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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 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.

Tuesday, August 05, 2014
By Jon Virkler, MD
Arrival in Haiti was a stark contrast from departure in Miami.
I had my passport scanned by an electronic sensor and rode two moving sidewalks and a train to gate D55 in Miami. I deplaned in Haiti at one of the two gates at the only international airport in the country, walked down the steps from the airplane onto the tarmac, and got onto a standing-room-only bus that took us to customs. Our bags arrived on the only baggage carousel in the airport.
The airport in Haiti.
We left the airport as a group, and fought through the throng of porters hoping for a tip of one or two American dollars, packing into the back of two Land Rovers. We drove past streets lined with shops and tap-taps — pickup trucks as taxis — and pulled into the gates of Hospital Bernard Mevs after passing by the guards armed with shotguns.
Guards at the gate of Hospital Bernard Mevs.
Hospital Bernard Mevs is one of many in Port-au-Prince, most of which are run through relief organizations or Doctors Without Borders. Bernard Mevs is supported by the University of Miami, and staffed by a mix of volunteers and Haitian staff. The Haitian staff was incredibly willing to learn and eager to have American involvement. Haitian nursing and medical students were also on hand.
The hospital itself had a triage shanty (three walls and some curtains), a two-bed ED, a four-bed ICU, a nine-bed medical-surgical unit, and a 10-bed spinal cord unit. A separate pediatric ward doubled as a PICU. The hospital also had an orthotic and prosthetic shop, outpatient clinics, three operating rooms, and an infectious disease ward with four beds.
The hospital’s triage area.
The hospital had impressive capabilities for Haiti. It had several adult ventilators, a BiPap machine for use in the ICU, and the only pediatric ventilators in the country. It sometimes had an onsite x-ray machine and a CT scanner. The CT scanner only worked occasionally because it ran on city power, which was frequently down.
All sorts of surgeons were on call: general, orthopedic, neurosurgery, and Ob/Gyn. Medical and pediatric admissions were handled mostly by the volunteer physicians. Sometimes capability or bed availability necessitated transfer to outlying hospitals. This was difficult because these either have a poor reputation or were in areas of town even Haitians are hesitant to enter.
Many of the simpler complaints were handled in the triage tent by the nurses, paramedics, and Haitian doctors staffing that area. The more serious complaints were brought to the ER for resuscitation, where most equipment was readily available.
Patients were initially screened at the gate by an armed guard and a translator. Their chief complaint was presented to the triage doctor or ER doctor, and the patient was allowed in or told to leave.
The Bernard Mevs ER.
Common complaints include vomiting and diarrhea, febrile illness, and traumatic injury. Haiti has a significant amount of street-level violence, so stabbings, assaults, and head trauma are all common. The country has no traffic laws, so pedestrian injuries and motor vehicle collisions are frequent. HIV is also rampant, and the sequelae of this disease are frequent. Other serious pathologies I encountered included eclamptic seizures, respiratory failure, PCP pneumonia, stroke, and pneumothorax. There were also many machete assaults and other simple lacerations.
Often, the CT scanner did not work and the x-ray machine was unavailable, leaving only the physical exam and an old SonoSite ultrasound machine. Ultrasound was incredibly useful for everything from cardiac and pulmonary exams to biliary and musculoskeletal complaints, and I used it to diagnose pneumothorax, long bone fracture, volume overload from renal failure, liver metastasis of gastric cancer, appendicitis, and many other conditions.
Volunteers were typically not allowed outside the gates, except for a nightly trip to the United Nations, which has a restaurant. This provided a nice respite from the stress of running a hospital in a developing country, and allowed a nice return to American food as opposed to the normal fare of goat, chicken, and rice. The local beer, Prestige, is cheap and drinkable, and flows freely at the UN.
Haiti had some comforts, but for the most part the complex definitely felt like a developing country. There was wireless Internet available, so we were able to chat or Skype with family back home. The showers were abysmal: there was no hot water. The water was unsafe in Haiti, so all drinking water had to be filtered. The mosquitoes and heat were intense, even in March, and the air conditioning worked well but infrequently. A week deployment feels longer when you are in the midst of it, but you realize you want to stay when the week reaches its end. Haiti grows on you, especially its people. There is definite need, and Bernard Mevs does well to meet that need in harsh circumstances. All told, it was one of the best experiences of my life.
Dr. Virker graduated from the University of South Florida School of Medicine. He graduated from the emergency medicine residency at Palmetto Health in 2012. He lives and works in Palm Beach, FL.

