 30, 2008) who met any of the following criteria: required hospital admission, required ED observation unit admission for more than 12 hours, were transferred from an outlying hospital, died in the ED. This study compared the GCS and the SMS of the subgroup transported by EMS. The analysis included 19,408 patients from the registry who had complete outcome data. The need for emergent intubation, brain injury, mortality, and the composite of the four outcomes had significant differences (i.e. GCS better), however the confidence intervals were not significantly different. These results indicated the SMS is comparable to the GCS in the out-of-hospital setting to predict the need for clinically meaningful outcomes. Â When evaluated by prehospital providers, the Simplified Motor Score (SMS) may perform as well as the Glasgow Coma Scale (GCS) for predicting negative outcomes in patients with traumatic brain injury. The strengths of this article include the consecutive nature of the patient selection and the large sample size. The authors make a clear argument for simplifying the score used by out-of-hospital providers given the poor inter-rater reliability of the GCS. The limitations center around missing data, as 34% of the out-of-hospital GCS scores were absent. Additionally, this study was conducted in a large urban Level I trauma system in the United States, and patients were scored by paramedics and emergency medical technicians with considerable trauma experience. While the SMS appears to be easier to calculate then the GCS, these results need to be validated in resource-limited settings before adoption of the SMS scoring system can be recommended in these settings. EPI Note: If validated for use in low- and middle-income countries, the SMS has the potential advantage of being easier to teach and use, and could be utilized at community health centers or district hospitals to determine which trauma patients should be transferred to a higher level facility -GJ, MB
nfant pain management has improved in recent years, however evidence shows that it is still undermanaged. The authors of this Cochrane review assessed the efficacy of non-pharmacological interventions for acute pain in infants and children. Analyses were grouped by age (preterm, neonate and older), accounting for altered responses with developmental stage, and by pain response (immediate pain reactivity and delayed pain-related regulation). This review is the first comprehensive meta-analysis of non-pharmacologic pain management in children under 3 years of age. The authors searched 7 databases for randomNon-pharmacoized controlled trials (RCTs) and RCT crossover logic intervenstudies with a non-treatment control group. A tions to reduce total of 51 studies with 3,396 participants met pain are particuinclusion criteria. For preterm infants, the follarly important lowing interventions were found effective and in resource-poor recommended: kangaroo care, non-nutritive settings where sucking-related interventions, and swaddling. limitations in For neonates, non-nutritive sucking-related interavailability, safety, ventions were found effective. For older infants, and monitoring evidence was limited, but both non-nutritive sucking-related interventions and video-mediated make analgesia distractions may reduce pain response. There was and anesthesia significant heterogeneity in the primary literature, difficult. which limited the authorsâ&#x20AC;&#x2122; ability to confidently make further conclusions. Emergency care often necessitates painful procedures for young children, including blood draws, sutures, and injections. Non-pharmacologic interventions to reduce pain are particularly important in resource-poor settings where limitations in availability, safety, and monitoring make analgesia and anesthesia difficult. This Cochrane review represents the most comprehensive data currently available on non-pharmacologic interventions for children younger than 3 years. Non-pharmacological interventions can reduce acute pain perception in infants and children. While more research is needed, global EM practitioners can utilize the authorsâ&#x20AC;&#x2122; recommendations to manage pain perception in young children. -GJ, RM
G J : G a b r iel l e A . J acq uet, M D , MPH; MB : Mark Bisanzo, MD, DTM&H; R M : R e g a n Mars h, MD , M PH ; X L: Xiaoguang Li, MD 20
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If validated for use in low- and middle-income countries, the SMS has the potential advantage of being easier to teach and use, and could be utilized at community health centers or district hospitals to determine which trauma patients should be transferred to a higher level facility
MARTINIQUE_Dengue Management Update Thomas L, Moravie V, Besnier F, et al. Clinical presentation of dengue among patients admitted to the adult emergency department of a tertiary care hospital in Martinique: implications for triage, management, and reporting. Ann Emerg Med. 2012;59(1):42-50.
Of 715 cases of Dengue Fever, 332 were categorized as “Severe Illness.” Of that group...
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his prospective observational study aimed at improving the triage algorithms and appropriate reporting systems for Dengue fever. The authors analyzed the clinical presentations for 715 Dengue fever patients admitted to a local adult ED. Among them were 332 patients with severe illness, including Dengue hemorrhagic fever or Dengue shock syndrome (104 of 332), severe bleeding (9 of 332), acute organ failure (56 of 332), and dehydration and electrolytes imbalance (171 of 332). The dehydration and electrolytes imbalance group had no evidence of plasma leakage and responded well to normal saline infusion. The results suggested that hematological presentations may help differentiate uncomplicated Dengue fever from more severe forms, i.e., those who exhibit plasma leakage. Such patients require more aggressive treatment. This is a promising study to improve triage, management and reporting for Dengue fever on the international level. Several factors may have biased the results, such Martinique, an as limited ethno-geographic origin, no exclusion of comorbidities, or a short observaoverseas region tion time in ED. The study emphasized the diagnostic and therapeutic significance of France, is of plasma leakage, as the presence or absence of plasma leakage remains an important an island in the factor in directing treatment for patients with Dengue fever. The results could assist in eastern Caribthe development of a Dengue fever classification system for adult patients. bean Sea. -GJ, XL
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// drugs in the middle east
Amphetamine Abuse a Growing Reality in Saudi Emergency Departments Saudi Arabia accounts for upwards of a third of all global amphetamine seizures. Government officials have long been in denial about the growing problem, but emergency physicians are bringing the issue to light.
