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Going Global

The Going Global blog is an opportunity for emergency physicians to share their experiences practicing and teaching outside the United States. Submit an article about your experience to EMN at emn@lww.com. Be sure to include a brief biography and photographs of the authors. Photos taken during time spent abroad are also welcome, and should be 300 dpi and in jpg, tif, or gif format.

This blog was started by the emergency medicine residents of Palmetto Health Richland in Columbia, SC, who travel the globe on medical missions. The program is under the direction of Thomas Cook, MD, who oversees one of more than 40 academic departments of emergency medicine that sponsors Global International Emergency Medicine Fellowships.

Monday, February 1, 2016

BY MICHAEL DAUM, MD

I had the wonderful privilege of visiting three different cities in India for 16 days during my third year of residency. My original impression of India was, "Wow." This country could not be any more different from what I am used to.I am just a small-town boy from southern Indiana, but my medical training has given me the opportunity to visit poverty-stricken areas and witness different medical practices in Honduras, Guatemala, and Haiti. But India was just different. Name anything. From the obvious — language, food, population density, climate, dress, and religion — to the not-so obvious — cleanliness, body language, hospitality, hospitals, patient acuity, and where health care priority fits into government.

India is roughly one-third the size of the United States, but it has roughly four times more people. It is home to 17.5 percent of the world's population, and has 53 cities with more than a million people (the United States has 10).

I went to three southern India cities: Bangalore (also called Bengaluru), Chennai, and Madurai. Each city had its own character. Bangalore was the first city I visited. George Washington University made my trip possible, and the hospital with which it partners is BGS Global Hospital. Dr. Samir Mohammad was the program director. I helped administer oral boards to residents the first two days and lectured the next two days. Fortunately, I had prepared six different hour-long lectures prior to arrival and many cases from my own experience in residency to use for case-based teaching. I used all of them because the residents in all three of the cities were so enthusiastic about learning. It was very evident that they were very well-read but not up to date with the new, ever-changing knowledge and clinical practices in emergency medicine. Their knowledge is almost solely built on textbooks like Tintinalli and Rosen. I had not realized how much FOAMed, UpToDate, and podcasts shaped my education.

The ED had three "trauma bays" that doubled as acute care rooms. They had approximately 10 beds total, which is large compared with other hospitals in India.



I visited BGS Global Hospital-Chennai next, where Dr. KR Ram Mohan was the program director. I spent a majority of the four days lecturing and doing bedside teaching. Almost every patient I assisted required intubation, cardioversion, or some other emergent necessity.

One of my favorite experiences was when I rode on the back of a resident's motorcycle to a World Heritage site one hour south of Chennai called Mahabalipuram. It was quite exhilarating to ride through chaotic traffic with seemingly no traffic rules. The monuments we visited were carved out of bedrock in 700 AD. I also visited a beach, and was amazed at the hundreds of people present and what they were wearing. Women were fully clothed and did not enter the water, while the men wore jeans and would play in the water.

I flew to Madurai after Chennai. It is is a city in the state of Tamil Nadu in southern India. The hospital was called Meenakshi Mission Hospital, and Dr. Narendra Nath Jena, the program director, is quite famous for his pioneering role in emergency medicine in India. He gave me a warm welcome, and his excitement for teaching and passion for the specialty was contagious.

The emergency department was the largest, nicest, and by far the most organized of the three I visited, and it was evident that it was because of the diligent work of Dr. Narendra Nath. I lectured here for three days and took one day to dedicate to clinical skills such as intubation, central line placement, ATLS, and ACLS cases. The residents here absolutely loved the one-on-one clinical teaching, especially using the dummies to intubate and do case reviews.

 

One of the residents took me to one of the largest Hindu temples in the world called Meenakshi Amman Temple, which forms the heart and lifeline of the 2,500 year-old holy city of Madurai. It is considered one of the "New Seven Wonders of the World" and was truly a sight to see.

One common theme that persisted in each city and hospital I visited was the wonderful hospitality. I was greeted with such warmth and kindness by the program directors, residents, and staff. The program directors in each hospital would constantly ask if they could do anything to make my stay and experience better. One even had the hotel chef prepare a different traditional south Indian dish every meal. And the respect shown by the residents was amazing. They would all stand when I entered the room, and would always say, "Yes, sir" or "No, sir," something I would never expect (not even when I am 65 and ready to retire).