Monday, May 12, 2014

By Peyton Hassinger, MD

Josh Skaggs, Nathan Ramsey, and I traveled to Samoa with Mission of Hope Ministries for two weeks in July 2012. We were part of a team of about 35 people consisting of four doctors (one other pediatrician from Hawaii), four nurses, medical students, and many other support staff.

Mission of Hope is a South Carolina organization that has been taking groups to Samoa every year for the past 15 years to do medical work. ( The leader is a pastor originally from American Samoa who now lives in Columbia, SC. He recently became the chief of his village in American Samoa, and is now spending about half the year living in Samoa.

The medical mission involved five all-day clinics offered in five different villages in Western Samoa and American Samoa. Each village requested the mission’s presence and hosted our group by providing facilities, food, and gifts. They were very gracious and routinely provided us with Thanksgiving-style feasts for breakfast, lunch, and dinner. We usually worked from first thing in the morning until everyone in the village was seen, which was usually between 4 and 7 p.m. We saw about 200 patients on a typical day.

One of our clinics in American Samoa.

We provided a range of services from routine checkups and acute complaint visits to wound management and optometry evaluation, and we provided glasses, wheelchairs, and crutches. We performed minor procedures such as laceration repair and abscess incision and drainage. A prayer group met with all patients and addressed their spiritual needs.

The twin-engine airplane we took between islands in Samoa.

 Dr. Hassinger attended the Mayo Clinic School of Medicine. He is originally from North Carolina. He is a member of the class of 2014 at the Palmetto Health emergency medicine program.

Wednesday, March 05, 2014
By Zubair Chao, MD
I had an opportunity to visit India as part of George Washington University’s International Emergency Medicine & Global Public Health Fellowship Program in April 2013. I gave lectures on endocrinology and HEENT as teaching faculty. I had already planned to go to China with my residency program and ultrasound fellowship directors, Drs. Cook and Hunt, respectively, and it was an easy decision for me to combine the trips for a firsthand view of emergency medical services in the world’s two most populated countries.
Emergency medicine is new in India, and it is not widely accepted as a recognized specialty. Only 20 emergency medicine residency positions have been approved by the Medical Council of India. George Washington University has set up a few clinical training sites, and it confers a master’s in emergency medicine on graduation. The program is essentially a three-year residency. Applicants come from a wide variety of backgrounds; many are straight from medical school, and many more are general practitioners, who are not required to complete residency training in India.
I was sent to Calicut (Kozhikode) and Kolkata (Calcutta). Calicut is a relatively small city in the south Indian state of Kerala, a place known for its greenery and the dubious distinction of having the country’s highest rate of alcohol consumption. The state has historically been a port of entry for commerce. It was also the place that the Portuguese explorer Vasco da Gama first landed, and Portuguese influences are still seen in Kerala. The city is known as a model of diversity and tolerance; Christians, Hindus, and Muslims live peacefully side-by-side.
Kerala has seven multispecialty hospitals, two of which are government facilities. I worked at the Malabar Institute of Medical Sciences (MIMS) and Baby Memorial Hospital. The George Washington program was established at MIMS many years ago, and it has already graduated a few classes of residents, some of whom have stayed on as faculty. The ED has 15 beds and a two-bed trauma bay, and it sees between 75 and 150 patients a day. The program at Baby Memorial is in its inaugural year, and it only has a class of seven interns right now. The faculty at Baby Memorial is also new; one is a recent MIMS graduate, and the program director is an orthopedist. Both hospitals have a full complement of subspecialty backup and residency programs in other specialties.
Kolkata is in the state of West Bengal in eastern India, not too far south of China. I worked at Peerless Hospital, one of 15 multispecialty hospitals. The hospital has more than 400 beds, and the ED has 18, six that are monitored and two that are isolation beds. This program has 15 second-year residents and 11 first-years as well as one third-year resident who transferred from another program. The city is known for its congestion, and has a great deal of poverty, even by Indian standards. Kolkata, the city where Mother Teresa worked, is rich in history, and was Great Britain’s seat of power during its colonial rule. The capital was subsequently moved to New Delhi after protests and clashes became too much for the British.
Emergency medicine is new to India, but the residents I saw were proficient. They came from many backgrounds, and most had clinical experience, either working in casualty, a small triage area attached to a hospital, or in other specialties. I noted immediately that residents have a great deal of autonomy, much more than we do in the United States. Part of this could be because many have had experience practicing clinical medicine. Another could be that India is less litigious for physicians. Indian practitioners also use their health care resources more judiciously, with none of the defensive medical practices that characterize medicine in the United States.