by eyad khattab, md
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ot long ago I had a night shift in the emergency department. While I was writing patient notes for a previous case a nurse asked me to look at a patient who was acting strangely: He was lying on the floor gasping for air. He could not talk and I still remember how he tried to show me the location of the pain by pounding his chest continuously. Before walking into the room I’d been ready to send the patient to the triage area, but then I saw the scene in front of me and quickly proceeded with checking vital signs, including EKG. Just then I was thinking an ischemic heart attack was occurring. The Acute Coronary Syndrome (ACS) Protocol was started immediately. At that time, his wife and son were waiting outside and I was able to talk to him alone. After asking me to close the curtain, he confessed in a low voice that he used stimulant tablets, also known as sympathomimetic drugs, and followed it by saying “don’t tell my family.” Fortunately, he survived that experience and hopefully learned from it. He was lucky to be alive. Because of religious and cultural norms, there has been insufficient research and lack of data collection on drug abuse in KSA, making it hard to identify the actual volume of the problem. In fact, some decisionmakers in the Middle East have been in denial for years that drug abuse occurs at all. However, that is slowly changing, in no small part thanks to the medical establishment. At medical conferences, suddenly the usage of stimulant drugs is becoming a big topic. I, for one, have witnessed too much drug abuse as a Saudi emergency physician to keep silent. I’ve compared notes with my brothers, both toxicologists, and the evidence is clear. One of the most common sympathomimetic tablets used in K.S.A is “Captagon”. However, Captagon was banned in 1986, so virtually all versions available today are Captagon mimics. According to a 2012 article in the Anatolian Journal of Cardiology, “Today,
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most of the Captagon mimic and counterfeit tablets contain amphetamine, caffeine, ephedrine, quinine, theophylline acetaminophen, diphenhydramine and lactose or a combination of these substances.2” Captagon mimics are currently a popular stimulant drug among the young population in the Middle East3. The Captagon trade journey usually starts from Eastern European countries then passes by into Turkey, then finally is shipped to the Middle East. Interestingly, Captagon is not widely used in Turkey2. Saudi Arabia has been reporting large amphetamine seizures since 2004. According to Council of The European Union, Saudi Arabia accounted for nearly 30% of all global amphetamine seizures in 20085. This represented a dramatic rise in amphetamine seizures in Saudi Arabia, which could signal the development of new routes and target populations for the drug. Another popular stimulant substance in the Middle East is Khat (Catha edulis). What complicates the situation and makes Khat hard to control is that it is legal and a common social habit in Yemen. Khat is packaged in Yemen and transported to Saudi Arabia. According to an overview of Middle East drug trends published in Life Science Journal, “Many Saudis also visit Yemen with the purpose of consuming Khat. Yet, Khat is cultivated as well in the Saudi Arabian part of the Yemeni border ( Jazan), where locals consider it as a part of their daily lives and culture.6” In Saudi Arabia, most of drug-related emergency room visits are due to drug abuse. The most frequently reported drugs are sympathomimetic followed by opiates, and psychotherapeutic drugs like Benzodiazepines. However, we do see a few cases of cocaine and heroin abuse from time to time. Cannabis is widely used in Saudi Arabia but does not usually cause acute medical emergencies. Psychosis and hallucination are the only cannabisrelated emergencies I have seen, and that was one
Spring 2013 // Emergency Physicians International
case. Club drugs like Lysergic Acid Diethylamide (LSD), Ketamine, and Gamma-Hydroxy Butyrate (GHB) are rarely reported. Car accidents secondary to drug intoxication are not uncommon. Euphoria, hypertension emergency, myocardial infarction, hyperthermia, rhabdomyolysis, and acute renal failure have been reported after the use of stimulant drugs like amphetamine. Opioid toxicity can lead to loss of consciousness, respiratory depression, pulmonary edema and coma. Convulsions and agitations are common with Benzodiazepine withdrawal. Many drug-induced emergencies are discharged with an out-patient follow-up appointment, though some needing admission. We need more research in order to understand the reasons behind this rapid increase in the number of cases of recreational drugs used in Saudi Arabia and the Middle East. We must understand the actual size and the amount of this problem, improve law enforcement efforts, and raise public awareness. We also need to develop plans to control this threat by using direct and indirect measures. Health education and information campaigns are a crucial part of any program, especially when we deal with behavioral issue like drug addiction and abuse. Finally, continuous evaluation of the outcomes is another valuable thing to do to determine program sustainability, design statistical measures, and know more about the community status before and after the application of programs. REFERENCES 1. Anglin, D.M., Burke, C., Perrochet, B., Stamper, E., Dawud-Noursi, S. (2000). History of the methamphetamine problem. Journal of Psychoactive Drugs. 32(2), 137-141. 2. Uluçay, A., Arpacık, K. C., & Aksoy, M. F. (2012). Acute myocardial infarction associated with Captagon use. Anadolu kardiyoloji dergisi: AKD= the Anatolian journal of cardiology, 12(2), 182. 3. Mahmoud A Alabdalla. Chemical characterization of counterfeit captagon tablets seized in Jordan. Forensic Sci Int. 2005; 152(2-3): 185-8. doi:10.1016/j. forsciint.2004.08.004. 4. UNODC (United Nations Office on Drugs and Crime). World Drugs Report. UN, New York. 2008. 5. Council of The European Union. Regional Report on the Near East. No. 5020/11 CORDROGUE 1. Brussels, Belgium. 2011. 6. Rahim, B. E. E., Yagoub, U., Mahfouz, M. S., Solan, Y. M., & Alsanosi, R. (2012). Abuse of Selected Psychoactive Stimulants: Overview and Future Research Trends. Life Science Journal, 9(4). 7. Ayalu A. Reda, Asmamaw Moges, Sibhatu Biadgilign, and Berhanu Y. Wondmagegn. (2012). Prevalence and Determinants of Khat (Catha edulis) Chewing among High School Students in Eastern Ethiopia: A
YOUR PATIENTS ARE ON THE CUTTING EDGE...ARE YOU?
