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Simple ED design tweaks on a budget The eight building blocks of austere medicine Karachi: Prepping the ED for the next blast Surfing doctors put new spin on training EMERGENCY PHYSICIANS INTERNATIONAL

ISSUE 13

. SUMMER 2014 . WWW.EPIJOURNAL.COM

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

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

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


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EDITOR’S DESK

Changing of the Guard

B

y the time you read this, the 2014 International Conference on Emergency Medicine (ICEM) will be underway in Hong Kong. At this biennial event, I will assume the duties of President of the International Federation for Emergency Medicine (IFEM). I will be following two genuinely esteemed prior IFEM Presidents, Drs. Gautam Bodiwala and Peter Cameron, who led IFEM after it significantly restructured eight years ago. I will give my best all out effort to continue their legacy of leadership. My vision in leading IFEM is for the organization to continue to be the world’s premier and leading organization for promotion and development of the specialty of emergency medicine worldwide, with the underlying main goal being to improve access to and quality of emergency health care in all countries. On my watch, IFEM will continue to strive to provide open access to all its products and services, since so many of IFEM’s members and potential members represent countries with poor economies. However this points out one of the major challenges for IFEM – a lack of funding. At this time IFEM does not have significant, reliable long-term financial resources to utilize to provide more direct assistance to its less resourced members. IFEM currently operates with significant financial support from the Australasian College of Emergency Medicine (ACEM) and the American College of Emergency Physicians (ACEP). Part of my vision for IFEM is for it to eventually be able to become financially independent of both ACEM and ACEP while maintaining its close working relationships with both organizations. I would like to see IFEM have sufficient funds to not only cover its administrative costs, but to directly supply teaching materials and programs and specific clinical care delivery programs to countries in need. One financial model – which may soon be realized – is the establishment of an IFEM Foundation, to which donors could directly contribute tax deductible funds. I happen to believe strongly that IFEM’s mission and activities promote global peace and stability, so it is my hope that regional and international organizations will see IFEM as a cause worth supporting financially. Besides financial challenges, I think the next big step for IFEM is addressing and helping find solutions for the emergency physician workforce issues which are problematic in a number of countries. IFEM will be addressing both local issues (such as excessive work assignments or caseloads) and national problems, like lack of governmental support or reduction in financing of emergency care. And of course IFEM will continue its presentation of ICEM, the best international emergency medicine conference in the world. In two years I look forward to welcoming you to the next ICEM in Cape Town, South Africa, and in 2018 we will gather in Mexico City. From 2019 onward, ICEM will start being held every year – a number of exciting venue bids are already being considered. IFEM has many ways for you to get involved, from using our educational materials (most of which are posted on IFEM’s web site www.ifem.cc) to joining one of IFEM’s many committees, task forces, or work groups. Or you can just reach out and say hello; all of us in the IFEM leadership are very interested in your ideas on what IFEM should do in the future and how the organization can function and serve its members better. I look forward to hearing your feedback, and I hope to personally greet you in Hong Kong, Cape Town, and Mexico City!

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

Besides financial challenges, I think the next big step for IFEM is addressing and helping find solutions for the emergency physician workforce issues which are problematic in a number of countries. IFEM will be addressing both local issues (such as excessive work assignments or caseloads) and national problems, like lack of governmental support or reduction in financing of emergency care.

Simple ED design tweaks on a budget The eight building blocks of austere medicine Karachi: Prepping the ED for the next blast Surfing doctors put new spin on training EMERGENCY PHYSICIANS INTERNATIONAL

ISSUE 13

. SUMMER 2014 . WWW.EPIJOURNAL.COM

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

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

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

ABOUT EPI With a quarterly print and digital distribution and an online network of more than 2,000 members, EPI is the essential hub connecting global emergency care, sparking dialogue and creating a space for new collaborations. Find copies of the print magazine at international EM conferences around the world, or read it online at www.epijournal.com

www.epijournal.com

3


LETTER FROM THE PUBLISHER

Resource Reality Check

I

remember walking around the exhibit floor at a recent EuSEM conference with an emergency physician colleague. At every booth, a proud spokesman hocked his wares and every time we walked away, my friend would shake his head. “Sounds great,” he’d say each time, “but we can’t afford it.” At every turn, he offered me his DIY, do-more-for-less solution to the shiny, wiz bang tech on offer. Why? Because he was from a resource-limited environment . . . known as the United Kingdom. Far from the so-called “developing world,” he was experiencing the kind of tightening budgets that lead to limits in care and training. In the world of global emergency medicine, countries are often stratified by economics – those who have and those who have not. Where we used to say “third world,” we now call a country a “resource poor” or “resource limited” setting. Even the term “developing country” has fallen out of favor because it implies that all countries are developing along the same “Western” trajectory. Ask the Bhutanese how they are “developing” and they’ll eschew GDP in favor of their excellent Gross National Happiness figures. Clearly, availability of resources is relative. The United States spends more than $8000 on healthcare per capita, compared with $1621 in Qatar and $126 in India. However, with the USA up to its eyeballs in debt and the UK considering privatizing the NHS, it’s clear that we live in a resource-limited world and we need to manage healthcare accordingly. Docs who have worked in varying international settings (i.e. our readers) get this better than most. They understand that there is best evidence, and there’s practical reality. Depending on where you practice, you might not always be able to get a specialist consult. And if you’re in a rural setting, there might only be enough blood on hand to save a couple major trauma patients at a time. What do you do? You adapt. In this issue, Manuel Hernandez talks about design improvements your ED can implement without breaking the budget (page 16). On page 30, Haywood Hall writes about how simple, lo-tech emergency obstetrics courses can markedly improve maternal mortality rates. As healthcare budgets across the world continue to shrink, EPI will be working to share the innovative spirit of the “global” emergency physician with EPs everywhere. By doing so, EM will become well situated to guide healthcare systems in the delivery of effective, resource-appropriate care for the world’s sickest patients.

Logan Plaster Publisher

on the web

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

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Summer 2014 // Emergency Physicians International

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

Emergency Physicians International is a product of Portmanteau Media LLC ©2013


JOIN THE #1 NETWORK FOR GLOBAL EMERGENCY MEDICINE WWW.EPIJOURNAL.COM JO B BOAR D | MAGAZINE ARC HIVES EVE NT CAL E N D A R | DISC USSION BOARDS

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EVENT CALENDAR 08/14–11/14 THE COMPREHENSIVE GUIDE TO GLOBAL EM CONFERENCES

AUGUST Emergency Tasmania 2014 // Cradle Mountain, Tasmania, Australia August 8-10. 2014 www.conferencedesign.com.au/et2014 Contact: anna@conferencedesign.com.au

SEPTEMBER International Emergency Care Symposium 2014 // Melbourne, Australia September 4-5, 2014 http://bit.ly/1oGh7CG Contact: etc@alfred.org.au

DevelopingEM 2014 Brazil // Salvador da Bahia, Brazil September 8-12, 2014 developingem.com/dem-2014 Contact: developingem@beatmedical.com

3rd Annual Conference on Surfing Medicine 2014 // Sligo/Mullaghmore, Ireland September 9-13, 2014 www.surfingdoctorseurope.com Contact: conference@surfingdoctorseurope.com

8th Annual Symposium on Advanced Emergency EKG - Mediterranean Cruise // Barcelona, Spain

European Congress on Emergency Medicine (EuSEM 2014) // Amsterdam, The Netherlands September 28 - October 1, 2014 www.eusem2014.org Contact: contact@eusem2014.org

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

IN THIS ISSUE www.epijournal.com

03 | Editor’s Letter 04 | Publisher’s Letter

Field Report 8 | Egypt

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

10 | Hong Kong

NOVEMBER

Departments

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

Young emergency physicians make their mark in Europe.

12 | India

13 | Next Gen

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

14 | Essay

EMCON 2014 (16th Conference for the Society of Emergency Medicine India) // Mumbai, India

16 | Interview

November 6-9, 2014 www.emcon2014mumbai.com Contact: vamahospitality@hotmail.com

4th Eurasian Conference on Emergency Medicine // Belek, Turkey

Harmonizing your ED: Lessons in leadership from the orchestra pit. Adaptability and flexibility are the key to efficient, low-cost ED design solutions.

Reports 18 | Journal // Global A new review by the Global Emergency Medicine Literature Review Group

November 12-16, 2014 www.eacem2014.org Contact: secretariat@eacem2014.org

20 | Doctors on the Edge

5th World Congress on Emergency Medicine // Guadalajara, Mexico

24 | Notes from Karachi

November 19-22, 2014 www.urgenciasmexico.org Contact: cgr@att.net.mx

September 14-21, 2014 www.floridaep.com Contact: isales@floridaep.com

DECEMBER

12th Asia Pacific Conference on Disaster Medicine // Tokyo, Japan

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

September 17-19, 2014 convention.co.jp/apcdm12 Contact: apcdm12@convention.co.jp

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

Dr. Darryl Macias offers advice on how to manage austere medicine missions. A delegation from Harvard’s South Asia Institute visited the Aga Khan University Hospital and observed some of Pakistan’s unique emergency care challenges.

27 | Medical Education’s Next Wave of Collaboration The European Association of Surfing Doctors combines a passion for surfing with cross-specialty emergency training.

30 | Maternal Health EP-led emergency obstetric courses help meet WHO maternal mortality goals

32 | Grand Rounds Qatari EPs use the outbreak of MERS to improve infectious disease practices.

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

Summer 2014 // Emergency Physicians International

34 | Dispatches Has the outbreak of MERS in the Middle East impacted your emergency department?


The new C-MAC® Monitor

AN 44 11/2013/A-E

Fine, Fast, Focused – Toggle Between the two Video Endoscopes

KARL STORZ GmbH & Co. KG, Mittelstraße 8, 78532 Tuttlingen/Germany, Phone: +49 (0)7461 708-0, Fax: +49 (0)7461 708-105, E-Mail: info@karlstorz.de KARL STORZ Endoscopy America, Inc, 2151 E. Grand Avenue, El Segundo, CA 90245-5017, USA, Phone: +1 424 218-8100, Fax: +1 800 321-1304, E-Mail: info@ksea.com KARL STORZ Endoscopia Latino-America, 815 N. W. 57 Av., Suite No. 480, Miami, FL 33126-2042, USA, Phone: +1 305 262-8980, Fax: +1 305 262-89 86, E-Mail: info@ksela.com KARL STORZ Endoscopy Canada Ltd., 7171 Millcreek Drive, Mississauga, ON L5N 3R3, Canada, Phone: +1 905 816-4500, Fax: +1 905 858-4599, E-Mail: info@karlstorz.ca www.epijournal.com 7 www.karlstorz.com


FIELD REPORT SUMMER 2014

t Chairman of the Egyptian Red Crescent Governing Board is appointed by a presidential decree, renewable every three years.