Allopathic medical education in India is different from that in the United States. Medical school graduates are awarded an MBBS degree, and they may then practice as general practitioners. They may also pursue post-graduate training in various specialties, such as cardiology or neurosurgery, which earns them MD certification. Many medical students pursue their MBBS education outside of India; I spoke to a few who went to Russia, and many go to China. Lessons there are in English, but clinical rotations require at least a basic knowledge of Chinese. This blew my mind because medical school for me was difficult enough. These guys had to do it in a completely different language. I had a difficult time communicating to some patients when I rotated in a busy Chinese ED last year, and I speak fluent Mandarin. I don’t know how these medical students do it; one person told me that they are encouraged to get a local girlfriend to work on their language skills so maybe that is the secret to learning a new language.
The residents’ attend didactic sessions, and each month a resident is assigned a topic to present. George Washington University also sends faculty members to give lectures, teach at the bedside, and prepare them for oral boards. Part of my role was to cover a series of lectures on endocrinology and HEENT. Residents rotate through other departments like we do in the United States, and residents from other specialties also rotate through the ED.
The selection process for applicants is different from the American match system. I was invited to observe on applicant interview day. Nearly 50 applicants took a test, and its results were combined with their previous training scores to provide them with an objective score. They were then interviewed by a panel, and each panelist gave them a subjective score. The top 10 applicants were offered a spot in the program. It was all done in one day.
These young physicians do not face language difficulties only when they travel abroad: India has more than 1,600 languages. Applicants were always asked what languages they spoke; most spoke at least three: English, Hindi, and another local language. Those who did not speak Malayalam, the language of Kerala, were asked how they expected to communicate with their patients. The usual response was that they would commit themselves to learning the new language. This is not as unreasonable as it sounds; some were able to learn it in as few as just a couple of weeks.
The hospitals where I worked were all modern, and the equipment and specialty backup were similar to the United States. Private hospitals in India largely had better facilities than government hospitals, and their resources were easier to access. These facilities were within the financial means of many middle and most upper class residents. A large number of Indian citizens are quite poor, meaning that a large segment of the population cannot afford this level of care. Their only recourse is to go to a government hospital because India provides national health care for all its citizens, and it is significantly less expensive. Care provided in government hospitals is lower quality than in private hospitals, in part because of the significant number of patients that flow through their doors. (Maternal hospital residents told me that women shared beds and delivered babies on the floors in Kashmir.)
Family expectations in India also seem to be significantly more tempered by reality. A family would consider the financial consequences of pursuing a particular medical treatment, choose to go to a government hospital, or proceed with a less aggressive approach (especially if the prognosis for meaningful recovery was poor) if a terminally ill patient needed intubation or an aggressive (and expensive) ICU course.
Unfortunately, I did not have much time to sightsee, but I did visit the Wayanad Sanctuary in Kerala. It is a beautiful forest reserve containing Mount Chembra, the highest peak in the state. Majestic peaks soared over pristine valleys, and verdant fields of fruit, coconuts, and tea stretched as far as the eye could see.
Calicut was rustic and green, but Kolkata was about as urban as it gets. You can truly appreciate the density of the country when walking there, and understand why India is on track to become the most populous country in the world. Poverty was visible everywhere; even Park Street, a posh area with fancy hotels and restaurants, was just a few blocks from alleyways where many people eked out a living selling small knickknacks and bathed in the streets beside communal water pumps. I passed through slums where people lived in shacks made of corrugated sheet metal supported by tree branches. I was unable to communicate with the majority of these people, but I did get a sense that the majority of them seemed content despite the abject poverty in which they lived. I would hesitate to say that all of them were happy because I think they all recognize that poverty and wealth distribution is a problem in India, but no one is sitting around feeling sorry for himself because he is poor.
What I saw was a great deal of resilience: the people living in slums took care of themselves by washing their clothes, brushing their teeth, and bathing in nearby ponds. They worked hard, exhibiting feats of manual labor that most of us from the West would have to see to believe. I saw many old men weighing no more than 120 pounds riding converted bicycles with loads of water containers on vast stretches of bumpy, unpaved dirt roads. Women would walk out of these slums with beautiful and clean saris to tackle the day.
Children played cricket in a nearby field with other kids from the slums. My observations and discussions with physicians there led me to understand that Indians do not have a great deal of mental illness, such as depression and anxiety, that we see quite often in America. A psychiatrist in Kashmir told me, though, that he saw a significant amount of post-traumatic stress disorder. I don’t know if they have a fatalistic outlook on life, find comfort in religion and spirituality, or just have a national sense of acceptance that that is the way things are. Maybe they are just too busy trying to get by to worry about it.