T-RING ADVANTAGES: King Khalid University Hospital
{King Khalid University Hospital}
Emergency Department Profile “I am a teaching assistant and emergency room physician in King Khalid University Hospital, the biggest affiliating hospital to the college of medicine at King Saud University. Our emergency room is one of the most loaded emergency rooms in the country. As the only level one trauma center in the north region of Riyadh city, the capital of Saudi Arabia, we see approximately 130,000140,000 patients in the emergency room annually. The Department of Emergency Medicine (DEM) is responsible for diagnosing and treating a wide variety of ailments. Every day we are exposed to the full range of medical, surgical and psychiatric emergencies. In terms of trauma, K.S.A ranks in the top three countries for road accident deaths in the world. All of this adds up to a very busy emergency department.” -Dr. Eyad Khattab --------------------------FOUNDED: 1982 WHO IS KING KHALID? Khalid bin Abdulaziz Al Saud was King of Saudi Arabia from 1975 to 1982. FACILITY SIZE: 800 beds OPERATING ROOMS: 20 PATIENTS SERVED: The hospital provides primary, secondary care services for Saudi patients from Northern Riyadh area. It also provides tertiary care services to all Saudi citizens on referral bases. All care is free of charge for eligible Saudi patients including medications.
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Cross-Sectional Study. PLoS ONE. doi:10.1371/journal.pone.0033946 8. Ageely HM (2009) Prevalence of Khat chewing in college and secondary (high) school students of Jazan region, Saudi Arabia. Harm Reduct J 6. 9. Saudi amphetamine seizures increase to 28% of world total. Retrieved February 10, 2013 from The Financial Times Web site: http://www.ft.com/home/us
CONTACT: PRECISION MEDICAL DEVICES (302) 778-2335 FOR MORE PRODUCT INFORMATION www.epijournal.com WWW.THETRING.COM
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// kumbh
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mela
Caring for Millions in a Pop-Up Metropolis In February, EPI publisher Logan Plaster traveled to Allahabad, India with a global health team from Harvard to study healthcare delivery at the Kumbh Mela – the largest human gathering in history. 01
by logan plaster
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ast month marked the end of India’s Kumbh Mela, a Hindu festival billed as the world’s largest human gathering. Over the course of the 55-day festival, as many as 100 million ascetics and pilgrims traveled by train, car and foot to perform a bathing ritual in the Ganges river in the city of Allahabad. Some came for a single dip while others settled for weeks, inhabiting a temporary tent camp that is arguably the largest pop-up mega city ever erected. Just how big is the Kumbh? The number of people present on the busiest bathing days – about 30 million – is roughly the population of Shanghai and New York City combined. But instead of living in dense high rises, the nomadic pilgrims of the Kumbh reside in tents on a fair ground that is 7.5 square miles – an area only slightly larger than the footprint of the Atlanta Airport and roughly a quarter the size of Manhattan. Making matters even more challenging is the unique fact that the Kumbh Mela completely temporary. In a dry river bed that is submerged for part of the year, officials line out wide avenues, pontoon bridges and rows upon rows of street lights. By the end of March, the entire city will have been dismantled. By the time the monsoons arrive, almost the entire area of
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01 Pilgrims stream across a temporary
bridge over the Ganges 02 Local medical students who implemented the iPad EHR 03 Designated Kumbh Mela ambulance 04 EMS insignia 05 ECG instruments in the central
hospitals’s ICU 06 Kumbh pilgrims 07 Temporary bridges span the Ganges 08 In-patient beds at sector hospitals
were generally underutilized.
the Kumbh will be reclaimed by the rising rivers. In February I had the privilege of traveling to the Kumbh with a team from Harvard’s FXB Center for Health and Human Rights to study how healthcare is delivered in this unique and challenging environment. Specifically, given the prevalence of many communicable diseases in rural India, how could local authorities monitor illnesses in a way that allowed early warning of disease outbreak.
What we found was both impressive and delicate – an orderly, seemingly well stocked system always just one disaster away from being massively overwhelmed. One of the goals of our trip was to perform an experiment. Would it be possible – and helpful – to deploy an electronic record system to help health clinics record and collate complaints so that they can be tracked over time? Would this be a sustainable way to track important changes in disease presentation (like diarrhea to pick an ever-present threat) and create an early warning system for outbreaks? As it stood at the Kumbh—and in much of India—such a warning sign would come anecdotally, and only after hundreds had fallen ill. The first step was to gain a comprehensive understanding of the healthcare system at the Kumbh. The health facilities at the festival are impressive by local standards, but overextended and underutilized by any American perspective. The grounds are divided into 10 sectors with one health clinic per sector. They’re clean, well stocked and staffed 24/7 by rotating physicians. According to Dhruv Kazi, a cardiologist and healthcare economist on our team who was born in Bombay, this is good representation of what the Indian government can
accomplish when it so desires. Each day between 500 and 800 patients arrive and are seen – briefly – by one of the physicians on duty. While that number seems high – it dwarfs the daily census at any American emergency department – it is only the slimmest fraction of the Kumbh’s population. Why these health clinics have such low utilization per capita remains unclear. Clinic doctors come from government clinics from around the state and are assigned to the Mela for two months apiece. The doctors work in 8-hour shifts, have no official days off, and sleep in tents that are pitched adjacent to the clinic. Each hospital has a pharmacy with over 90 drugs that are provided free of charge. At the center of this pop-up health system is a central hospital, where patients can be seen by a range of specialists, including orthopedics, surgery, and obstetrics. There is a 100-bed inpatient unit and a 2-bed ICU. Diagnostic tools such as X-ray, ultrasound and electrocardiograms are available. Amazingly, during our visit to this hospital, it was anything but overwhelmed. There were many empty beds and there were virtually no queues. But in light of the millions upon millions of pilgrims camping nearby, one could only conclude that
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// kumbh
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Kumbh Mela Burning Man
=50,000 people
5000 ft
How does the Kumbh Mela compare to that other enormous, crazy pop-up city, Burning Man?