EGYPT Initiatives, prescriptions and imperatives to overcome Egypt’s most pressing emergency medicine problems by drs. walid hammad,

mohamed a mohmed, nermen khairy, jon mark hirshon

I

n 2002, emergency medicine was introduced as a recognized board specialty in Egypt. Though still a young in its formation, there has been growing interest in emergency medicine and its training continues to evolve. However, there remains a wide difference between training and current practice. Emergency Departments (EDs) are still viewed by both patients and other specialties as “hospital reception units” that mainly function as triage units to direct patients to specialty departments or specialty disciplines within the ED for management. The old structure of separate EDs for surgical and medical 8

patients still exists in Egypt. Thus, the emergency physician’s role is viewed as the inter-departmental referring physician, a perspective that creates a discrepancy between modern training and practice. There are five emergency medicine educational programs in Egypt which are primarily based upon the British model of obtaining a masters or higher degree. The largest of these, the Egyptian Fellowship program, is supported by the Ministry of Health and Population (MOHP) and is the country’s most formalized and acknowledged training program. During the past two years it has transitioned from a 3-year to a 4-year residency program that grants its graduates board certification in emergency medicine. According to published data in 2009, the Egyptian Fellowship boasted 24 accredited training centers, 33 trainers and 218 trainees. Additionally, in aiming for international recognition of its emergency medicine curriculum, the Egyptian fellowship has successfully collaborated with the College of Emergency Medi-

Summer 2014 // Emergency Physicians International

5 Emergency medicine educational programs in Egypt

2012 Founding of the Egyptian Society of Emergency Medicine (EgSEM)

cine (CEM) in the United Kingdom. The Membership of the College of Emergency Medicine (MCEM) part A exam is now held in Egypt, giving emergency physicians the opportunity to further their education and improve their credentials closer to home. Egypt’s first society for emergency medicine (EgSEM) was founded in 2012 and is dedicated to improving patient care by advancing the science and practice of Emergency Medicine. EgSEM is an interdisciplinary organization whose members are involved in the provision of emergency care. It envisions an environment in which every patient receives safe, efficacious, and high quality emergency care. EgSEM held its first conference along with the Egyptian Society for Intensive Care and Trauma (ESICT) in December 2012. Driven by the growing interest in emergency medicine, the MOHP and a number of universities have hosted several trauma management courses. The University of Maryland School of Medicine (UMSOM), in collaboration with the MOHP and Ain Shams University and sponsored by the U.S. National Institutes of Health’s Fogarty International Center, established the Sequential Trauma Education Programs (STEPs). These programs are a key educational component in the process of improving trauma care. To date, approximately 750 trainees from Egypt and other countries in the Middle East and Africa have participated in STEPS training courses. Initially, the lectures and training were run by U.S. physicians, but now the program is completely taught by trained Egyptian physicians. From a practice perspective, interest is growing in establishing trauma centers within areas known to have frequent and multiple injuries. These injuries are primarily traffic crash (blunt) injuries, and trauma centers often include the Al-Ahly Bank hospital on Cairo’s ring road and Al-Zaytoun hospital in Al-Zaytoun area in Cairo. While not formally designated as trauma centers, these hospitals represent an attempt to


l

improve trauma care through improved management of patients. Injuries remain a significant cause of morbidity and mortality in Egypt. Structured and laid out as individual treating specialty areas, EDs still generally act as reception and triage units and are primarily staffed by junior specialty physicians, each having their own “private” workroom. Thus, EDs may be viewed as 24-hour outpatient clinics with some form of emergency treatment delivery and management. This frequently creates irregular flow and mis-triaging of patients based upon specialty requirements rather than urgency. Hospital administrations, various specialty physicians and even patients contribute to this problem, due to endemic expectations. The desire for specialty-driven care is a trend among Egyptian patients and significantly impacts the perception of medical security and trustworthiness of treatment. A general lack of public awareness to the importance and role of emergency medicine and EDs contributors to the current scope of practice. There is certainly a need to address the issue headon to attain an improved model of emergency care. Troublingly, this urgency is met with several barriers to the development of the scope of practice of emergency medicine. All emergency training programs share a significant knowledge gap and lack of supervision of junior physicians. Due to financial and economic stresses, most of the senior physicians charged with supervising young in-training physicians are usually not available to spend time teaching in emergency rooms. Many of the physicians, including the seniors, hold more than one job to sustain a living. Emigration to higher income countries also contributes to the lack of qualified supervisors able to train future generations. Many of the emergency trained physicians in Egypt realize that their skills can be improved. Money, welltrained supervisors, structured training programs, and suitable work environ-

During the Egyptian Revolution in 2011, a Kentucky Fried Chicken on Tahrir Square was converted into a makeshift clinic aiding the injured and dispensing drugs.

Report: ‘Arab Spring’ Could Help Slow Down Regional Brain Drain

ments seem to be the biggest barriers. The evolution and continuation of riots and social instability following the Egyptian revolution on January 25th, 2011 creates an additional stress on the need for further development in the provision of emergency care and management and growth of emergency medicine as a specialty. However, until the Egyptian society and political structure stabilizes, it will be difficult to move forward with substantial system improvements in the provision of emergency care.

The Egyptian Fellowship Program, by the numbers: 4-year residency 24 accredited training centers 33 trainers 218 trainees (2009)

SUBMIT A FIELD REPORT EPI’s “Field Reports” section is a vital way to keep your colleagues up to speed with your region’s medical developments. Send reports to Logan@EPIJournal.com for consideration.

Despite trends of emigration by senior emergency physicians, one positive trend is that the Arab revolution has shown some signs of reversing brain drain within governments, international organizations, and the private sector. Other nations are becoming aware of a “window of opportunity for the region to leverage its ‘youth bulge’ …” International support could stoke reform as these professionals return to Egypt with a modern understanding of ED practice and a renewed passion for Egypt’s future. world economic forum’s

2011-2012 arab world competitiveness report.

www.epijournal.com

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FIELD REPORT SUMMER 2014

HONG KONG tal executives, (2) revamp the process of in-patient bed allocation and (3) control of the influx of old age home residents through the enhancement of hostel visitation doctors

by dr c.w. kam

SOS Survey In an interesting SOS (ServiceOriented Survey), a self-administered questionnaire in 2012 by the HKSEMS (Hong Kong Society for Emergency Medicine & Surgery), over 65% of the respondents (192 doctors & 314 nurses – 40% of the workforce of the HK EDs) indicated the preference to switch from ED to other units or to quit, indicating a very high level of dissatisfaction and burn out. Respondents suggested three main remedies to help with burn out: (1) reduction of the non-clinical workload of the clinicians coupled with additional assistance by the non-clinical staff; (2) introduction of flexible work incentive; (3) prevention of non-booked mainland pregnant patients from using ED for delivery. The latter two solutions have been implemented and hopefully working conditions would further be improved.

H

10

NEW YORK CITY

Hon 7.2 M

Sing 5.3 M

HONG KONG

This year’s ICEM host struggles against high EM burn out rates and a lack of food regulations in the marketplace

ong Kong, known for its towering buildings and bustling economy, is a city of increasing healthcare demand. In this city of 7 million, there are around 12,000 doctors with about 450 serving in the 17 emergency departments (16 public & 1 private). This month Hong Kong will also be known as the hub of global emergency medicine as it hosts the International Conference on Emergency Medicine, a multi-faceted symposium covering the recent advances, major controversies and cutting-edge technology in emergency medicine. Access to emergency care has been strained in the past few years owing to an aging population, more space required for infectious disease isolation and brain-drain of the public doctors to the private sector. It’s gotten so bad that, despite heavy demand, some inpatient wards have closed. In the past, most ED patients admitted to the hospital waited 30 minutes to and hour to get a bed. Now, it would take several hours in many hospitals to obtain a bed allocation. In one hospital, it is quite usual to wait up to day for a bed. The long-term policy of constructing more hospitals and turning out more medical graduates can hardly extinguish the current burning fire. Currently we need to (1) focus on making the in-patient admission interval a key performance indictor among hospi-

New 8.3 M

EMW – Emergency Medicine Ward Hong Kong EDs have developed the EMW (Emergency Medicine Wards) for about eight years as short-stay units to manage some of the less serious cases (chest pain, poisoning, disturbed patients, chest infection, acute pyelonephritis, cellulitis, musculoskeletal pain) with the aim of shortening the total length of stay (LOS). This model has one EM specialist do the ward rounds two to three times a day. The conventional model has a junior ward round followed by senior ward round, and only one regular ward round per day.

Summer 2014 // Emergency Physicians International

SINGAPORE

1990

p The current 1990 Population of three megacities

8.3 Million New York City

7.2 Million Hong Kong

5.3 Million Singapore Sources Include: World Bank, United States Census Bureau

2012 One the average, the LOS can be shortened from two to three days to 21 to 2010 232000 hours. EMWs might sound like observation units, but the term “observation” is falling out of favor. It is felt to be too passive, too much, “Wait and see until the patient deteriorates and dies”. On the contrary, the “emergency medicine ward” provides timely, necessary treatment and actively monitors and reviews the patient’s progress. There has been a recent proposal to rename the EMW as the Emergency Medicine and Toxicology Ward since most qualified toxicologists in general hospitals are emergency physicians. Nearly all stable poisoning cases are managed in the ED or on the EMW. The severe poisoning cases would continue the treatment in ICU after the initial critical care in the ED. When the patient’s condition has been optimized and the poisoning treated, most Hong Kong EDs now transfer these patients to the EMW instead of the conventional in-patient ward to perform the subsequent care including psychiatric consultation, monitoring of the body functions and future poisoning prevention. Avian Flu Every year during the flu season – winter and spring – patient volume surges in the ED. To worsen the situ-


The introduction of Emergency Medicine Wards aims to shorten the length of stay from 2-3 days to less than 1 day.

ation, there are sporadic cases of avian flu imported from the southern parts of the Mainland of China. These cause tremendous workload to the HK city as physicians have to manage more critical patients, conduct large-scale contact tracing and post-exposure prophylaxis administration, and ramp up PPE and infectious disease history screening. These and many other reactive measures have led to tremendous additional workload and expenditure. For physicians to take part in the prevention of avian flu we must work with healthcare policymakers to prevent the general community from coming into direct contact with the

excreta of the live poultry in the market. This will require a major change in the cuisine culture in China, including the adoption of central slaughtering of chickens in isolated facilities and the replacing of “delicious� fresh chicken with safer frozen chicken in the market. This challenging work includes negotiations with poultry farmers and the market dealers as well as the compensation for the business change. However, health protection should be of higher priority and we hope the government will accomplish the risk removal in the coming few years.

12,000 doctors in Hong Kong 450 doctors working in emergency wards 17 Number of emergency wards in Hong Kong (16 public, one private)

Simulation-Based Education High-fidelity clinical simulation training has been carried out by anesthesiology for over two decades. In the past five years, EM has started utilizing simulation to train the juniors as well as to enhance the skills of the seniors on resuscitology, traumatology, critical airway management, paediatric resuscitation, obstetric emergency, vital clinical communication and efficient team work.

www.epijournal.com

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FIELD REPORT SUMMER 2014

This year’s International Summit of Emergency Medicine & Trauma (ISEMT) gathered more than 1000 emergency care workers from across India in Pondicherry.

INDIA International collaborations have enabled EM in India to progress rapidly in the last 15 years, but a lack of trained physicians remains a major hurdle. by anita bhavnani, md pankaj arora, mbbs

T

&

hey were a cute couple: he was 70 and she was 64 years old; they were on vacation and jet lagged from their long flight from the US to India. Not being able to sleep, they decided to go out for their morning walk. It was 5:30am. They enjoyed a peaceful walk and witnessed the early morning stirrings of the city. They crossed the last road before climbing the hill to get to their apartment, with him 10 steps ahead of her. What neither of them saw was the truck that was driving just a little too fast. It struck her broadside, throwing her nearly 10 feet. He rushed back to find her conscious and in a lot of pain. He didn’t have his phone with him since he hadn’t gotten the Indian SIM card yet. He looked up for someone to help him; no, the truck had not stopped. Within a minute a taxi did come by and the driver was kind enough to allow him to use his phone and offered to take them to the hospital. There was no emergency number to call in this city so with the help of the taxi driver he scooped up his wife, placed her in the back of the taxi and rushed her to the hospital. She remained conscious though in a lot 12

of pain. Upon arriving at the casualty ward of the nearest hospital, the doctor (a general medical officer, 2 years post-MBBS, no residency training) examined the patient and determined that they were unable to take care of her injuries at his hospital. Over the next hour he went about arranging for ambulance transportation to a higher acuity hospital. Little was done for her in that hour: no stabilization, no IVs and no pain medication. She was placed in an ambulance and transported to the second hospital. She died en route. There are so many ways that this tragic story could have played out differently in another city in India or in another part of the world. There are some cities in India, such as Calicut, with well-known emergency phone numbers, well-developed pre-hospital systems and state-of-the-art emergency departments where emergency medicine is practiced by EM-trained physicians. But the fact remains that in general, India’s emergency medicine system is in its nascent stages and emergency care is often inadequate or variable at best. Most casualty wards are ill equipped and ill-staffed and they more closely resemble triage centers versus emergency departments.