The acuity of patients presenting to the emergency departments at each of the three hospitals were quite different from here in America. We generally see anywhere from 93,000 to 100,000 patients in our ED every year. We admit approximately 23 percent of our patients to the hospital. An even lower percentage are admitted to the stepdown unit, and even fewer are admitted to the ICU. The staff at Meenakshi Mission Hospital and Research Centre, however, sees approximately 14,000 to 15,000 patients per year in the ED, and they admit more than 50 percent to the ICU. These numbers were pretty similar at the BGS Global Hospitals in Bangalore and Chennai. The patients present with much higher acuity in India because they do not have great access to health care and because they often attempt to treat ailments with home remedies and prayer.

I could not be more thankful for the opportunity to participate in such a wonderful experience. I know it could not have been possible without the partnership of the Palmetto Emergency Medicine Residency Program with the GWU International Medicine Program. Most notably, I would like to thank our program director, Dr. Thomas Cook, whose championing involvement in global health, international travel, and its unbelievable life-impacting potential proved 100 percent true. Also, I would like to thank Dr. Heather Brown and Dr. Kate Douglass who helped make this all possible. I will never forget this great experience.

 

Dr. Daum is a third-year resident in the emergency medicine program at Palmetto Health Richland in Columbia, SC, which is under the direction of Thomas Cook, MD.


Wednesday, November 18, 2015

BY RACHEL EDWARDS, MD

 

I traveled to India in August 2014 with Himalayan Health Exchange (HHE), which organizes groups of attending physicians, residents, medical students, and nurses from around the world to travel to one of the most remote parts of the world, deep in the Himalayan Mountains. Our route took us to the Pangi Valley of Northern India, where the road we traveled has only existed for a decade and is impassable during the winter months when the road is covered in snow. The people who live there are resilient and hardened by their environment of mountainous terrain and harsh climate.

 

 

Our group, escorted by a talented team of men, traveled by caravan to remote areas where we would set up camp and clinics. The local people would travel long distances to be seen. Some had acute complaints, some had already seen a doctor and wanted a second opinion, and some just wanted to see the show.

          I had the opportunity to see pathology that I would otherwise never see in the United States, but most of the patients complained of common disease processes like arthritis. Sufferers of this common ailment received little relief without access to NSAIDs or acetaminophen.

          This baby suffered from spina bifida. Nothing could be done for her in our clinic except to refer her to a hospital, but we were able to give her mother folic acid supplementation.

 

 

This 15-year-old-boy suffered from scoliosis and chronic leg pain from walking with a limp. Our osteopathic doctors were able to give him stretching exercises to help keep him mobile.

 

 

This young boy had a heart murmur I had never heard before. He said he had never had anyone listen to his heart before. Thankfully, we had a cardiology fellow in our group who identified the murmur as a patent ductus arteriosus, likely with a septal defect as well. The child was hypertensive, and said he had trouble keeping up with the other children. All we were able to do was write down our findings and refer him to the nearest hospital. I'm not sure if he was ever able to get the corrective surgery that he needed.

 

 

Abhimanyu Uberoi, MD, the cardiology fellow from Cedars-Sinai, brought an iPhone cover that had sensors to take an EKG of the person holding it. We were able to look at the EKGs of our patients complaining of chest pain to help us decide whether to refer these patients to the hospital.

 

 

Never in my life have I seen mountains as breathtaking as the Himalayas. These pictures hardly do it justice. We were all mesmerized by what we had previously only seen in pictures.

 
 

Our group developed some pretty close friendships after spending a month with each other living in tents, driving long distances, and working side by side. We were all moved by the patients who were so grateful for our care. We tried to treat as many patients as possible and make the biggest impact we could. There were times we were satisfied by the care we were able to give, but more often, we were frustrated by our lack of resources in this remote area.

 

 

Dr. Edwards is a graduate of the University of South Carolina School of Medicine and a member of the 2016 emergency medicine residency class at Palmetto Health. 


 


Monday, February 2, 2015

BY LUKE HUSBY, MD, & AND LESLEY OSBORN, MD

 

Ten hours of air time and three cities later, we arrived in the Honolulu airport to be greeted by the Samoan travelers who would be guiding us around Samoa.

  

 

 

Once we arrived in Pago Pago in American Samoa, we hit the ground running with a quick trip to the supply cache at a nearby pastor’s house. After a few hours of sorting, we were ready for the week with the pharmaceuticals, bandages, durable medical equipment, and other supplies that we’d need.

 

Each plane had a weight limit, and there was only one plane with 31 volunteers. The plane made multiple trips to get the entire crew from one island to the next. With the supplies sent, we took the ferry to Savai’i, Western Samoa.