By total area, it would take approximately four Burning Man festivals to fit inside the Kumbh Mela grounds in Allahabad, India. By population, it would take more than 1,000 Burning Mans to equal the 2013 attendance at the Kumbh Mela. That’s using a conservative estimate of 50 million pilgrims over the course of the Kumbh; some estimates put the number as high as 100 million.
the relative tranquility of the hospital had much more to do with a lack of utilization than an inherent efficiency or readiness. How would trauma be handled on a larger scale? How was the sector hospital prepared to surge in size in the case of an emergency? Connecting these hospitals was a fleet of more than 100 ambulances which were responsible for transferring patients from the sector hospitals to the central hospital. The ambulances, like the doctors who staff the hospitals, were drafted from community health centers across the state. Each ambulance arrives with its own driver, who is then provided with accommodation at the Mela. “The ambulances themselves appear to be new and well maintained, with clean stretchers to transport patients and a hand-held radio device for communicating between ambulances and with central dispatch.” said Kazi. “Each ambulance carries an oxygen tank, a host of emergency medications, and four disaster kits: for drowning, burns, bomb blasts and stampedes. It is evident that a reasonable amount of thought has gone into designing each of the kits, but there are no paramedics (which is typical in India) and a physician must accompany seriously-ill patients. It appears that an ambulance makes 5-6 trips a day.” Yet, while the facilities at the sector hospitals
may have been well stocked, health records were nearly non-existent. As our team observed, after a one-glance patient encounter, the doctor quickly scrawled down age, sex and a chief complaint. These notes were mostly illegible, largely incomplete and essentially useless. It’s understandable given the strain on each doctor, but it made syndromic surveillance all but impossible. To address this issue, Harvard’s team created a simple iPad-based electronic medical record that tracks chief complaints and prescriptions and then deployed an enthusiastic team of Indian medical students and interns to gather the data from four clinics each day. The iPads were linked to a webbased portal that synced and collated the data, ran simple analytics, and provided real-time results. The building blocks—a few iPads and a webbased application—are elegantly simple, and the manpower manageable. But thanks to the proliferation of internet connectivity across India, these tools could allow rural clinics to “leapfrog” from handwritten charts to a portable, web-based system accessible on any mobile device. This would give previously unconnected clinics the benefits of real-time syndromic surveillance without the burden of a resource-intensive electronic health record system, something American physicians have struggled under for years.
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“First, we want to show that it is feasible to use low-cost technologies to gather quality data in a resource-scarce setting,” says Kazi. “The fieldwork for the project is being done with a small team of passionate (and remarkable) students wielding a handful of iPads. If we can do it, the government certainly can too.” So far the Harvard team has gathered more than 30,000 patient records, an impressive number by any research standards, and arguably the largest public health dataset ever gathered on a transient population. Their findings have been stable and predictable; most complaints are of cough and cold, and most prescriptions are for anti-inflammatory drugs, like ibuprofen. Prior experience might suggest that generating quality data in resource-scarce settings is prohibitively expensive and that ad hoc planning is therefore unavoidable. By collating and analyzing data from over 30,000 patients, the Harvard team turned that assumption on its head. With current smartphone and tablet technology and cell phone coverage, even the poorest, most remote medical systems can employ a cloud-based electronic medical records that spot outbreaks before they happen and save thousands of lives.
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Dawn at the Kumbh
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awn is perhaps the best time to witness the ancient ritual of bathing where the Ganga, or the Ganges river, meets the Yamuna. Together with a colleague, I descended from the hill where our tent was perched. He was a cardiologist from San Francisco who completed our team of four from Harvard’s FXB Center for Health and Human Rights. Harvard researchers have been here for weeks to understand the logistics, economy, and population control of one of the largest gatherings of humans ever. We heard the Kumbh long before we entered its hazy, golden streets. In fact, if you close your eyes anywhere in the river valley where this pop-up mega city has been erected, you can hear the constant, occasionally thunderous hum—car horns, public announcements and sacred song punctuated by the occasional blast of fireworks. But don’t close your eyes for too long. Cars and motorbikes speed down muddy makeshift roads made of endless connections of steel plates. One must keep their wits about them to walk safely on the Mela’s bustling avenues. The crowds are thick but subdued near the water, some anticipating and others savoring the memory of the morning’s sacred dip. The morning sun is full and low on the horizon, shrouded in a haze of smog. A family gathers at the water’s edge to light a paper diya, a handmade paper boat bearing a small, lit candle. Their prayers complete, they launch the offering into the Sangam, the confluence of the holy rivers. A long-haired Sadhu, or religious ascetic, plunges fastidiously into the shallows again and again, drawing the attention of a gaggle of foreign photographers. A woman squats shivering on the bank and tries to cover her cold, wet shoulders with a dry sari. The crowds are quiet, attentive to the task at hand. I, too, keep silent, feeling more than ever that I am in another’s world. I put my camera away and give what I hope is a friendly nod to a boy selling diyas made of large leaves. He knows I am a stranger, but his smile bridges the gap and welcomes me all the same.
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01 Lead Harvard
researcher Satchit Balsari 02 The open air central hospital 03 Crowds surge through one of the Kumbh Mela’s massive avenues
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// design
Powers of Observation In part III of EPIâ&#x20AC;&#x2122;s ED design series, Dr. Manuel Hernandez explains why designing observation units into the emergency departments structure improves care while lowering costs. 01
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nown by different names around the globe, observation units have become a new area of focus for maturing emergency medicine systems. Driven partly by inpatient capacity constraints creating access block for ED patients and the realization that emergency physicians can safely and cost-effectively provide advanced diagnostics and management for a number of diagnoses, the goals of observation units are quite simple. Namely, many observation units exist to expedite diagnostics for low-risk patients that, once risk-stratified, can be managed safely in ambulatory settings; to accelerate management of low-risk patient populations that, when managed aggressively, will not require longer inpatient management; and, in partnership with inpatient physicians to more effectively allocate inpatient beds for higher acuity patient populations.
Fig 2: Observation unit in close proximity to main ED and imaging
Emergency Department
Diagnostic Imaging
Observation Unit
The Case for Observation Units
The value of many observation units is rooted in their ability to reduce length of stay for a number of common conditions. Figure 1 illustrates that observation units have been responsible for lowering total patient length of stay from 20% to as mush as 65% for a number of common presenting complaints when compared to total length of stay when inpatient management is required (Greenberg, Roberts, Roberts et al, Ross). In addition to lowering overall length of stay for patients with a number of medical conditions, observation units, when properly implemented, have also been shown to reduce the overall 30-day cost of care for patients. A study by Jagminas, et al demonstrated a reduction in the cost of care for chest pain patients in an observation unit of nearly 20% compared to inpatient hospitalization while another study by Ross showed cost of care reductions approaching 45% for
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TIA patients ( Jagminas, Ross). While reductions in length of stay and total cost of care are valuable metrics, the value of observation units is dependent upon their quality outcomes and patient acceptance of the emerging clinical practice. Studies evaluating quality outcomes for both medical and trauma cases have demonstrated no variation in outcomes when compared to traditional inpatient management (Madsen, Ross). Similarly, assessments of patient satisfaction in observation units in the United States and Singapore both demonstrated overall patient satisfaction with the observation unit setting (Rydman, Ng).