Summer 2014 // Emergency Physicians International

Currently, there are less than 500 EMtrained physicians in India. Officials say that that number needs to grow tenfold to adequately serve the population.

The need for a more developed emergency care system throughout India is palpable. It is a well-known fact that India remains the road traffic accident capital of the world. On top of that, heart attacks and strokes are leading causes of death. Currently, there are less than 500 EM-trained physicians across all of India and some officials say that that number needs to grow to 5000 to adequately serve the population. What will it take to grow the EM workforce tenfold? It starts with education. Emergency medicine residency programs will need to train new physicians with the knowledge and skills for modern emergency care. Emergency medicine was officially recognized by the Medical Council of India in 2009 and by the National Board of Examinations in 2013. As a result, residency training programs are cropping up across the country. The quality of these residency programs is variable with little standardization. Additionally, it is impossible to train residents in EM without having faculty that have EM training themselves. Herein lies the rate limiting step to addressing the dearth of well-trained EM doctors. Innovative collaborations with US institutions CONTINUED ON PAGE 31


Next Gen

Young Emergency Physicians Make Their Mark in Europe

Dr. Pieter Jan Van Asbroeck is the chair of EuSEM’s Young EM Doctors Section.

EM trainees organized under the EuSEM banner set aside national goals in favor of a united vision of European emergency medicine. by dr. pieter jan van asbroeck

D

espite its standing as a relatively new specialty in Europe, some enterprising trainees in emergency medicine have envisioned the potential of a group to represent their colleagues in European EM regulatory bodies. With the hopes of achieving such, the Young Emergency Medicine Doctors section (YEMD) was formed as part of the European Society for Emergency Medicine (EuSEM) in 2011. In many European countries there is a vast need for more structured EM education and the YEMD is organizing courses for EM trainees. These ‘Refresher Courses’ are aimed at standardizing practice across the continent. The first courses organized in Berlin (Germany) and Turku (Finland) and a course on ultra-sound in Ljubljana (Slovenia) were a great success. Croatia is next on our list and even cooperation with the Middle East could be a possibility. Having participants from all over Europe and beyond gives the course great educational value while creating a unique environment that makes it possible to learn the variability of health care organization from country to country. The ultimate goal is to define a fixed standard of accredited EuSEM courses which will travel around Europe. While we are mindful of the need to keep our courses as low-priced as possible, this can be prohibitive in expanding them. Receiving large amounts of sponsorship from industry has never been part of EuSEM’s culture.

Ideally, we would like to set up a European exchange program between EM residents, but this is very difficult to impose from a practical and legislative standpoint. Working conditions vary widely in Europe. Obtaining the requisite insurance for each country is just one of the logistical barriers. The US resident associations have existed much longer than the YEMD, and they represent a model to be followed. Admittedly, a single language and government make it much easier to organize and collaborate. Europe’s complexities add to the obstacles and EM is still far away from being accepted as a full specialty in many countries. While we fully recognize the difficulties in attempting to recreate the US model in Europe, we can make our mark in other ways. At EuSEM, it has been beneficial to have separate tracks for trainees and young doctors. This creates opportunities to mix and mingle between residents, young doctors, and experts in the field. It is also important to keep a tight bond with our younger colleagues who have not yet graduated. We fully support and endorse the newly founded International Student Association for Emergency Medicine (www.isaem.net). This organization comprises a group of extremely enthusiastic students who are interested in pursuing a career in emergency medicine. It is certainly a victory that YEMD is represented in most European EM

bodies. We are, however, frequently lacking the money and time required to achieve all the goals we pursue. It is also not easy to find enthusiastic people who are willing to engage them. As is the case with most organizations, it is easier to find people willing to verbally endorse ideas than it is to find those that are eager to tangibly help reach your goals. We therefore plead for a stronger support of the future leaders in emergency medicine. Envisioning the future and achieving goals can bring European EM to the next level. It is vital that we set aside our nationalism and unite behind a European vision. We need to continue along the path we have started. We have set the first steps and are hopeful for what lies ahead. If you wish to contact the EuSEM Young Doctors please send an email to yemdsection@gmail.com

A participant practices ultrasound technique at a recent YEMD course in Ljubljana, Slovenia.

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Essay

Harmonizing Your ED: Lessons in Leadership from the Orchestra Pit Want to learn how to better lead your emergency department? Consider putting down your stethoscope and picking up a conductor’s baton. by dr. barbara hogan president of the european society for emergency medicine

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ast weekend, I decided to lead a team of 50 highly-trained, motivated professionals – including several prima donnas. I made decisions under time pressure, with no leeway for error, but in the end, I created harmony. No, I wasn’t working an extra shift leading my emergency department in Hamburg, Germany. I was taking a special training course about how to conduct an orchestra. The parallels in the leadership of an emergency department and conducting 14

an orchestra have long fascinated me, partly because they both are as much art as science. You can see and hear the dire results immediately when an emergency department or an orchestra is not led properly, but the precise formula for success is complex and extremely difficult to find. I traveled to Berlin for the first session of the seminar, which took place in the Berlin Philharmonic Orchestra’s grand concert hall where the likes of Herbert von Karajan and Leonard Bernstein have conducted. Our course was called

Summer 2014 // Emergency Physicians International

Conducting and Leadership (Dirigieren & Fuehren). The group of nine participants gathered in the concert hall and were immediately assigned a spontaneous task: listing the essential qualities that a conductor must possess. Here’s what we came up with: visibility, clarity, creativity, charisma, transparency, professionalism, musical virtuosity and the ability to interpret. But, truth be told, most participants said they had no idea of what conductors actually do apart from wave their arms around and acknowledge applause. Our seminar leader, Professor Gernot Schulz, an eminent German conductor, showed us the three basic figures to conduct music in the three main slow, medium speed and fast rhythms using the right hand. He also showed us the basics of using your hands to direct the orchestra to play more loudly or quietly. He also explained that the key point of conducting is not to order the orchestra to play the beat of every note but to give the impulse for the music — at precisely the right moment — and to set the speed of the music. Between the impulse strokes, the conductor gives guidance, allowing the musicians to use their own genius to contribute to the music’s beauty. We began with an exercise of

Dr. Hogan hones her EM leadership skills at an orchestra conducting training course


An emergency department leader needs to be visible and accessible. Instructions must be very clear. But if you have no vision about the daily work of your department, how can the clearest instructions be carried out to reach your goal? conducting the other students in handclapping. We quickly discovered that even this was difficult. You need to decide in advance what you want and then communicate clearly what people must do. Non-verbal communication is 80 percent of conducting, we were told. Only 20 percent is musical knowledge. Next came our first encounter with a musician and with another part of conducting: The orchestra will do exactly what you tell them. If you tell them to play in the wrong beat, then, guess what, they will play incorrectly. Our pianist would play the prelude from Bizet’s opera Carmen with full Spanish temperament and passion – if you gave him the correct beat. But if you gave him the beat of a funeral march, he would play Carmen like a dirge. The day ended with a concert from the Berlin symphony orchestra with special seats watching the conductor from the front. Here we could see a master at work, using the techniques we had just learned — but, with the minimalism of the maestro, to gain the maximum beauty of the artistic work through the harmony of the orchestra. The music was fantastically beautiful because the conductor maximized every musician and brought them together as a single unit and by trusting them to perform their solos. The next day we had the chance to put this active and passive learning into action by conducting an orchestra of 50 musicians ourselves. We learned that an orchestra consists of sub-units with a leader: such as the violins, violas, cellos, wind instruments and percussion. Each of the leading players needs clear instructions from the conductor with the other players in the section following. We learned that breathing and eye contact are crucial. My first piece was the allegretto from the second movement of Beethoven’s symphony number 7, slow music which builds up in stages like a procession

coming closer and closer. I brought myself into the starting posture with upright yet relaxed body with both hands up in front of my body. Then I made eye contact with the leaders of each section to ensure they were ready to start. I learned the initial intake of breath is a vital signal that I am about to start and the intake of breath was part of the beat, creating controlled tension like a sprinter ready to start a race. I gave the signal for the orchestra to start with a clear stroke of the baton, which also gave the critical impulse for the music. The impulse stroke always goes downwards as a straight and clear stroke. The following strokes can be smaller, giving harmony to the music. You allow the musicians freedom to play their harmonies after your main impulse, letting them use their skill to achieve a creation of beauty. Then came a new impulse stroke with eye contact with the section leader as each section of the orchestra joined in one after another as we built up slowly to the piece’s crescendo. I signaled the increase in volume by gradually widening my arms until the beautiful crescendo was reached. Then I gave a clear signal with my fist – rather like catching a ball – that we had reached the end and we must stop, suddenly all together. I felt a wonderful wave of happiness because I had created this music. I had directed the musicians to play this great piece of beauty. I had had to fight the urge to shut my eyes to enjoy the wonder of Beethoven’s genius because I would have lost eye contact with the musicians and so lost control of the orchestra. The next challenge was to conduct music with very different speeds: The fire-like pepper of Brahms’ Hungarian Dance and the luscious and faster harmonies of the minuet from Mozart’s symphony number 39. I was delighted to get a round of applause from the musicians who “clap” by hitting their music stands with their

bows. The musicians also gave direct feedback to the student conductors about what they found good and bad, this can be fun – and can be painful. Thinking back about the words we had used to describe what talents a conductor needs, I came away convinced of the strong parallels between an orchestra and an emergency department team. An emergency department leader needs to be visible and accessible. Instructions must be very clear. But if you have no vision about the daily work of your department, how can the clearest instructions be carried out to reach your goal? An orchestra comes together to create work with the highest possible perfection. So does the team in an emergency department. What work, after all, could be more critical, more essential, than saving lives when every minute counts. The role of an emergency department leader is to provide the impulse, to guide physicians, to help them use their genius to care for patients, not to control them every second of the day. Providing clarity, giving a clear goal, holding the controlled tension until the goal is reached but allowing the team freedom inside this structure is the challenge when you “conduct” an emergency department. Furthermore, no emergency department leader should insulate themselves from feedback, good or bad. Charisma? The experience of conducting 50 musicians to create beautiful music certainly gave me the feeling I indeed had charisma. Whether this is true will have to be judged by the people who watch my next EuSEM speech! And to my ED friends, if, at a moment of stress, you’re wondering how to make your department function harmoniously, remember: The answer may lie in your ability to provide the right impulse, at the right moment, to bring everyone into harmony.

Providing clarity, giving a clear goal, holding the controlled tension until the goal is reached but allowing the team freedom inside this structure is the challenge when you “conduct” an emergency department.