Dr. Chao graduated from the emergency medicine residency program at Palmetto Health Richland in Columbia, SC, last year, and is currently a fellow in emergency ultrasound there.

Monday, December 02, 2013
By Nathan Ramsey, MD
I’ve had the privilege of going on two medical missions to Samoa during my residency at Palmetto Health Richland. The first was after my intern year in July 2009; it changed my life and helped to solidify my chosen career path.
I fell in love with the Samoan people during my first trip, and returned the following year with several people from Palmetto, including emergency nurses and fellow residents.
The trip was made possible by a nondenominational Christian organization in Columbia, SC, called Mission of Hope. The director is a local pastor who grew up in American Samoa, and has been leading well organized and safe medical mission trips for the past 15 years. This time will be my first trip with the University of Texas Southwest Parkland Hospital International Emergency Medicine Fellowship Program.
The medical aspect of the Mission of Hope team is set up like a mobile clinic with a multidisciplinary medical staff. We arrive in a village early in the morning and set up shop in a community building. We are organized into several stations, including triage, medical, wound care, dental, physical therapy, pharmacy, eye glasses, a prayer station, and a children’s program. We usually see the majority of a village, and treat anywhere from 300 to 500 people every day.
Villagers will come to be seen even if they are not sick because they rarely have the opportunity to receive medical care. The majority of what we see is minor, such as runny noses, aches and pains, and skin conditions. We are, however, able to diagnosis treatable chronic conditions, such as diabetes and hypertension, start people on medication, and set up local follow-up. Some patients even come in with complicated, unusual, or challenging conditions that require real creativity. The villagers express their appreciation for our hard work with a special ceremony.
Dr. Ramsey graduated from the Palmetto Health emergency medicine residency in 2011. He completed fellowship training in global health at the University of Texas Southwestern in Dallas this year2013. He is now an attending emergency physician at Palmetto Health in Columbia.