01 Staff workspaces in proximity to patient treatment stations in the observation unit 02 Floor layout for observation units within close proximity of main ED and imaging suites.
Planning for an Observation Unit
The development of a successful observation
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All Images Š 2012 Cannon Design
Fig. 1: Comparison of length of stay (in minutes) for common ED conditions
The value of observation units, as measured in CDUs, is rooted in their ability to reduce length of stay 88
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unit begins with identification of the appropriate patient population. Diagnoses appropriate to an observation unit are those that can be safely and efficiently managed with accelerated diagnostics and treatment. In the United States the typical length of stay is less than 24 hours. In other models around the globe the length of stay may be up to 72 hours. While a number of organizations such as the Agency for Healthcare Research and Quality have published guidelines detailing recommended diagnoses for inclusion in an observation unit, the selection of appropriate presenting complaints will be dependent upon the available resources and standards of care of each individual health system. For example, systems able to provide daily MRI capability and / or carotid ultrasonography may opt to include patients presenting with TIA symptoms. Conversely, system without advanced abdominal imaging capabilities such as CT may find the observation unit the ideal location for serial abdominal exams for patients with medical or traumatic abdominal complaints. An additional consideration when planning for a clinical decision unit is the governance model to be selected. Specifically, who will be responsible for medical and nursing leadership of the department. Early evidence has shown that observation units operated exclusively by emergency medicine tend to yield lower lengths of stay for chest pain patients (Somekh, et al). This lower length of stay easily translates to lower total cost of care and higher capacity of any planned unit.
Croup
I.D.
A final important consideration is the technology required to support an observation unit and its proximity to the actual department. While these decisions will vary based on patients targeted for inclusion, projected volumes and available resources, a number of options exist. For example, observation units with a large proportion of chest pain patients may opt for an in-department cardiac treadmill versus leveraging nearby stress testing or CT diagnostics. Similarly, observation units caring for a significant amount of TIA patients may elect to position the unit in close proximity to a CT scanner. Observation Unit Design
The actual design of an observation unit is relatively simple and based upon the anticipated patient population to be cared for, projected volumes and cultural norms for healthcare delivery within a particular system. The first consideration is location of the observation unit within the larger clinical enterprise. If the unit will be operated by emergency medicine it is recommended that the observation unit be position adjacent to the main emergency department. Anecdotal evidence from multiple sites around the globe has shown that physical separation from the emergency department presents use of the observation unit as a general emergency department treatment area during periods of surge. While this may seem like a logical operational model, high-performing observation units will experience unnecessary
increases in length of stay and operational costs as a result of this decision. Figure 2 represents the location of the observation unit in close proximity to both the main emergency department and dedicated diagnostic imaging for the emergency department. Figure 3 (page 30) demonstrates an observation unit located adjacent to, but separate from, the main emergency department. In this model the two clinical areas are separated by a set of doors to distinguish their functions. In both models, the observation unit is physically separated from the main emergency department flow. Within the observation unit itself, there are two design standards that are typically employed across the globe. The first is an â&#x20AC;&#x153;openâ&#x20AC;? model. In the open model, patient treatment stations are typically separated by curtains or other moveable objects such as privacy screens. The open model allows for a higher capacity unit in a smaller space. While typically desirable for institutions with more constrained facilities budgets, these designs lack the privacy and infection control expectations commonly seen in some health systems. The lack of patient privacy during treatment and discussions with health providers is often cited as a point of dissatisfaction for patients in many parts of the world (Moore, Chaudhury, van de Glind) A benefit of the open design model is the ability of staff to visualize all patients with relative ease from most vantage point within the observation and, in particular, from the work stations. Another benefit is the ability to use the open model to cohort groups of patients as illustrated by the clusters of three, five and six bed pods within the unit. These clusters can be arranged to align with nurse staffing ratios, expected volumes based on presenting complaint such as chest pain or asthma, by gender or even to separate special populations such as pediatrics or patients with infection control considerations. The second common design model for observation units is the private room model, as demonstrated in Figure 4 (page 30). In the private room model, each patient is provided their own room for the duration of their stay in the observation unit. Patient rooms are commonly designed with uniform standards, technology and equipment so that any patient in the observation unit can be cared for in any room. The private room model is considered beneficial for increasing patient privacy, providing dedicated and comfortable accommodations for family members and to reduce noise levels which are typically much higher in open unit designs. The private room model is also considered to be advantageous for promoting www.epijournal.com
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// design
RECEPTION/ GREETER 2-214
CONSULT/ REGISTRATION 2-218
TRIAGE 2-217
TRIAGE 2-216 CORRIDOR 2-102
CORRIDOR 2-201
VENDING 2-122
COM 2-220
HALLWAY 2-122A 82 SF
Fig. 4: Observation unit with private room design
Fig. 3: Location of observation unit relative to main ED