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Q&A

The Best ED Design Promotes Flexible, Adaptable Spaces Dr Manuel Hernandez suggests that mixed-use exam rooms and a re-ordering of the patient intake area are examples of simple and low cost design solutions aimed at increasing efficiency. interview by logan plaster

EPI: In what countries are you seeing innovative design in emergency medicine? Are certain countries putting a higher emphasis on this than others? DR. MANUEL HERNANDEZ: One of the often overlooked aspects of designing healthcare spaces is that the design solutions needs to reflect the clinical and cultural realities of the communities being served.  For example,  what works well in a North American emergency department that sees 150 patients a day is not going to work in a Chinese emergency  department that averages over 1,000 patient encounters per day.   The operational, staffing, and technology considerations are, and should be, vastly different in these environments. In North America much of the innovation in emergency department design is being developed in community hospitals that are heavily focused on balancing clinical quality with efficiency and the optimal patient experience. This is where all-private room designs first emerged, as did operational innovations like physicians in triage, the use of advanced technologies for arrival, and new registration processes. In emergency departments in Asia, the Middle East, and Gulf Cooperative Council countries, the emphasis has been on designing solutions that support parallel patient streaming in an effort to 16

support hundreds of patient arrivals per hour.  In this situation, the design solutions are very different than those employed in North America. For example, designing a 200 treatment station emergency department with all-private rooms would be spatially impractical. EPI: When we talk about the best design in emergency departments, a lot of it can feel like it has to be high tech and expensive. What’s an example of great design being implemented that is lo-tech and easy on the budget?  HERNANDEZ: Great  design does not need to be expensive or overly reliant on technology.  The greatest solutions I have seen in emergency department stem from proper pre-design planning activities that focus heavily on rethinking the process and patient flows. They are then able to translate these into responsive physical solutions. A perfect example of this type of design thinking is demonstrated in emergency departments that have placed the x-ray unit closer to the arrival and intake zone with the intention of securing the xray prior to physician evaluation.  With the proper policies and procedures in  place, this model accelerates patient throughput without adding any  additional expense to the design solution.  Another great example of low-cost

Summer 2014 // Emergency Physicians International

innovation is the introduction of the vertical patient model that replaces some expansive exam rooms with trolleys and smaller treatment stations with lounge chairs. This solutions reduces the footprint of the department which translates into lower design and construction fees while maintaining the overall capacity of the department. EPI: A lot of emergency physicians want a better-designed emergency department yet they are a decade away from a full re-design. What is a simple first step that an ED can take towards better design today?  HERNANDEZ: It’s  important to remember that design is about more than the physical space. Design is about the sum of all parts that come together to create the entire emergency department experience. It’s about how processes, staffing, models of care, technology, equipment and the physical space interact with one another in ways that deliver results beyond what any solution

BudgetFriendly Design Tips -----------

1. Place the x-ray unit close to the arrival and intake zone in case x-rays need to be taken prior to physician evaluation. 2. Replace expansive exam rooms with trolleys and smaller treatment stations with lounge chairs.


Designing flexible, adaptable spaces that can provide services to a patient with a fracture one minute, a patient with a corneal abrasion the next, followed by a patient enduring chest pain represents the most efficient and effective emergency department design available today.

could provide on its own. Many emergency departments are not in a position today to engage in a full-scale renovation or redesign.   For those that are in this situation they can still achieve improvements in efficiency and patient experience from simple, inexpensive solutions.   My experience has been that this process is best achieved by looking comprehensively and objectively at where the department is today with respect to performance and where it realistically aspires to be in the foreseeable future.  With a clear picture of the distance between current and future state of the ED, decisions can be made that will help  it advance toward creating an optimized structured and a methodical approach.   In many instances completely innovative patient flow  models can be developed within existing spaces.  Innovation in process is simple,  inexpensive and offers some  of the best design solutions available. EPI: What one design fix (big or small) does nearly every emergency department need? Put another way, what is the highest-yield design improvement world wide?

HERNANDEZ: In my experience the most important design innovation that can be incorporated into any emergency department  design is flexibility  and adaptability to the  physical environment. If you look at the evolution of emergency  departments across all countries where emergency medicine as a specialty has grown and evolved, what we do and how we do it has evolved.  If our physical environments are not able to respond we risk compromising quality, performance,  efficiency and cost.   One the worst mistakes  I see many new emergency departments make is overspecializing their design solutions.  Insisting on specialty treatment spaces such as an eye room, an orthopedic room, a gynecology room and the like result in rigid spaces that are unable to serve multiple functions when demands require. This results in underutilized spaces.  Designing spaces that can provide services to a patient with a fracture one minute, a  patient with a corneal abrasion the next, followed by a patient enduring chest pain represents the most  efficient and effective emergency department design available today. EPI: What are the global trends that you’re noticing in emergency department design? Differences by region?  HERNANDEZ: Emergency department design varies considerably across regions.   In North America and other advanced emergency medicine models we are seeing a number of key trends evolving.   The first trend, which began many years ago, is the evolution of the

all-private room emergency department design.   Additionally, the inclusion of clinical  decision (observation) units in emergency department design is gaining momentum, particularly in the  United States.   Additional emerging trends in design include internal waiting areas that are able to serve as clinical spaces when necessary, evolving patient intake and triage concepts, and a growing number of dedicated  behavioral health zones. These include exam and consultation rooms, safe rooms, and patient reception/waiting areas that are separate from the main emergency department. In other areas of the world the emphasis has been on evolving design to reflect the growing prevalence of emergency medicine, advancing diagnostic capabilities, and evolving patient expectations for their emergency department experience.   As  I discussed earlier,  countries with high-volume emergency departments such as India and China are experimenting with patient streaming designs that focus on  receiving a large number of patients simultaneously without the typical queues that result.   Advances are also taking place in response to new emergency models of trauma and critical care in which the emergency department often play a prominent role.   Another major innovation we are seeing is in response to pandemic situations like the MERS outbreak in the Middle East. In this model, emergency departments are able to respond to a profound surge in patient volumes with potentially communicable  conditions while  continuing to manage the general  emergency department  population that continue  to seek care during a pandemic.

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journal // global

Global Research Review by Torben K. Becker, MD on behalf of the Global Emergency Medicine Literature Review Group

KENYA_An analysis of patients presenting to the emergency departments in Kenya demonstrates a need for the development of a more sustainable emergency care system. Wachira BW, Wallis LQ, Geduld H. An analysis of the clinical practice of emergency medicine in public emergency departments in Kenya. Emergency Med J. 2012: 29:473-476.

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urrently, emergency medicine is not an organized specialty in Kenya. Most of the ED’s are run by clinical officers and physicians who lack specific training in emergency medicine. There are very few published data on patients seen in the ED in Kenya or their clinical management. Most ED’s do not even keep records of the patients seen in the department. This is the first study to describe the profile and outcomes of patients presenting to ED’s in Kenyan hospitals: In this observational study, the authors sought to explore the range of demographics, chief complaints, interventions, and management of patients that presented to public emergency departments (ED’s) in Kenya. The study was conducted over a three month period from October 1 through December 31, 2010. A total of 15 public ED’s participated in the study, including two national referral hospitals, five secondary level hospitals, and eight primary level hospitals. All patients presenting alive to the ED who were seen by a doctor or clinical officer were included. Data collected on each patient included: age, sex, presenting complaint, investigations ordered, clinical management (including medications and procedures performed), diagnosis, and disposition. Any patient that had incomplete data or who had multiple ED visits was excluded from the study. Data on 1887 total patient presentations was obtained. Of the chief complaints, trauma-related (21%) and respiratory (20.8%) presentations were the most common. Only 545 (29%) of the patients received interventions in the ED, which included blood tests, imaging, and specimen tests (urinalysis, sputum cultures). Ultimately, 74% (n=1391) of the patients were discharged, 19% (n=354) were admitted to the wards, 7% (n=127) were referred to a specialist or other hospital, and <1% (n=8) went to emergency surgery. Even though only 15 of the total 235 hospitals in Kenya were included in the study, the results appear to be representative of the typical patient profiles. One limitation of the study was that they were not able to determine bounceback rates or outcome data for the patients. The 3 month study period was also not long enough to evaluate for weekly or seasonal trends in the different hospitals. With Kenya’s growing population of over 38 million people, it is essential to develop a sustainable emergency care system for the country. This study highlights a number of important features of ED presentations and patient management in public hospitals across Kenya, which has significant implications for the development of this emergency care system. -TN, HD

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SOUTH AFRICA_A needs assessment involving community leaders can facilitate the establishment of a first responder system that can appropriately assess and stabilize emergencies in the field. Sun JH, Wallis LA. The emergency first aid responder system model: using community members to assist life-threatening emergencies in violent, developing areas of need. Emerg Med J. 2012; 29:673-678.

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his paper is a narrative analysis and post-intervention survey describing the establishment of a first responder system in a violent, resource-poor urban district in South Africa with poor access to Emergency Medical Services (EMS). The authors sought to identify a cost-effective strategy to improve EMS at the local level in this unique environment. They utilized a needs assessment followed by a pilot training course and first responder mobilization program. Local community needs were assessed by consultation with doctors and nurses in the local hospital and primary care clinics, local community members serving on the municipal Health Committee, and focus groups. The needs assessment identified four areas for training including emergency scene management, unconscious patient assessment and stabilization, violent injury care, and treatment of medical emergencies. There were 628 individuals who undertook a one-day training curriculum based on the needs assessmentidentified topics. Knowledge-based pretest and posttest scores improved from 28.2% to 77.8%. Those trainees that scored at least 75% (n=423) were certified as Emergency First Aid Responders (EFARs) and were thereafter available in the community to offer first aid response when needed. A total of 274 EFARs completed a follow up exam at 4 and 6 months and demonstrated adequate knowledge retention. The authors reviewed a random selection of 29 patient care reports authored by EFARs and determined that appropriate care was delivered. The cost for the program was estimated to be US$700 for startup and US$6570 annually, based on 100 trainees per month. The authors describe a well-planned and implemented program of training local first responders in a community that suffers from lack of rapid EMS dispatch. The utilization of local community members was essential for identifying those components of a training curriculum that were needed in this unique environment. The authors also sufficiently demonstrate that those trainees that were available for follow up had good knowledge retention, provided appropriate care, and were involved in treating conditions that had been taught in the course. However, the paper lacks clarity in adequately describing the methodology for either the needs assessment or the monitoring and follow-up of the trainees, which limits this program’s reproducibility.. A majority of the trainees were lost to follow up (56%), calling in to question the validity of the results. However, the project clearly had some impact on the community and came with a relatively low cost. The study demonstrates that involving local community members for buy-in, training, and monitoring is essential in the mobilization of first responders. -BH, TB


TRINIDAD AND TOBAGO_In resource-limited settings, mixed opinions on the presence of relatives during CPR Mahabir, D and Sammy, I. Attitudes of ED staff to the presence of family during cardiopulmonary resuscitation: a Trinidad and Tobago perspective. Emerg Med J 2012; 29:817-820.