 

After the 45-minute ferry ride, we drove to our first mission site, and began seeing the loads of patients waiting for us in Taga. Some kinks had to be worked out during the first day of medical clinic, but we quickly became a machine with various clinical stations, including four practitioners with segregated workspaces made up of church benches, chairs, and walls of tablecloths, all of which were set up in the local community’s church fale. We had two triage tables where blood sugar, medical history, and vitals were documented before the multitude of patients waiting outside were seen.

 

 

We also had a staging tent for those waiting to be triaged. On day one, we saw about 200 patients. We were setting up for, traveling to, or running medical clinics for various churches and the surrounding community for the next several days. Each village meeting requires a gift from the guest and for the guest, typically books or food.

 

 

 

 

 

We wrapped up our work in Western Samoa, and transitioned back to American Samoa for clinics where we saw another 250 patients. We were given at the conclusion of the trip, as is customary, canned tuna, locally made jewelry, lava-lava skirts, and cookies. After endless “faafetais” or “thank yous” and hugs, the team of 31 from seven different states began to disband to Hawaii, California, Nevada, Texas, North Carolina, South Carolina, and Louisiana.

 

Overall, we held six clinics, and saw more than 1,200 patients, dozens of whom ended up hospitalized for various injuries or illnesses. At least one woman was rescued from an abusive situation. The education imparted by pharmacy, wound care, nurses, the Christian-based team, and the practitioners was probably the longest lasting effect we had, although whenever possible, the positively-screened patients were able to be referred to local physicians. It was an unbelievable trip with a layover in paradise.

 

Dr. Husby and Dr. Osborn are second-year emergency medicine residents at Palmetto Health Richland in Columbia, SC, under the program director Thomas Cook, MD.

 

 

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Friday, January 9, 2015

By Christine Butts, MD

 

I typically write my columns about the “how” of ultrasound, but it's also important to think about the “why.” Ultrasound to me is a tool that can be shared across cultures and barriers to broaden education and to improve patient care.

 

So when a colleague approached me about teaching ultrasound in Kurdistan, Iraq, I was intrigued. Nervous but intrigued. I have been teaching ultrasound to residents, students, and other faculty here in the States for almost seven years, but have always harbored a desire to teach internationally.

 

I spent two months as a medical student working in a hospital in Zambia, and had experienced firsthand how devastating a lack of resources and knowledge can be. I was hopeful that bringing my experience with ultrasound to underdeveloped regions would empower local physicians to improve the care of their patients. Since that first anxious trip to Iraq, I have had the opportunity to teach in Kurdistan twice and also spent three weeks this summer working and teaching in an ED in Haiti. Ostensibly, I went to these regions to teach, but I also learned a great deal about ultrasound and its place within emergency medicine.

 

Twenty-four hours into my first trip to Kurdistan, Iraq, I was reminded of just how far from home I was. Patients surrounded our small group, holding copies of blood work, CT scans, and MRIs. Looking through the information they held in their hands, I saw that most of them had undergone appropriate workups and were on the appropriate treatments. Our evaluation of their workups seemed to reassure them because we were “American doctors.” I wrote prescriptions for medications, crutches, wheelchairs, and, in one strange circumstance, a house. It was certainly a far cry from my day-to-day job of teaching emergency medicine and ultrasound here.

 

I spent most of my time in Kurdistan teaching surgeons and internists because emergency medicine is not yet a separate specialty. The physicians I encountered there were adept and capable in their respective specialties, but the idea of using ultrasound at the bedside to evaluate critically ill patients and to augment the physical exam was foreign to them. They accepted its use in the FAST exam and for guiding central lines, but my suggestions to use ultrasound to evaluate the soft tissue of a patient with skin changes or the lungs of a patient with undifferentiated shortness of breath were met with quizzical responses.

 

Surgical residents practicing FAST skills in Duhok, Iraq

 

The Kurdistan emergency departments are staffed by internists at one hospital and surgeons at another. The concepts that we hold dear as emergency physicians, such as triage and rapid evaluation and treatment, were not universally evident. Seeing people wander through the ED at will and having to push my way through a group of family members surrounding the bedside of a critically ill patient was culture shock.

 

I was encouraged that trainees I met on my initial visit, however, shared cases in which they used bedside ultrasound when I returned a second time. Many physicians, particularly those in training, were intrigued by the idea of point-of-care ultrasound, but I realized that the concept of bedside ultrasound was as foreign as the concept of emergency medicine as its own specialty. It seemed on my return visit that some inroads had been made because the skills used to evaluate critical trauma patients had been passed from my initial trainees to a new group of residents. Some reluctance still remained, however.