STAFF TLT 2-419A
PUBLIC TLT 2-124
PUBLIC TLT 2-123
OBS EXAM 2-422
OBS EXAM 2-421
OBS EXAM 2-420
OBS EXAM 2-424
HALLWAY 2-403
TEAM CARE STATION 2-433
OBS EXAM 2-417
CLEAN HOLD 2-431
OBS EXAM 2-416 HALLWAY 2-402
MEDS/ NOUR 2-434
WORK AREA 2-435
OBS EXAM 2-425
Emergency Department
AHU #2 SHAFT S-2
OBS PT TLT 2-418
EQPM ALCOVE 2-432
HALLWAY 2-404
OBS PT TLT 2-415
TEAM CARE STATION 2-430
OBS EXAM 2-414
HALLWAY 2-401
OBS EXAM 2-426
RADIOGRAPHY RM 2-223
RADIOGRAPHY CONTROL RM 2-222
STAFF LOUNGE 2-419
OBS PT TLT 2-423
Observation Units
AHU 1 SHAFT ABOVE
SPECIMEN PROCESSING AREA 2-224
EXAM 2-310
EXAM 2-311
ELEC 2-312
EXAM 2-313
OBS EXAM (BARIATRIC) 2-428
WAITING 2-113
OBS EXAM 2-427
PRIVATE REGISTRATION 2-114
infection control, particularly when contract or respiratory precautions are indicated (Hamel, et al). Taking infection control measures one step further, some observation units are designed to include one or more reverse isolation rooms for respiratory precautions. When designing private rooms models, it is important that situational awareness is maintained in order for the staff to safely monitor all patients and monitoring equipment. This is often accomplished through the “racetrack” design where patient rooms are positioned in a rectangle around a central area
that includes staff workspaces that are position to face the patient rooms. The image at the top of page 28 illustrates a staff workstation facing private patient rooms. In this design the observation unit staff are about to visualize patients from their work stations. WAITING 2-112
VEST 2-110
Conclusion
Observation units provide the opportunity for emergency departments to efficiently and safely care for patients requiring extended diagnostics or treatment in a cost effective manner. Further, observation WHEELCHAIR STORAGE 2-111
OBS EXAM 2-413
EQPM ALCOVE 2-429
WORKROOMSTAFF 2-116
SOILED UTY 2-412
AHU #3 SHAFT S-3
EQUIPMENT 2-410
units have been proven to reduce overall length of stay for a number of presenting complaints and provide an effective solution to address access block stemming from potentially-avoidable admissions. Design evidence points to the benefits of private room design in observation units from infection control, patient privacy and patient satisfaction perspectives. Regardless, designing the proper observation unit requires careful attention to diagnostics needs, governance models and evidence-based design solutions tailored to the unique aspects of individual health systems and available resources. CORRIDOR 2-400
RECEPTION/ REGISTRATION 2-115
Chaudhury H, Mahmood A, Valente M. Nurses’ perception of singleoccupancy versus multioccupancy rooms in acute care environments: an exploratory comparative assessment. Appl Nurs Res. 2006 Aug;19(3):11825. Greenberg, RA, et al. A reduction in hospitalization, length of stay, and hospital charges for croup with the institution of pediatric observation unit. American Journal of Emergency Medicine, 7(24), 818–821. Hamel M, Zoutman D, O’Callaghan C. Exposure to hospital roommates as a risk factor for health care-associated infection. Am J Infect Control. 2010 Apr;38(3):173-81.
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Jagminas L, Partridge R. A comparison of emergency department versus in hospital chest pain observation units. American Journal of Emergency Medicine, 2005, 23:111–113. Madsen TE, et al. Observation unit admission as an alternative to inpatient admission for trauma activation patients. Emerg Med J. 2009 Jun, 26(6):421-3. Moore M, Chaudhary R. Patients’ attitudes towards privacy in a Nepalese public hospital: a cross-sectional survey. BMC Res Notes. 2013 Jan 29;6:31. Ng CW, et al. Patient satisfaction in an observation unit: the Consumer Assessment of Health Providers and Systems Hospital Survey. Emerg Med
Spring 2013 // Emergency Physicians International
NOUR 2-315
CORRIDOR 2-300
JC 2-411
EQUIPMENT 2-410A
HEART CENTER LOBBY 2-100
PUBLIC ELEVATORS
CORRIDOR 2-101
PUBLIC TLT 2-119
STAIR B S-B
COM 2-120
J. 2009 Aug, 26(8):586-9. Roberts, R, et al. Costs of an emergency department-based accelerated diagnostic protocol vs hospitalization in patients with chest pain: A randomized controlled trial. Journal of the American Medical Association, 278(20), 1670–1676. Roberts, R, & Graff, LG, Economic issues in observation unit medicine. Emergency Medicine Clinics of North America, 19(1):19–33. Ross, MA, et al. An emergency department diagnostic protocol for patients with transient ischemic attack: A randomized controlled trial. Annals of Emergency Medicine, 50(2):109–119.
EXAM 2-316
TRAUMA ELEVATOR
TRANSPORT ELEVATOR
EXAM 2-317
PIPE/DUCT SHAFT
ELEC 2-118
REFERENCES
EXAM 2-314
tion with an Emergency Department Asthma Observation Unit. Academic Emergency Medicine. 1999; 6:178183. Somekh NN, Rachko M, Husk G, Friedmann P, Bergmann SR. Differences in diagnostic evaluation and clinical outcomes in the care of patients with chest pain based on admitting service: the benefits of a dedicated chest pain unit. J Nucl Cardiol. 2008 Mar-Apr;15(2):186-92. van de Glind I, de Roode S, Goossensen A. Do patients in hospitals benefit from single rooms? A literature review. Health Policy. 2007 Dec;84(23):153-61.
Rydman RJ, et al. Patient Satisfac-
All Images © 2012 Cannon Design
PSYCH EXAM 2-318
R report
// fire in brazil
Regional EMS Rally After Night Club Blaze When Santa Maria experienced a tragic night club fire, emergency crews in Porto Alegre flew to their aid.
by drs. márcio rodrigues & bianca domingues bertuzzi 01
O
n Sunday, Jan 27th at 03:00 AM the world’s 3rd deadliest nightclub fire took place in the city of Santa Maria in southern Brazil. It was a party organized by college students, so most of those in attendance were between 18 and 25 years of age. Around 2:45 am, the band that was performing started a pyrotechnic show and a flare touched the ceiling. The ceiling had a flammable polypropylene foam used as an acoustic cover which caused the fire to spread almost instantly. The extinguisher didn’t work when triggered and there were no sprinklers inside the club. The burning foam generated a deadly cyanide black smoke making it almost impossible for the victims to breath and to find a way out. It turned the club into a deathtrap. There were 180 immediate deaths with more than 200 injured. The number of dead has since climbed to 241. The vast majority of the casualties were caused by the inhalation of the cyanide coming from the flammable product used to muffle the sound of the place. There were no cases of carbonization.