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his observational survey aimed at to determining the attitude and opinions of ED doctors and nurses in Trinidad and Tobago public hospitals towards the presence of relatives in the resuscitation room during cardiopulmonary resuscitation (CPR). Over a 6-week period in 2009, a modified validated questionnaire was distributed to all ED doctors and nurses working in 8 public Trinidadian hospitals. 244 questionnaires were distributed to the entire population of 254 ED staff members in all 8 hospitals, with 214 responses (106 doctors and 108 nurses), a response rate of 85.65%. The authors found mixed attitudes and opinions regarding the presence of family members in the ED during CPR in this developing Caribbean country. 51.9% of ED doctors and nurses in Trinidad and Tobago disagreed with the presence of relatives in the resuscitation room. The presence of family members in the resuscitation room during CPR is increasingly accepted in developed countries. But in resource limited settings, the authors showed that attitudes were mixed about the presence of relatives during CPR. The high methodological quality of this study is highlighted by the high response rate (85.65%), predetermined power calculation and the use of validated questionnaire. The authors offer physical infrastructural changes and educational training as solutions to acceptance of relatives witness CPR in Trinidad and Tobago. The authors acknowledged some limitations imposed by exclusion of part time staff and under-representation of senior medical and nursing staff. But the lack of numerical data respectively of the proportion of teaching and district hospitals and ED staff with previous CPR experience introduced further limitations. The authors made no effort to minimise or analyze the effects of missing data such as unrecorded gender (10.2%), unrecorded ethnicity (6.5%), and unrecorded religion (18%). -OJ, MF

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

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

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// austere

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Summer 2014 // Emergency Physicians International


doctors on the edge Austere, remote, and disaster medicine missions – what to do, and how to get home alive. by Darryl Macias, MD SCENARIO 1: you are an emergency medicine physician search and rescue volunteer in southwestern Colorado, USA. You are called for a rescue of five lost hikers missing for two days during a severe winter snowstorm. The avalanche danger is significant. You have three paramedics experienced in this environment, and ten experienced mountain rescue technicians. You deploy at nightfall, in blizzard conditions, at a mountain pass 3500m (11,500 feet) above sea level. The local law enforcement officials, an ambulance, and some journalists also rendezvous with you. Scenario 2: You deploy to Haiti one week after the 2010 earthquake accompanying a group of 15 from your disaster medical team (other physicians, nurses, paramedics, and experts in logistical support and informatics), to deliver urgent medical aid. In the airport, the television media invokes a strong sense of calamity, suspense and fear to the viewer, as the drama of looking for the lost, or foraging for basic needs as civil violence and gunfire are unleashed. Aside from an overwhelmed government offering no help, daytime temperatures are 35 degrees °C (95°F), with 95% humidity. How will you manage? World catastrophic events and humanitarian crises have demanded more assistance from relief workers than ever before. We rise to the occasion to serve in these limitedresource environments because of an inherent sense of social responsibility, a commitment to serve, and, if we’re honest, the desire for adventure. While we might inherently recognize some general challenges in these places, we often fail to realize the subtle challenges that will impede our return home to safety.

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Austere medicine is patient care in a resource-limited setting, where advanced technology is unavailable. This may be in a remote wilderness setting, an in-flight emergency, a space mission, a tactical or battlefield operation, or a disaster situation. Prolonged pre-hospital or aeromedical transport with a decompensating patient would also qualify, with a time frame of hours, days, or weeks. Success isn’t simply arriving at a hospital with a patient with a pulse: it also means returning you and your crew, teammates, or staff to safety, while not endangering the public. If you work in a chaotic environment, be it in areas of limited, or plentiful resources, which could be compromised, these lessons apply to you. Here is a simple mnemonic that will help you remember the components of a successful deployment during an austere medical mission: The 7 P’S. Preparation Without preparation, failure is certain. The value of simulated, frequent training in the anticipated environment where care will be delivered cannot be overstated. Basic skills needed for the operation – be it rope rescue skills or setting up a field hospital, must be mastered. Once achieved, these skills must be tested repeatedly under increasing amounts of external stress. For an untrained person, memory impairment, and psychomotor failure often supervenes. To illustrate, recall the first time you attempted to perform endotracheal intubation on a patient with a traumatized airway, with bloody emesis spewing out of the mouth! The laryngoscope blade stopped working, and you may have panicked, in an attempt to find another blade, as the oxygenation saturation plummeted below 40%. Be honest. Your hands shook, and you may have experienced “tunnel vision.” You either reacted in haste, or were paralyzed in fear, as a more experienced practitioner pushed you aside to manage the airway decisively. You realized that you were not calm, you were not organized, and you were not aware, all of which impaired judgment. With time and experience, you can lessen a counterproductive stress reaction through gradual amounts of induced stress. Induced stress is used for operational medicine (think combat and tactical medicine), and is gaining acceptance in emergency medicine training as well. Debriefing and review is paramount to this process of “stress inoculation.” Needless 22

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to say, successful rescue programs and disaster teams also use this technique, which appears to improve performance. Physical preparation is also necessary. In scenario #1 above, one should appreciate the need for altitude acclimatization and heat acclimation. Take the time to do this, lest you become ill. Adapting to hostile physical environments, along with a modicum of physical conditioning with training equal or above the anticipated tasks, will allow you to excel in such arduous conditions. Survival training, and practicing skills in an austere (or simulated) environment for prolonged periods, initially under supervision, helps you know how you will respond under such circumstances. Such training should later take place as a team, in order to know how members react physically and psychologically under stress. Planning Knowing the composition and availability of a team is essential, whereupon roles are pre-determined. Who will be responsible as a commander (the “incident commander”)? Who coordinates all rescue efforts? Who is responsible for scene safety and security? Is there logistical support to get needed supplies to the scene? How will supplies be delivered safely? Who will arrange travel? Who are the medical providers? What provisions for sustenance are there? Knowing about local geography, climate, and culture is crucial. On arrival, how will you complete the operation, and how will a patient be evacuated, and to where? What role will

Summer 2014 // Emergency Physicians International

other interested parties (rescue, pre-hospital, law enforcement) play in the operation? These are only a few questions that should be answered before arriving on scene. Personal safety and protection The traditional health care provider has been taught through antiquity to put the patient’s needs before their own. In an austere environment, this idea kills! Remember: an impaired provider will impair the patient. Personal physical and emotional limitations should be addressed, and proper training in the conditions is essential. Arrive well rested! Each rescuer must ensure that they are properly immunized and carry on their person proper medications that will prevent, or manage illness in that particular environment, such as anti-malarials. A provider with a chronic illness with the potential to decompensate (such as diabetes) could endanger the mission. Mastery in survival, using the “rule of 3’s” as a preparatory guideline, is recommended. Remember that you can survive approximately three minutes without air, three hours without a heat source (fire, clothes and shelter), three days without water (carry water and means of purification/procurement), three weeks without food (carry high energy foods and know how to forage), and three months without love (carry a means to navigate, and signal for help, if lost). Lastly, ensure that your safety equipment functions properly. In a potentially hostile urban environment, knowledge of evasion and self-defense techniques is wise.


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Partner safety and protection. Simply put, ensure that your partner or staff undertake the same measures that you did to assure your own well-being outlined above. If going into a hazardous environment, a “contingency” plan to rescue your partner or facilitate escape, in case of an unanticipated challenge, is paramount. Ensuring partner safety in an austere environment may save you later, should you experience trouble. Do not let a poorly trained partner deploy, because that partner could also end up as a patient, jeopardizing a mission. Public safety and security Well-intentioned rescues might endanger bystanders and inexperienced participants in a scene. Some may simply “want to help,” and the media may unwittingly impede a rescue in order to make the six o’clock news. Crowd control must occur in the safe zone, away from the center of operations, well away from the actual rescue zone. In the first vignette, rescuers causing an avalanche during a rescue on “innocent

01 An urban survival course teaches situational awareness 02 An emergency in a remote beach setting means that providers have to improvise 03 Trainee attempts a digital intubation on a mannequin in a confined space.

bystanders” below will end the mission quickly.

environment.

Patient Care and protection In an austere environment, one is faced with prolonged patient care in potentially hostile surroundings. Triage decisions adapted to the environment may differ from a classic hospital or urban pre-hospital scenario: providing advanced life support on few critically ill patients might endanger the salvageability of others. Improvised medical care is the norm since a rescuer may be limited by what is inside the rescuer’s backpack. Heavy electrical equipment is impractical, and diagnostic tools such as point-of-care analyzers, or hand-held ultrasound machines may be the ultimate in sophistication. Nonetheless, knowing about the diagnosis and treatment of environmental illnesses (tropical infections, high altitude illness, temperature-related illness, trauma, and the like) is important.

Situational awareness In the first vignette, objective hazards such as a blizzard, avalanche, or simply getting lost will terminate the mission; an earthquake, tsunami, or street violence with gunfire ends the second. Constant vigilance for sudden danger, with an escape plan, must always be in your mind, along with the ability to act quickly and decisively. Such skills can be enhanced with habit, and stress desensitization opportunities, helping you become more experienced in risk assessment and anticipation of potential problems. Prolonged vigilance, “rushing to just get the task over with,” boredom, or fatigue will threaten your awareness, and must be addressed. Changing operators, or simply a short rest with nourishment, may be the answer.

Prognosis of the patient, mission, and evacuation plan Advanced life support may not alter patient outcome in certain wilderness settings. Furthermore, a mission may not be completed if the risk of injury is too high, at that point in time, for rescuers. An evacuation plan, such as a litter rope descent, helicopter evacuation, or ground transport to a particular receiving institution, with inter-facility communication, changes with the conditions. Several potential evacuation alternatives will lessen rescuer frustration, and minimize patient contact with the

Summary This methodology, using an easily remembered mnemonic, “the 7 P’S” (or 7P and 1S) has been the framework for several austere medical undertakings in wilderness, operational, disaster, humanitarian aid, and pre-hospital environments. Readers who are not involved in these situations can also apply these ideas to their own practices in emergency medicine, given the episodic and often chaotic nature of our environment. go to www.epijournal.com for a full list of references

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// notes

from karachi t Large swaths of congested, illegally-built

houses in Karachi – known as katchi abadis – have little or no access to public services.

Disaster Mitigation in the City of Migrants Earlier this year, a delegation from Harvard’s South Asia Institute visited the Aga Khan University Hospital and observed some of Pakistan’s unique emergency care challenges.

by satchit balsari, md, mph

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ne of the most populous cities in the world, yet one of the least understood, especially in the West, is the bustling port-city of Karachi, home to over 20 million residents and financial capital of Pakistan. Spread over 1360 square miles, Karachi is a dense urban agglomeration accommodating over 15,000 people per square mile. Tracing its roots back to the old town of Kolachi, settled by Sindhi and Baloch tribes, Karachi saw exponential growth in the second half of the 20th century. Starting with a population of about 400,000 on the eve of Pakistan’s Independence in 1947, the city absorbed wave after wave of migrants - first Muhajirs from partitioned India, then immigrants from the newly independent Bangladesh (erstwhile East Pakistan), and finally Pashtuns from Khyber Pankhtunkhwa, the Federally Administered Areas, northern Balochistan, and Afghanistan. Consequently, Karachi is now a bustling South Asian metropolis, with all the trappings of modern South Asian cities: overcrowding, 24

unplanned growth, inadequate rapid transit facilities, poor water and sanitation facilities, unsafe housing, unorganized labor, and an unflappable, can-do populace with hopes for a better tomorrow. Burden of Violence In addition to the challenges faced by rapidly expanding urban centers, Karachi faces the constant threat of terrorism. In 2013, there were 94 bombings in Karachi - one every four days. More than 700 Karachiites were injured, and 124 died. As recently as April 24, 2014, six people were killed and over 30 injured as a result of another suicide bomb in the city. The bombings have not spared healthcare facilities, either. In 2010, as victims of a bomb blast were being brought to one of Karachi’s premier public hospitals, Jinnah Post Graduate Medical Centre, a bomb went off outside the emergency department, shattering glass, breaking walls and injuring and killing patients and staff. Dr. Seemin Jamali, who has served as chief of the emergency department at JPMC for two decades recollects the day vividly. “We