 

Both places are very hot, but you couldn't find more different cultures than Kurdistan and Haiti. Emergency medicine is a burgeoning specialty, and the trainees were eager to learn ECHO, FAST, and pulmonary ultrasound. I felt a real satisfaction in seeing them grasp the concepts and put them to use, at times in diagnostically challenging cases such as undifferentiated pelvic masses or strangely dilated loops of bowel. I was frequently reminded of my limitations by theinability to act on the diagnoses that were made. A case of pyomyositis that was identified and aspirated with ultrasound guidance had me on top of the world until the news that the patient had died shortly after surgical debridement sent me crashing back to the ground. Despite these challenges, seeing a trainee get a look of understanding was as fulfilling as it is here in the States.

 

But these young doctors had learned to think like EPs, and they were able to understand how a quick cardiac exam might be beneficial in a hypotensive patient or how evaluation of the soft tissue might help to distinguish septic bursitis from a septic joint. Fittingly, this fall, the hospital will launch its first class of emergency medicine residency trainees.

 

Point-of-care ultrasound has great power to improve medical care in areas lacking resources. Lack of equipment, meager financial resources, and lack of proper training are barriers to its integration. But failure to incorporate the basic concepts of rapid evaluation and treatment may prevent the widespread adoption of point-of-care ultrasound in areas where emergency medicine has not yet been established as a specialty.

 

Dr. Butts is the director of the division of emergency ultrasound and a clinical assistant professor of emergency medicine at Louisiana State University at New Orleans. Follow her @EMNSpeedofSound, and read her past columns at http://bit.ly/ButtsSpeedofSound.


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Monday, November 3, 2014

By Remi Kessler & Natalie Catherwood

 

Ms. B was middle-aged and lying on a gurney without a sheet in the grossly under-resourced ED of the largest public hospital in Phnom Penh, Cambodia. She clearly had an altered level of consciousness, and she was not attached to the monitor that was behind the bed. Her open shirt exposed her to the entire ED, but her family had other concerns.

 

They were quick to leave as we made our way toward the bed. It became evident that she had not been seen by a doctor, despite her deteriorating condition and her family's persistent anxiety. We saw her chest rise and fall irregularly with fast, shallow breaths. Her glassy eyes failed to meet ours as we attempted to introduce ourselves.

 

We rapidly assessed her condition, simultaneously auscultating her chest. Her lung sounds were not normal. Upon closer listen, we heard an extra noise, similar to that of a heartbeat, just at the tail end of her expiration. Uncertain of what it was, we auscultated once more, closing our eyes to block out the surrounding mayhem. Her breathing became more labored until it dramatically slowed. That extra sound was still there, but brief gasps for air characterized her respirations as agonal. We held our breaths as we waited for her chest to rise again. We listened once more, this time unable to identify a heartbeat.

 

We felt for a pulse, struggling to identify its presence because of the girth of her neck. We watched as her heart came to a stop. It was disturbing to realize that we, the most inexperienced people in the room, had recognized a critical situation and needed to act. Her family watched what must have appeared to be an assault on their mother as we began resuscitation and chest compressions. No local staff had discussed the care plan with the family, who only spoke Khmer. Instead, Ms. B's family stood stunned at the pace at which she appeared to deteriorate.

 

A crowd of medical students and nurses quickly circled the bed, yet most were merely observing. They were apprehensive and unsure of how to help. This was unsurprising, given that Cambodian medical and nursing students' knowledge of chest compressions was based solely on textbook learning; they had never practiced on a manikin, much less a live patient. The ED's main physician was nowhere to be seen, which added to the chaos of the situation. Because there was no functioning monitor, we couldn’t get a blood pressure or cardiac rhythm for Ms. B, and not one nurse or staff had bothered to call another department for ECG stickers or a defibrillator or contact a physician with knowledge of advanced life support.

 

It was baffling to us that none of these items or a physician was readily available in the ED. Chest compressions were performed in a chaotic manner because many were struggling with basic techniques and required simultaneous instruction. Medical staff did not know to move when it was time switch compressions, which resulted in lots of pushing people out of the way. Two doctors who finally arrived: One was feeling for a pulse during compressions, while the other, who was in charge of medications, quickly left without a word. No one was in charge of Ms. B's care, and no one responsible for charting which drugs she had been given. It was utter madness.