02
01 When Santa Maria’s emergency departments were overwhelmed, patients were transferred to nearby Porto Alegre by military aircraft
The Response
The city of Santa Maria has five hospitals and all of them were quickly overcrowded. Almost immediately all ICU beds were occupied and ventilators were no longer available. As soon as the fire was reported, neighboring cities started helping by sending to Santa Maria ambulances, ventilators and medications. Porto Alegre, the state capital located 300 km (186 miles) away, sent a volunteer group of emergency physicians, intensivists, nurses and psychologists to augment of the local staff. Equipment like ventilators, endotracheal tubes, normal saline,
02 Air transports were managed by teams of emergency physicians, even though emergency medicine is not yet a recognized specialty in Brazil. 03 The Kiss night club, where the deadly fire killed hundreds. 03
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R report
// fire in brazil
lactated Ringer’s and medications were also donated to Santa Maria. Hospitals in Porto Alegre started managing emergency departments and intensive care units to arrange as many ICU beds as possible to receive the victims from the fire. Recovery rooms were transformed into ICU beds, elective surgeries were canceled, emergency departments doubled their staff. Regardless of the lack of ICU beds in the city of Porto Alegre, 105 beds became available for the fire’s victims among public and private hospitals. Everybody started working for the same cause; even the population of Porto Alegre agreed to seek help only in emergency cases in order to leave more space for the burn victims. The physicians who volunteered to go to Santa Maria were designated to lead and attend the aeromedical transport. The aeromedical team consisted basically of emergency physicians. Even though emergency medicine is not a recognized specialty in Brazil, Porto Alegre has had an emergency medicine training program since 1994. The emergency physicians divided themselves in two groups: one to take care of the air transport and the other to manage the
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emergency departments among the private and public hospitals. This made the distribution of the beds much easier. The transports were made by military aircrafts and in 48 hours, 72 patients were transferred to Porto Alegre. All of the victims were intubated and the majority of them were already using vasopressors. Even though the victims were critical there were no complications or deaths in any displacements. There were 6-7 patients carried by plane and 1-2 by helicopter at a time. The amount varied according to the number of physicians available per flight. After 92 flights the transports stopped, leaving the city of Santa Maria with an adequate number of occupied beds for an ideal assistance. New technologies played a strong role throughout the emergency response. Portable ultrasound was crucial, especially when used as a guide to detect pneumothorax before the air transport. This helped to reduce the need of hospital staff involved with a patient. Telemedicine was another key element to this disaster response. We had conference calls with experts from all over the world about the best ways to treat the burn victims, especially the cases of smoke
Spring 2013 // Emergency Physicians International
inhalation. The lung problems we had were very similar to the ones Argentina saw in 2004 during a nightclub fire at the República Cromañón where 194 people died. There were 7 telemedicine meetings and this interaction among other centers became indispensable. Today a lot of the burden falls on the psychiatrists and psychologists who are in Santa Maria dealing with the mourning of the survivors, families and anyone else involved in this tragedy. The chain of survival continues, and hopefully those who are still hospitalized are going to be able to go home safe and sound. Disaster Preparedness: Fire Safety
It’s believed that the major fire safety hazards contributing to this death trap were the lack of exit doors – there was only one – and the lack of security personnel to control the situation. Having only one exit door for 950 panicked people –not to mention no emergency lights – was a clear disaster waiting to happen. In their confusion many club goers ran into the bathroom, thinking it was an exit, and couldn’t get out in time.
There were no commands from the security force prohibiting people who had fled the club from reentering. Many people died because they realized (or thought) their friends or relatives were not outside and decided to get back in to try to get them. Others died because they took it upon themselves to start pulling others from the blaze, even though they lacked masks or proper clothes. This could have been avoided with better command on the ground. There are lots of lessons to be learned from this tragedy. The first one is the necessity to enforce fire regulations. Many night clubs and bars are having their doors closed for failure to keep up to date with safety regulations. Moving Forward with an Organized Specialty
A key take-away from this disaster response is the reminder that emergency medicine needs to become a specialty in Brazil. Other states congratulated the state of Rio Grande do Sul for their quick organization in managing the situation. Without a doubt, what made the difference in Porto Alegre was the hard work of the emergency physicians who tirelessly talked to hospital presidents, local and state authorities and partnered with military aeronautics. They took initiative and demanded what needed to be done in order to deal with this catastrophe. It’s time that emergency medicine be a fully recognized part of the house of medicine in Brazil, not simply a third-tier add-on. Two big worldwide events – World Cup and the Olympics – are about to come to Brazil and the country needs to be ready. Bianca Domingues Bertuzzi is an emergency physician who currently works at Hospital de Clinicas de Porto Alegre. Márcio Rodrigues is an emergency physician and is the Unit Chief at the emergency department of the Hospital de Clínicas de Porto Alegre.
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Grand Rounds
PETER CAMERON, MD // PRESIDENT OF IFEM
Applying the ‘Quality Framework’ Now that IFEM has published a quality and safety framework, EPI executive editor Peter Cameron turns the spotlight on his own facility in Qatar. How does his new department stand up under scrutiny?