Summer 2014 // Emergency Physicians International

were busy taking care of the crowded emergency department when there was a huge explosion and I was thrown to the ground. One of my staff helped me out.” The sporadic bombs and targeted killings continue unabated, adding a sheen of perpetual uneasiness to daily city life. This reign of violence overlays all other medical emergencies in Karachi, including an astounding 30,000 annually reported road traffic injuries. Philanthropy and commitment: the evolution of emergency medicine in Karachi Victims of accidents and injuries are taken to one of several hospitals in Karachi, including the Jinnah, Civil, Abbasi Shaheed and Aga Khan University hospital, each with varying capacities to respond. While most of these facilities do not have formal EM training programs, all of them mobilize existing resources to respond to this large burden of violence on a daily basis. In 2004, when Dr. Junaid Razzak returned home to Karachi after more than a decade spent in the US and Sweden completing his advanced medical and public health training, there were no emergency medicine specialists in all of Pakistan. Most hospitals had a oneor two-bed “casualty ward,” typical of hospitals across South Asia, that served as receiving rooms for patients coming to the hospital. Most patients arrived by foot, bus, two-wheelers, or taxis. Some had private cars. A few called for an Edhi ambulance. Edhi ambulances, about 400 of them, driven by volunteer drivers and sponsored by the Edhi Foundation, were then the only organized emergency medical service in all of Pakistan. Started by Pakistani philanthropist Abdul Sattar Edhi, the ambulances met a critical need: they ferried those that had no other means of transport. Dr. Razzak, who had dedicated his doctoral thesis to the evolution of Edhi ambulances, knew that this critical, lifesaving service was only the first of a series of interventions necessary to provide state of the art emergency medical services to one of the


largest cities in the world. Earlier this year, a delegation of public health practitioners from the Harvard South Asia Institute joined Dr. Razzak’s team on rounds in the emergency department at the Aga Khan University Hospital (AKU) in Karachi. A gleaming 48-bed emergency room, bustling with emergency physicians and nurses hovering over their patients, many of whom were attached to several intravenous lines, monitors, and ventilators, looked like any other in the United States - save the intricately latticed windows that allowed natural light to filter in. “This area is for patients on BiPAP,” explained Dr. Munawar. “We have over-crowding issues. The hospital is often full, and we must take care of the patients while they are waiting for a bed. We have many patients with cardiopulmonary issues, and starting our own BiPAP unit has been very helpful.” Behind Munawar was another familiar sound - residents clicking away at the EMR - final proof that emergency medicine as we know it had arrived in Pakistan. Fondly remembering the decade he served as chair of the department he helped build, Dr. Razzak recalled the time when patients did not understand what to expect in the emergency department. While some were surprised at the plethora of services now available at the hospital’s doorstep, others couldn’t comprehend why they couldn’t just be transferred to a room upstairs. And, it seemed, nobody understood triage. The AKU emergency department runs the flagship emergency medicine residency training program in Pakistan. To date, the program has graduated 12 residents, most of whom have continued their careers in EM in Pakistan and other countries. The department also boasts a robust research division staffed by several doctoral candidates, epidemiologists and biostatisticians. A Fogarty-funded grant has helped advance research capabilities through collaboration with the Johns Hopkins Bloomberg School of Public Health. The department is also a WHO Collaborating Center on Emergency Medicine and Trauma, and has grant support from the WHO and the NIH. Dr. Razzak noted that the AKU model stands apart from its many counterparts in the region, where the department has not sought foreign collaboration or endorsement. “The faculty have developed their own rigorous standards of education, examination and certification with quality being the primary driver,” said Razzak. As we stepped out of the emergency department into the warm afternoon sun, we saw a

bright yellow Aman ambulance pull into the ambulance bay. Two uniformed paramedics deftly extricated their patient from the ambulance and trotted up the ramp into the ED. The patient was breathing through an oxygen mask and had an intravenous line. Dr. Razzak smiled. “At Aman, all our paramedics and nurses receive six months of rigorous training. We now have 100 ambulances and have an average response time of 8 minutes for acute cases. Traffic density and road behavior remain our greatest challenges.” Aman Foundation,

The AKU emergency department runs the flagship EM residency training program in Pakistan. A Fogartyfunded grant has helped advance research through collaboration with the Johns Hopkins. The department is a WHO Collaborating Center on Emergency Medicine and Trauma, and has grant support from the WHO and the NIH.

started by a Dubai-based Pakistani philanthropist, Arif Naqvi, is one of the most recent players in the social sector, but one with a highly visible footprint. Focused on health, education and nutrition, the Foundation espouses the mantra, “transforming lives,” which it seems to have successfully done by providing parts of Karachi a state-of-the-art EMS system in a mere five years. Dr. Razzak also runs the Aman Healthcare Services, a system now comprised of a paramedic training school, EMS, Telehealth services, and community and school health programs. The constant threat of targeted and random violence has not deterred Karachi’s physicians from committing themselves to advancing medical care. With government support and private donations, Dr. Jamali has also rebuilt her emergency department. A large concrete barrier stands in front of the entrance; the ED can now only be accessed by passing through several security checkpoints. Vehicles, including ambulances, are parked a short distance

from the entrance and carriers run stretchers to and fro. As Dr Jamali walked us through the various new additions to the ED, one could not help but notice the constant state of vigilance the providers were under. In her office, two television screens were tuned onto news channels 24/7. “I have to keep looking at these screens. We have to be prepared at all times. You never know when something bad is going to happen again.” Katchi abadis: Karachi’s informal settlements In spite of these impressive strides in emergency medicine and preparedness, much still remains to be done. The majority of Karachi’s population have limited or no access to these services, especially those provided by the private sector. To reach the masses in Karachi, it is important to examine the social fabric of Karachi’s society, and the distribution of wealth along its ethnic and geographic divisions. Just north of Jinnah Hospital is Shahar-eFaisal, or national highway 5, which begins its journey at the Karachi port and then makes a wide north-south sweep across Pakistan linking the historic cities of Hyderabad, Multan, Lahore (close to the border with India) Gujranwala, Rawalpindi, and Peshawar (on the border with Afghanistan). After a brief period of decline when the nation’s capital was moved from Karachi to Islamabad, Karachi regained its stature as the nation’s economic engine. Consequently, upwards of 45,000 migrant workers are now estimated to arrive monthly in Karachi, from as far at Peshawar and Quetta. As is the case with almost all South Asian cities, Karachi has no organized mechanism to absorb this large influx of migrants, and they take refuge in informal shelters in unplanned settlements, mostly across ethnic and regional divisions. This large, unchecked, continuous migration significantly stresses the city’s limited infrastructure, civic amenities, and law and order provision. Karachi has long struggled with the challenge of its Katchi Abadis (“impermanent settlements”), that have continued to grow through Pakistan’s years of military rule and elected governments. The Katchi Abadis have either lived under the threat of regulation (implementation of existing zonal laws, eviction and prevention of further settlements), or have successfully managed to mobilize the political process toward regularization (post hoc legalization of existing settlements). This phenomenon is ubiquitous in Asia, Africa and www.epijournal.com

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// notes

from karachi

Latin America. Regularization most often happens in incremental milestones - all of which are necessarily intertwined in local politics: the issuance of identity cards with addresses, gas and electricity connections, water pipes, etc. This is important from the standpoint of disaster management because “formalization” often ends with the provision of these basic utilities. The private sector attempts to step into the void to provide other equally important services like healthcare, education, and employment. Mr. Ahsan Jameel, CEO of Aman Foundation, contends that there is only so much the private sector can do. He expects Aman to provide an evidence-based robust model of sustainable service delivery, but sees partnership with the public sector a necessary ingredient of scalability. Dr. Razzak, Mr. Jameel, and their team at Aman are now committed to strengthening Karachi’s disaster management system, with special emphasis on medical response and mental health. Dr. Sadia Qureshi, who also returned to Karachi after several decades of practice in the UK, heads Aman’s mental health program. “We must figure out how to build resilience in these communities,” notes Dr. Quereshi as the team recognizes the multiple onslaught of isolation, poverty, illiteracy, social marginalization and the constant threat of eviction and violence faced by the urban poor. Remembering Virchow: mapping Karachi’s vulnerabilities Disaster management plans in South Asia, including those of the National Disaster Man-

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p Professor Jennifer Leaning from

Harvard University accompanies Dr. Razzak at a visit to the Aman Ambulance control room where televisions are tuned onto news channels 24/7.

agement Authorities in India and Pakistan, are sound in principle. However, they fail to achieve their desired goal for lack of administrative will to address implementation gaps. Most government plans focus on rescue and response and pay lip service to mitigation. The scope of government aid does not extend to the tens of millions that live in informal settlements across the cities of South Asia. For these millions living at the brink of poverty, the impact of a disaster-event can be so detrimental as to push them into a downward spiral of extreme destitution. The lack of social and economic safety nets among the urban migrant poor makes them significantly more vulnerable than their better-off neighbors. Effective mitigation and response strategies require a deep understanding of the social, economic and cultural milieu of these cities, a point reiterated often at the Pakistan Urban Forum during the South Asian Cities 2014 Conference in January. At this gathering, domestic and international scholars acknowledged the complex, evolving identities of today’s South Asian cities. Disaster preparation in Karachi must therefore now expand far beyond the confines of “response” to include robust mitigation strategies built around community

Summer 2014 // Emergency Physicians International

resilience: social, cultural and economic. In addition to violence and urban accidents, Karachi is also prone to monsoon floods, and is a short distance from several existing and proposed nuclear plants. The impact that most of these events would have on the various populations of Karachi would vary tremendously. Mapping the risks and vulnerabilities of Karachi’s socio-economically diverse populations would be a prerequisite to meaningful disaster planning for the city. Mitigation strategies will require a whole range of solutions that may include highly polemical political interventions like regulation and regularization, or the less controversial expansion of EMS services, or social programs like micro-insurance schemes to build resilience among the urban poor. As local Karachi institutions begin partnering with international universities and hospitals, it is imperative that all stakeholders, whether foreign or domestic, adopt this comprehensive approach early on. “Disaster planning” collaborations in the region are often limited to highly visible mock-drills and medical training. In spite of the enthusiasm and eagerness of all participants, much of what is taught and learnt at these drills is hard to integrate into existing systems for want of political will required to facilitate the necessary personnel and resource allocation. There is growing recognition among stakeholders across the region that in addition to capacity building, a concomitant drumbeat of advocacy and policy making is essential. In the mid-nineteenth century, Virchow noted, “Medicine, as a social science, as the science of human beings, has the obligation to point out problems and to attempt their theoretical solution: the politician, the practical anthropologist, must find the means for their actual solution... The physicians are the natural attorneys of the poor, and social problems fall to a large extent within their jurisdiction.” Today, Dr. Razzak, Dr. Qureshi, Mr. Jamal, and their team are committed to understanding and addressing the social determinants of disease in their community. Those of us that will partner with them are equally obligated to delve deep into Karachi’s socio-economic milieu to formulate meaningful strategies to make the city safer and healthier for its citizens.


// surfing doctors

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Medical Education’s Next Wave The European Association of Surfing Doctors – brainchild of Ingvar Berg and Dion van de Schoot – combines a passion for surfing with cross-specialty emergency training. EPI sat down with Berg to discuss the formation of this unique group and the specific areas it addresses.

01 01 Board rescue at Advanced

Surfing Medicine Life Support Course in 2013 in Ericeira, Portugal

How did the European Association of Surfing Doctors come to be? INGVAR BERG: I met my Surfing Doctors co-founder Dion van de Schoot in high school. He went on to study medicine in Rotterdam while I studied in Utrecht. We kind of lost contact. Coincidentally, we were hired on the same job at the same time. Our new boss told us we were going to do this course together and since we both surfed, we studied at the beach. I had always wanted to start a business and so Dion and I brainstormed a bit. There are so many things in medicine that you see that you have ideas about but as a doctor, you usually don’t have the time to actually innovate directly yourself. Perhaps we should develop some kind of a sterile food that surgeon’s could actually have on the operating room? That’s something we could all get behind! Dion told me about a website that was already out there called “Surfing Doctors.” When we realized that this organization didn’t exist yet in Europe specifically, we thought it would be great to start a conference and gather doctors that surf and discuss some serious medical topics. Along the way, of course, we’d get to meet all these interest-

02 Raising the flag at the founding

conference in Sagres, Portugal. 03 The “paddle out” is a tradition

on the final morning of a Surfing Doctors conference.