Monday, November 11, 2013
By Mara Levitt, MD, & Ashley Davis, MD
Honduras, a Central American country bordered by Guatemala, El Salvador, and Nicaragua, is home to more than eight million people, and produces minerals, coffee, tropical fruit and sugar cane. The capital, Tegucigalpa, is divided into 18 departments; we traveled to Intibuca.
Honduras has the highest rate of homicide in the world. The water supply and sanitation varies from modernized water treatment systems to basic systems, from sewer systems to latrines and basic septic pits. A lack of maintenance leads to poor water quality, and residents’ health varies depending on whether they live in urban or rural areas, but overall is poor. The average life span is 70 years old.
We had personal guards escort us out of the city of San Pedro Sula until we reached La Esperanza, a more remote and less dangerous part of Honduras. Our mission was sponsored by Medico (, which provides medical care to the underserved areas of Honduras and Nicaragua. Established locations in each country are sponsored by local patrons.
We were stationed in the community of Monte Verde. Three nuns were the leaders of this community, and have welcomed MEDICO for many years. Three residents, one family practitioner, one critical care pulmonologist, two emergency physicians, many nurses, paramedics, and translators took the trip. We stayed in small rooms with our teammates, and ate the local foods that were prepared for us daily. Warm water was sparse, bug bites in abundance, and bonding at its best!
The main clinic was in the town center near the church, school, and house for the nuns, who are the matriarchs of this village. We were able to treat hundreds of people a day, many of whom walked six or more hours to receive medical care.
The majority of our cases were skin ailments and malnutrition. We were able to give nearly everyone vitamins from our well stocked pharmacy and to treat most other diseases we encountered. Sometimes, however, we had to improvise. One patient had multiple warts on his arms and hands for which we had no treatment. The next best thing? Duct tape.
We also saw a textbook case of pityriasis rosea, and many patients with scabies and lice. Hygiene was very poor, and the large majority of the population did not have clean running water. The Sisters had a protein-rich nutritional supplement that we gave each child in addition to multivitamins, soap, and shampoo.
The dental clinic was the place to be! It was always busy. The dentists would easily see up to 100 patients a day and pull hundreds of teeth over the whole week. One dentist in particular, Charlie, took the time to teach each of us the pearls of dentistry. We were able to perform extractions, dental blocks, and countless intraoral sutures. It was a tremendous learning experience. The Hondurans overall had terrible teeth because they have no dental care or education.
Even very young children had multiple cavities and missing teeth. It is probably because of a local treat, which is flavored ice in Ziploc bags that the children suck on all day. Nurses spent time teaching the importance of brushing and flossing. Despite all the bad teeth, there was one young man who did have a perfect set of teeth.
Medico has many missions in addition to its dental and medical teams. Several ongoing projects in Monte Verde include planting crops, a clean water project, and providing basic needs to school children such as uniforms, book bags, shoes, pencils, and paper.
A water tank was made possible with Medico’s support. The water tank was presented a Medico volunteer (sixth from left) in honor of her son who was a past volunteer and had recently passed away. They sang songs of praise and worship in thanks for this project.
The people of Monte Verde are extremely resilient. They walked miles up and down clay hills in flip-flops with children strapped to them. The day before we arrived, they worked tirelessly to cut a path so that we could pass through more easily.
Through education and hands-on instruction, the people of Monte Verde were able to create a small garden of fresh fruits and vegetables. This project aims to provide the community with resources to expand their diet beyond rice, beans, potatoes, and bananas.
It was a week full of hard work, but you can't go on a trip like this without a little fun! We spent the last day at Lake Yojoa. It is a beautiful lake with spectacular views!
A group of us went ziplining. It was fantastic. The last line was straight across a huge waterfall with a rainbow. Words cannot describe the beauty of Honduras. Some of us were scared, but we all made it across safely.
We traveled into San Pedro Sula for an afternoon of shopping at the market after our morning by the lake. There were tons of local gifts and food including a row of women making fresh tortillas on hot stoves.
This was an amazing experience! We would like to thank everyone who made this unforgettable trip possible. Our lives and careers have been forever changed by our experiences.

Dr. Levitt, left, attended the University of South Florida School of Medicine in Tampa. She was graduated from the class of 2013 at Palmetto Health. Dr. Davis attended the University of South Carolina School of Medicine. She is a member of the class of 2014 at Palmetto Health.

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