F
Following the successful launch of the quality and safety framework policy under the International Federation for Emergency Medicine (IFEM), now available on the IFEM website, I was stimulated to review
before, with different social and religious norms, made me a little nervous about my ability to interpret what I was seeing. Physically, we were in the middle of a renovation program, so the environment was suboptimal. There were cramped spaces, noisy building works, poor signage and “way finding”. I got lost just going from triage to the trauma room. In addition, there was significant overcrowding with patients pending admission cluttering the ED bays and little room for new patients. Patients were cranky to say the least, with a number of physical and verbal assaults evident. Staff were not communicating well and there was a lack of respect between professions exactly how I was going to measure quality in my own department and how we and also between services attending the ED. Further compounding the negawould know whether we were actually improving the department and its functive approach of staff was the fact that patients and their relatives showed little tions. The quality framework document asks some very simple questions: respect for the staff. There was a high commitment to working hard but a lack • Are the facilities adequate? of initiative to solve problems, especially amongst the junior nurses and doctors. • Are the numbers and quality of staff adequate? Observing processes, there was a lot of movement, much of which seemed • Is there a culture of quality? inefficient, with patients being moved backwards and for• Is the data support adequate? wards and poor handovers. There was a high level of noise • Are the key processes in place? and lack of coordination between doctors and nurses. • Is Access Block present? Gestalt vs. Metrics Communication was not efficient, with repetition and • Is evidence-based practice resulting in optimal results? I have noticed that misunderstanding. In spite of this, staff did smile and • Is the patient experience measured and acted upon? within minutes of greeted me with appropriate salutations. Doctors from • Is the staff experience measured and acted upon? entering an ED, most other units appeared to have little respect for ED decisions senior emergency and would frequently disagree with emergency physician By asking these questions and measuring as well as actdoctors will quickly opinions. ing upon the relevant parameters, it is likely that an ED decide whether the ED is Regarding culture, our department looked like it was in would function very well. functioning well or not. trouble. My gestalt, based on the “vibe” of the place, told I have always been a believer in the “gestalt” of medicine But what if the numbers me the ED processes and outcomes must be poor. So I tell a different story? at a clinical level – that is, by asking a few basic questions, looked at numbers to see if the quality indicators reflected a senior clinician can learn quite a lot. Is the patient sick? what I saw. Will they need to be hospitalized? Are they likely to die? Using typical indicators such as length of stay, the overall Usually, this clinician can give reasonably accurate answers numbers were good by any standard with a median time of about one hour for to these questions within minutes, approximating or even bettering elaborate total length of stay. Even patient satisfaction looked fairly good – over 90%. For decision rules with complex algorithms. Of course, there are some patient outlia department that sees over 1200 patients per day, figures such as mortality rates ers and we sometimes get it wrong… and complications also looked very impressive, with very low rates (not risk adWhen it comes to assessing the quality of an emergency department, simple justed). Even the indicators such as staff turnover were better than what I had questions give us a decent view of the ED as a whole. Is this a good department, been used to in Australia. Did this mean that my gestalt was wrong? somewhere I would bring my family to get treatment? Does attendance here reWell, not exactly. Statistics don’t always give the full picture. The length of sult in unnecessary morbidity or mortality? Is this a place I would like to work? stay numbers did not reflect the fact that there were a large number of minor paI have noticed that within minutes of entering an ED, most senior emergency tients that were handled very effectively, were managed by ED staff and turned doctors will quickly decide whether the ED is functioning well or not. There is a around within an hour. These patients were generally satisfied and received a “vibe” in a good department – people smile, they talk courteously to each other. reasonable service. However there was a small percentage of seriously ill patients It may be busy, but it looks like activity is coordinated. Clearly poor physical who were in the ED for many hours and a significant number waited for days facilities are immediately apparent and overcrowding is obvious with a quick for a bed. The time for admitted patients to reach an inpatient bed was averagwalk around. Outcomes are not obvious from quick observations, however, in ing more than six hours. Critically ill patients were receiving sub-optimal care. other industries there is good evidence that the right culture, or “vibe”, actually The low staff turnover was not necessarily related to satisfaction with the prescorrelates well with outcomes. ent job. Most staff were expatriates who came on fixed contracts and had limited So, getting back to my ED, what sort of vibe did I get walking around the ED options because of these contracts. In some cases they had no chance of returnwhen I first visited more than six months ago? Coming from Australia and being to their home country. This might bring stability, but it does not ensure an coming Chair of a very large department in Qatar, a country I had never visited
34 Spring July 2012 2013// // Emergency Physicians International
It is interesting to see that the cultural change appears to be happening faster than the numbers would indicate. In many organizational change situations, it is often easiest to get the numbers to change, even when attitudinal change has not occurred.
enlightened, enthusiastic, innovative workforce. Furthermore, there were staff shortages which resulted in extraordinary overtime and fatigue. This resulted in high levels of sick leave. Data on fully risk-adjusted outcomes for key diseases were difficult to come by. We are now developing the capacity to do this in trauma, cardiac arrest, stroke and intensive care patients. From the limited data we have, the trauma outcomes appear reasonable. Six months later, after initial policy changes, organizational changes and some senior staff recruitment, can we measure any positive changes? From the “vibe” perspective, it is clear that many of the staff feel more comfortable and are communicating with each other in a positive way. Importantly, staff feel free to bring forward suggestions regarding improvements to services and how they can make changes. Interactions with inpatient services still need work – but are mostly cordial. Visitors to the ED comment on the enthusiasm and positive attitude of the staff. The enthusiasm amongst the junior staff now is much higher than I have seen elsewhere. The question remains: how do these cultural changes translate into numbers? There is still very efficient flow of minor cases through the ED. Patient satisfaction is still high and staff turnover low. We still have access block for major cases, but it’s better than last year. More importantly, it is apparent that there is hospital engagement to get this fixed. Staff satisfaction is improving and sick leave has definitely decreased. Staff are now saying, “I want to work here”. It is interesting to see that the cultural change appears to be happening faster than the numbers would indicate. In many organizational change situations, it is often easiest to get the numbers to change, even when attitudinal change has not occurred. On this occasion, it appears to be the other way around. This may be partly because we have had major senior staff changes that have allowed rapid cultural change. There is a lot we don’t understand about organizational change, it may be that the most important changes are those we can’t measure.
IEDLI
International Emergency Department Leadership Institute
The International Emergency Department Leadership Institute (IEDLI) was created by Harvard Medical School faculty and other international experts to provide ED leaders with the skills and knowledge to operate successful 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 • Form a strong leadership structure • Educate and motivate ED doctors and nurses This program is designed for doctors, nurses and administrators.
www.IEDLI.org Early registration discounts end 31 July 2013!
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Spring 2013 // Emergency Physicians International
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