 

As CPR continued, we began to fear the worst given the circumstances. Who would be the one to determine when to stop these extreme measures? What if this was the end for Ms. B? How would we know? After 15 minutes, we thought we felt a pulse. We auscultated. It was only after we heard the heartbeat that we realized we had been holding our breaths the whole time. No one had yet spoken to Ms. B’s family or even acknowledged their presence, and they had become increasingly confused and horrified.

 

It was only at this point that the main physician returned to the ED and asked why Ms. B had sought medical attention. She had had a syncopal episode and hit her head. Western medicine would have surely sent her for a CT scan. Because Ms. B's family could not afford one, however, she was instead shipped off to the general medical ward with no transfer of care. There wasn’t as much as a scribbled note, a drug order, a patient history, a diagnosis, or a care plan. As two foreign students, we were the only ones there the entire time. Now on the ward, we felt utterly helpless because there was no one around for us to share our account of her situation.

 

The general medicine doctor received an intubated, critical patient for which he had no information. And once more, Ms. B's family was left at the end of the bed, uninformed, their eyes silently pleading with ours. After completing his assessment, the doctor spoke briefly with the family before disappearing again. Unable to pay for Ms. B's hospital stay, the family asked requested to take their mother home. Ms. B's daughter broke down in tears because she realized that her mother's death was inevitable and quickly approaching.

 

This triggered our own emotional shock and sense of defeat. We struggled to suppress the feeling of finality and the frustration that resulted from our inability to alter the transpired events. The uncertainty, chaos, and unanswered questions left us with a sense of failure that we could not fully grasp. We had brought Ms. B back from the brink of death, and now she was being sent home to die. We knew we had to leave the family to be with Ms. B for whatever time she had left.

 

As we were leaving, our eyes met with Ms. B's daughter’s. It was clear to all of us that these were Ms. B's final moments. Many other patients in the ED required our attention. In the midst of this busy department, life carried on for everyone but Ms. B.

 

Without a dedicated physician assuming charge of Ms. B's care, she suffered in a medical culture that unfortunately lacks accountability and professional responsibility. Would anyone ever reflect upon her death and attempt to improve the quality of care for future patients? Will the chaos of the ED be repeated with the next patient who comes through the doors?

 

This type of medical culture permits recklessness and neglect, and the lack of reflective practice means that opportunity for learning and quality improvement is swiftly lost. But patient outcomes can be improved by incorporating basic measures into medical training, including promoting clear communication during hectic situations, thoroughly discussing a patient's condition following a transfer, and identifying what can be done differently in the future. Similar to many developing nations, the prevailing medical practices in Cambodia have yet to recognize the importance of accountability in medicine, prioritizing patient safety, and reducing preventable harm. This is no doubt in part because of Cambodia's brutal history under the Khmer Rouge.

 

 

The Communist-backed Khmer Rouge systematically destroyed health care institutions, all health care infrastructures, and exterminated virtually the entirety of its educated population, including nearly all of its physicians. Cambodia had approximately 270 physicians between 1975 and 1979, and only 40 remained in 1979, and 20 of those emigrated. (CMAJ 2000;163[9]:1176.) Emergency medicine is not a recognized specialty in Cambodia, and the infrastructure in the ED is wholly inadequate. Severe trauma patients often wait days for appropriate consults, and the continuity of care is hindered by inept patient handoffs during shift changes. With an overall increasing demand for acute care services, it is of utmost necessity to address these shortfalls as developing nations grapple with simultaneous capacity strengthening and quality improvement.

 

Emergency medicine as a specialty offers the opportunity to care for patients during the worst and often the most traumatic moment of their lives. That comes with a tremendous responsibility. Valuing this responsibility is fundamental to the quality of care that is provided, not just in the ED, but for the health care that follows. Often this is underemphasized as emergency medicine becomes grounded in foreign health care systems that may not yet recognize the vital role that EPs play in providing the bridge to further health care and the evident benefits to society as a whole. Only when a heightened sense of professional responsibility becomes standard protocol in these developing nations can the quality of care become what patients in these countries deserve.

 

Ms. Catherwood, is a fourth-year medical student at Queens University Belfast School of Medicine in the United Kingdom. Ms. Kessler is a freshman at Johns Hopkins University.

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About the Author

Thomas Cook, MD
The emergency medicine residents at Palmetto Health Richland in Columbia, SC, under the direction of program director Thomas Cook, MD, relate their experiences on global health rotations in places such as India, Nepal, Kenya, Ghana, Samoa, Korea, and China. These reports provide unique insights into why the next generation of emergency physicians will know more about the world and global health than ever before.