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// surfing doctors

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01

ing people who share the same passion. And that’s how we began. As we continued to formulate the idea, we discovered other similar organizations like the Surfers Medical Association which was started in 1983. We wrote to them to gauge their activity in Europe. SMA does several conferences around the world each year, but only one small one in Biarritz. We were really aiming for something bigger within Europe, so it seemed opportune to start our organization and make a website [surfingdoctorseurope.com]. Our main goal was to bring doctors together that have an interest in surfing by organizing a conference. Now we are a non-profit organisation with a crew of 21 volunteers. Why Bring Docs Together Around Surfing? We felt that medicine usually is a bit conservative in culture. But if you meet a “surfing doctor,” a barrier comes down. The name instantly lightens the mood and connects people. It also acts as a great equalizer. If you just love to surf, it turns the typical system of medical 28

hierarchy on its head. When we gathered together these professionals, we found that they were a truly unique composition of characters. Most surfers obviously like traveling and they’re quite sporty. They also possess an element of persistence because it’s not a sport that you learn very quickly. There’s a also an aura of exploration around surfing that doesn’t necessarily exist with other sports, as we search for the perfect waves. What do you actually discuss at a Surfing Doctor conference . . . or do you just surf? We find that there are a lot of medical subjects that you can link to surfing, some which you might not encounter in the hospital. For example, through surfing medicine I learned a lot about stings – what to do if you get stung by a Portuguese man o’ war – and about drowning resuscitation. We also talk about skin cancer, which is a major problem for people that surf. So there’s an enormous mix and all specialties have something to offer, which makes it very interesting.

Summer 2014 // Emergency Physicians International

01 Dr. Ognjen Markovic, Ophtalmologist

and EASD board member, takes part in a self-rescue pool training 02 Morning surf session 03 Belgian-based sports doc Kristof

Peeters presents on reduction techniques in a shoulder dislocation 04 Frederique Tan, Dutch ENT Surgeon,

speaks at the founding Surfing Doctors conference in 2012. 05 Scenario training at the ASLS

Course

If you’re a doctor and you surf, it’s more and more common that you will encounter those stings or maybe reef cuts. Do you treat them the same as you would in the hospital? We really wanted to learn ourselves about these things. And we discovered there’s a lot more to learn. Yearly we have a 3-day conference and an ASLS course. This year’s conference will be held in Mullaghmore, Ireland, in September. The separate 6-day ASLS Course (Advanced


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Surfing Medicine Life Support Course) is aimed at preparing health care professionals who are traveling to remote locations. What do you bring in your medical kit? How do you get someone on the board if he’s unconscious? How do you perform a rescue? What should you think about in legal issues? We try to keep everything relevant to surfing and to medicine, and try to keep it interesting since there’s more than 20 specialties represented in the audience. What could the average emergency physician stand to learn from the Surfing Doctors curriculum? Drowning is something that we discuss very thoroughly. We presented the newest research on drowning and had a practical talk about what happens, perceptions, and misconceptions. For example, even among doctors there are misunderstandings that if foam is coming out of somebody’s mouth, you want to suck that away in order to give their ventilations. Hopefully everybody knows that the foam is not that important because every time you start

suctioning you intervene with the actual therapy which is providing oxygen. The common thread in drowning, of course, is that those in danger need oxygen (breath, air or supplemental). You should put all your efforts in that direction. Robbie Lendrum, an anesthesiologist and EMS doctor in Great Britain, gave a talk about a critically injured surfer. He talked about the teamwork that is required when helicopter transport gets involved. Dr. Lendrum also discussed amputations in reference to a new kind of catheter that you can put into the femoral artery if it’s exposed. You are able to guide it a bit higher. The aorta can blow up the balloon that’s on the tip of the catheter which will stop the blood flow totally to your lower limbs. Another surf EM issue is the potential for trauma due to reefs. The professional surfers usually don’t wear helmets and if hitting a pipeline over a reef, there is a good chance that you can hit your head. Say you crash on a three- to five-meter wave and you hit your head on a reef, there is a lot of force behind that. You could quite easily hemorrhage intracranially. We discussed the question of how long it

takes to get someone from the scene of the accident to the hospital where they can actually do neurosurgery? One lecturer explained a particular case in his helicopter, where a patient’s brain pressure became so great that they were losing vital functions and dying. His technique was to release the pressure by drilling a hole in the skull. It seems like an extreme measure to take, but given the remote location, they know that the patient will die if they do nothing. These types of more extreme cases – added to the everyday examples of drowning and skin cancer that covered – taught me a bit about the pre-hospital side as well as the importance of teamwork. What sort of practical wisdom might you offer for the practicing surf doctor? I think what you really learn in surfing medicine by visiting remote locations is how to prepare well, and then improvise when necessary. You learn to think outside the box. It is an important skill to develop and one that can see benefits far beyond the realm of surf medicine. www.epijournal.com

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// maternal mortality

//

Emergency cardiac care, focused on elderly and often requiring expensive technology, simply does not have the same moral imperative of saving a healthy mother’s life during labor.

Emergency Obstetric Programs Play Key Role in Maternal Health Goals Fourteen years have passed since the World Health Organization and United Nations identified and vowed to reduce the problem of maternal health. Programs like Advanced Life Support for Obstetrics are leading the way in meeting the need for emergency care at the community level.

by haywood hall, md

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n September of 2000, world leaders signed a United Nations Millennium Declaration committing themselves to fight some of the world’s most imposing issues, including poverty, hunger, and disease. From this Declaration came the Millennium Development Goals, a set of eight objectives that the combined 193 members of the UN aimed to achieve by the year 2015. The fifth goal on this list is to improve maternal health. More specifically, the hope is to reduce the maternal mortality ratio by three quarters and to achieve universal access to reproductive health. In the past, this goal might have seemed outside the purview of emergency medicine, 30

but that is changing as emergency physicians the world over take an interest in global health. One out of three emergency medicine residency programs in the United States have international health fellowship programs. If can harness this interest and combine it with critical knowledge of obstetric emergencies, we’ll go a long way towards proving the role of emergency medicine internationally. When I first got interested in maternal health and obstetric emergencies I thought that I already knew all about Life Support courses. I was quite surprised to hear that there was an Advanced Life Support for Obstetrics (ALSO) course that has trained over 160,000 people to date. In reviewing the

Summer 2014 // Emergency Physicians International

materials in order to prepare a student to teach the course in Guatemala, I was led down an exciting rabbit hole of maternal health. This journey brought me far beyond my experience as an emergency physician in the United States. Eventually I began to teach ALSO courses in Mexico, and the results have been life changing. The ALSO Course is a typical Life Support Course which uses mnemonics and simulations with manikins before ending with a “Mega Delivery.” It is competency-based certification for the management of postpartum hemorrhage, pregnancy induced hypertension, and obstructed labor. Our workshops in Mexico include vacuum-assisted delivery, FAST OB ultrasound, and neonatal resuscitation. The Basic Life Support in Obstetrics (BLSO) course is directed at nurses and EMTs and the new EM Community. CLSO, or The Obstetrics First Responder, is directed at low literacy community levels, bringing traditional midwives and community health workers into the “Chain of Survival” for the new mother and child. Originally designed so that family physicians could become credentialed in US hospitals, the ALSO program underwent a rebirth in the international arena. One important shift taking place globally is that in various countries emergency physicians have taken the lead in the implementation of ALSO training. The fact is that in most locales, especially in less urbanized settings, emergency specialists do not exist. Because EM is an urban specialty, there are typically OB Specialists that manage all of these cases wherever there are EM training programs. Yet there are many urban areas that have no emergency specialists at all. As emergency medicine ventures into the prehospital arena and into almost all emergency departments, we see that third trimester pregnancies


are being evaluated in emergency departments. The emergency physicians throughout the world need this type of training as much as they need to train in trauma and pediatrics, and probably more than they need to train in cardiac. This need can be seen in Ethiopia, for instance, where there is an EM residency training program which trains in the ALSO courses because of the burden of obstetrical problems facing EDs. In India there are over 8,000 EMTs that have been trained in the BLSO course. In Hong Kong the emergency specialists are leading ALSO training courses. In Mexico, our PACE Program runs a successful ALSO Program that has trained over 8,000 providers. PACE adapts ALSO to the various settings in Mexico and PACE has helped set up programs in Argentina, Chile, Panama, and Costa Rica with future plans to introduce the program to Cuba. While PACE teaches Basic and Advanced Cardiac Life Support and Pediatric and Trauma Life Support courses – standard for any

field report // india CONT’D FROM PAGE 12

have boosted the numbers of EM trained physicians in India in the past six years but there is still very far to go. The Global Academy of Emergency Medicine (GAEM) is currently coordinating with several institutions and physicians around the world to advise and assist private and government institutions with their residency programs and to help provide faculty from around the world. At this year’s International Summit of Emergency Medicine & Trauma (ISEMT) in Pondicherry an MOU was signed between GAEM and the Jawaharlal Institute of PostGraduate Medical Education and Research (JIPMER) to support JIPMER MD EM Residency program with international faculty from GAEM. GAEM also launched a Faculty Development Program for India. Although EM residencies are a recent

New UN data show a 45% reduction in maternal deaths since 1990. An estimated 289,000 women died in 2013 due to complications in pregnancy and childbirth, down from 523,000 in 1990. Eleven countries that had high levels of maternal mortality in 1990 have already reached the MDG5 target of a 75% reduction in maternal mortality. SOURCE: WHO

EM training – we have found that it is the emergency obstetrics programs that can lead the way for better emergency care in general at the community level. Postpartum hemorrhage requires that hemorrhagic shock be managed. Pre-eclampsia/eclampsia requires that IV medi-

phenomenon in India, short courses and conferences have been taking place in India for the past 15 years. The first conference of emergency medicine took place in Hyderabad Andhra Pradesh in 1999 and was supported by the American Academy of Emergency Medicine for India (AAEMI). At this conference, the Society Emergency Medicine of India (SEMI) was created to promote the specialty. Emergency medicine in India has progressed rapidly over the past 15 years and has benefitted from much international involvement. The All-India Institute of Medical Sciences collaborated with the University of Florida to create an Indo-US Society of Emergency Medicine. AAEMI – which as been providing international speakers for the conference, running workshops, and evaluating research for 14 years – has been an integral part of the wellregarded annual conference in emergency medicine, EMCON, put on by SEMI. The ISEMT conference held in February – a collaboration between GAEM and JIPMER, brought more than 1000 attendees and 100

cations be used and airways managed. Neonatal resuscitation requires that there be some critical care management at a pediatric scale. It requires that EMS and communities in austere settings develop “chain of survival” capabilities. And of course, it requires that prevention and early warning signs be learned. Emergency cardiac care, focused on elderly and often requiring expensive technology, simply does not have the same moral imperative of saving a healthy mother’s life during labor. A dead mother and child is a devastating event for the family and for the community.  The home is destroyed, the children are orphaned, often scattered. The community disintegrates, losing faith in their healthcare providers and their government. The social fabric is frayed. These are loaded issues, and they are indicative of our society’s values. Civilizations advance when women are literate and safe. As emergency physicians, lets engage the global maternal mortality rate as a marker of progress. We have much to offer in this battle, and a moral obligation to do so.

international speakers to Pondicherry. Several initiatives have been created from ISEMT, including setting up trauma registries, multi-level collaborations for disaster management, GAEM’s Research Mentorship Program to guide emergency medicine residents across India in effective research, and recognition of the need to standardize and validate current residency programs Emergency medicine is practiced at various levels in countries across the world. Some countries set the benchmark by trending towards evidence-based medicine and being destinations for world-class emergency medicine education. Other countries are still struggling to have emergency medicine recognized by their peers as a bona fide medical specialty and fail to adequately man EDs with emergency medicine trained doctors. India has its foot firmly in both groups and will need to focus on training EM physicians and educators as well as standardizing residency training if it is to make the leap forward.

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Grand Rounds

PETER CAMERON, MD // PRESIDENT OF IFEM

Making the Most of MERS When Saudi Arabia was hit by a deadly coronavirus, Qatari emergency physicians used it as an opportunity to catalyze hospitals into improving infectious disease practices.

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In a bizarre twist of fate, I now find myself in the midst of a second deadly coronavirus outbreak. A decade after SARS – which I saw first hand while practicing in Hong Kong – I find myself working in Qatar and facing the Middle East Respiratory Syndrome (MERS), which originated in Saudi Arabia.

Being an emergency physician means that we are always on the frontline of any new epidemic or pandemic. In the last decade we have had “bird flu”, “swine flu”, SARS and now MERS, each of which put health care workers and patients in the ED at risk. In most cases involving infectious disease, the risk is most apparent after initial exposure has occurred. Which means that for emergency medicine, we have to assume the worst and protect our patients (and ourselves) on the basis of prioritization of risk without knowing what is actually going on. The two coronavirus outbreaks (SARS and MERS) were particularly unusual in that they had the potential to explode into international pandemics and kill thousands (maybe even millions) but for some reason, stayed regional with only sporadic cases outside the epicentres of the outbreaks. Many groups have claimed credit for the containment of these epidemics, but no one can be certain exactly why there has been such limited spread. It is not even clear why the epidemics occurred when and where they did. During the SARS epidemic in China and Hong Kong, there was a big increase in the number of cases over a couple of months in early 2003, then the virus seemed to “disappear” after a few months. Improvements in infection control procedures in hospitals and behavioural modifications within the community probably curtailed the epidemic, but this did not really explain the complete disappearance of the virus. The MERS epidemic in the Middle East is now gaining some momentum, with most cases reported being in Saudi Arabia. There have been a few cases reported elsewhere but so far only from travelers coming from the Middle East. This is an unusual epidemic for a number of reasons. First, it has developed very slowly with only small numbers in any one centre. Second, it has a high mortality rate of 30-40% of cases reported. There appears

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to have been very few cases due to person-to-person spread, other than in hospitals (especially with healthcare workers). The origin of this outbreak is being slated to camels, where the virus has been isolated. However the epidemiology of many of the cases is difficult to trace back to camels! As with the SARS outbreak, the politics of this infectious disease are possibly more serious than the actual disease. Hospital administrators and politicians who do not pay heed will lose their jobs and their reputations (as occurred recently in Saudi Arabia). The fact that many more patients will die from the daily influx of suboptimally-managed patients with septic shock, heart attacks and trauma, due to inadequate facilities, organisation and training does not register on the political radar. A handful of cases from an infectious disease outbreak will create community fear and loss of faith in public institutions. Health workers should not underestimate this effect on our political masters. So far the MERS outbreak has caused more than 500 infections and more than 100 deaths globally. Fortunately, only nine cases have been reported in Qatar, even though it is immediately adjacent to the worst hit areas in Saudi. It is unlikely that there have been many more cases in Qatar because of the extremely active screening program that we have in place, especially for travelers returning from Saudi. The impact of these few cases has been enormous, with a complete reorganization of patient flow within the main ED at Hamad General Hospital. All cases arriving to the ED with fever and cough are immediately isolated and given a mask. After a quick assessment, an X-Ray is performed and if positive for pneumonia, ongoing airborne isolation is enforced until two negative swabs for novel coronavirus are documented. Patients without pneumonia and without other reasons for admission, are sent home for home isolation. Given that coughs and colds are common presentations to EDs and with a census of more than 1300 per day, the impact on patient flows is great. Fortunately the general public has remained calm and we have not had a large number of “worried well” attending the ED or primary health clinics. Although there has been a lot of media coverage, it has been responsible. As a result of the outbreak, we have been able to enforce better isolation procedures for patients, improved infection control procedures (such as washing hands) and a major improvement in staff attitude toward vigilance in maintaining good infection control habits. Thankfully, so far we have had no staff affected by the virus, and no new


The impact of these few cases [of MERS] has been enormous, with a complete reorganization of patient flow within the main ED at Hamad General Hospital. All cases arriving to the ED with fever and cough are immediately isolated and given a mask. After a quick assessment, an X-Ray is performed and if positive for pneumonia, ongoing airborne isolation is enforced until two negative swabs for novel coronavirus are documented.

cases for the last 6 months. Importantly our infection control procedures for H1N1, measles, TB, meningitis and other infectious diseases have greatly improved. The hospital is also expanding the facilities for isolation rooms to cater to a much larger number than previously. Virology services have also improved with short turnaround times (<24 hours) for screening to rule out the disease. The outbreak has also allowed us to reinforce with the

local community what strict isolation actually means. For example, when a 15-person family arrives to visit – and wants to spend the whole time with the patient -enforcement can be difficult, but it is improving! Despite the evidence that good basic infection control will deliver most of the benefit, clinicians the world over seem to obsess over negative pressure rooms, hepafilters and advanced PPE. These are important for very high risk patients, such as those ventilated with proven infection undergoing respiratory procedures. They are simply not practical on an ongoing basis in busy overcrowded EDs for every potential case. Distraction with the high end infection control kit is a major concern when basic infection control guidelines are not being followed. As emergency doctors we will be in the frontline when the next epidemic occurs. Having good patient flow through the ED, separating out patients with potential infectious disease syndromes and insisting on a high level of compliance with basic infection control procedures will prevent infections from most known infectious diseases. For the safety of the healthcare workers and the patients that you treat, it is imperative that a regular audit and feedback process are in place. Your ED shouldn’t need an epidemic to force your department to do what is expected. Nevertheless, an epidemic can be an opportunity, helping to catalyze the hospital into improving patient flow, reducing overcrowding in the ED and ramping up facilities for isolation and improved diagnostics.

infected patient to other patients, health-care workers and visitors. Health-care workers should be educated, trained and refreshed with skills on infection prevention and control. It is not always possible to identify patients with MERS-CoV early because some have mild or unusual symptoms. For this reason, it is important that health-care workers apply standard precautions consistently with all patients – regardless of their diagnosis – in all ased on the current situation and work practices all the time. available information, WHO enDroplet precautions should be added to courages all Member States to conthe standard precautions when providing tinue their surveillance for care to all patients with symptoms severe acute respiratory infections of acute respiratory infection. (SARI) and to carefully review Contact precautions and eye from any unusual patterns. protection should be added www.who.int Infection prevention and when caring for probable or May 28, 2014 control measures are critical to confirmed cases of MERS-CoV prevent the possible spread of infection. Airborne precautions MERS-CoV in health care facilishould be applied when performties. Health-care facilities that proing aerosol generating procedures. vide for patients suspected or confirmed Patients should be managed as potentially to be infected with MERS-CoV infection infected when the clinical and epidemiologishould take appropriate measures to decrease cal clues strongly suggest MERS-CoV, even the risk of transmission of the virus from an if an initial test on a nasopharyngeal swab is

WHO: Advice on MERS

B

negative. Repeat testing should be done when the initial testing is negative, preferably on specimens from the lower respiratory tract. Recent travellers returning from the Middle East who develop SARI should be tested for MERS-CoV as advised in the current surveillance recommendations. All Member States are reminded to promptly assess and notify WHO of any new case of infection with MERS-CoV, along with information about potential exposures that may have resulted in infection and a description of the clinical course. Investigation into the source of exposure should promptly be initiated to identify the mode of exposure, so that further transmission of the virus can be prevented. People at high risk of severe disease due to MERS-CoV should avoid close contact with animals when visiting farms or barn areas where the virus is known to be potentially circulating. WHO does not advise special screening at points of entry with regard to this event nor does it currently recommend the application of any travel or trade restrictions.

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DISPATCHES READER-SUBMITTED UPDATES FROM THE FOUR CORNERS

Global Response to Middle East Respiratory Syndrome (MERS)

Q. What steps, if any, has your hospital taken in response to the recent cases of MERS in the Middle East and the USA? ______________________

01 AUSTRALIA No ED impact yet, but weâ&#x20AC;&#x2122;ve been advised of local management to be undertaken when a patient is suspected of having MERS. Andrew Watson ______________________

02 BELGIUM No impact on our ED. Pieter Jan Van Asbroeck ______________________

03 BOTSWANA No cases, and no steps taken. Megan Cox ______________________

06 IRELAND No cases, but we get regular updates from national public health service and our staff has been alerted regarding appropriate measures to take if cases are encountered. Conor V. Egleston ______________________

07

04 ICELAND MERS has impacted our ED in that there has been increased awareness, though no identified cases (yet). David Thorisson ______________________

05 INDIA MERS has had no impact on our ED. ----------There is no case reported of MERS in our ED....till now. I canâ&#x20AC;&#x2122;t comment what will be the hospital policy regarding

34

this, but I think this should be notifiable disease like others in the list. Dr. Sudipta Barua ----------No ED impact yet, but we are to isolate any cases and inform the local infection control authority. Dr. Sunil Kumar Choudhary ----------Nothing has been done in my hospital. Dr. Rahmat Farid ______________________

ITALY There are no real responses in my hospital to the cases of MERS Davide Spolaore ______________________

08 FINLAND No ED impact, but the hospital has informed doctors and ER and ambulance staff about MERS. The team responsible for infection control and alertness in the hospitals and healthcare area are following the situation. Peter Holmstrom

Summer 2014 // Emergency Physicians International

______________________

09 MEXICO We dont have any MERS cases. Miguel Mondragon ______________________

10 NETHERLANDS No impact on our ED, but the hospital has made a protocol for identification and treatment of MERS. ------------ Anybody coming from Saudi Arabia, Yemen in the past two weeks, and presenting with fever at the ED is suspected of having MERS. They will be picked up at the registration desk (or triage). Zero cases suspected up to now. Information sent to staff via email and newsletters. Carianne Deelstra ______________________

11 SOUTH AFRICA No cases or hospital changes. Heike Geduld ______________________

12 SOUTH KOREA No cases or hospital impact from MERS. Sam Beom Lee, MD ______________________

13 SPAIN No impact to report. Luis Garcia-Castrillo ______________________

14 TURKEY No MERS cases to report.

______________________

15 UNITED KINGDOM No ED impact from MERS. Deepankar Datta ____________________

16 USA No impact on our ED Nathaniel Greenwood ---------No cases, but the infectious disease department has put together a protocol to deal with this. Marie Quarles ---------Hospital has instituted the policy of asking about travel when patient presents with fever at triage. Frederick Thum ---------We now ask everyone presenting to the ER at triage a couple questions to determine if they are at risk for MERS. If so, then they are placed under airborne precautions until testing for MERS comes back. Tiffany Alexander ____________________

17 YEMEN MERS has impacted our ED. Any cases with high suspicion are isolated. Hospital has implemented simple mask wearing for health care providers. Mohammed -----------My hospital just established an infection control program and they are preparing for the exposure plan. Samah Mohammad Lotf Al Attab


DISPATCHES

Global Response to Middle East Respiratory Syndrome (MERS) EPI polled more than 7,000 emergency physicians from nearly 100 countries about the impact of MERS. Hereâ&#x20AC;&#x2122;s what you said.

Q. Have the recent cases of MERS in the Middle East and the United States impacted your emergency department in any way?

Countries with Lab-Confirmed MERS Cases Countries in the Arabian Peninsula with Cases

Countries with Travelassociated Cases

Saudi Arabia United Arab Emirates Qatar Oman Jordan Kuwait Yemen Lebanon

United Kingdom France Tunisia Italy Malaysia Philippines Greece Egypt USA Netherlands

SOURCE: CDC

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EPI Issue 13  

The latest in global emergency medicine, from MERS in Saudi Arabia to surf medicine in Ireland to emergency medicine wards in Hong Kong.

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