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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.

Wednesday, September 03, 2014

By Zubair Chao, MD

 

Dr. Thomas Cook and I escaped the dry heat of South Carolina to land in Chengdu, China, home of West China Hospital, in July 2012. He was set to teach an emergency ultrasound class, and I was on a global mission as part of my emergency medicine residency.

 

Some say it is the largest hospital in the world, boasting 5,000 beds, nearly 100 operating suites, and a large outpatient center, which, on any given day, has about 10,000 patients.

 

 

West China Hospital

 

The ED at West China Hospital recently moved to its new home in a larger, more modern facility. It sees about 160,000 patients a year, which is about twice what we see at Palmetto Health Richland. They have about a dozen attendings and more than 30 residents, in addition to rotators. The department is divided into several areas based on the severity of the case, and it has a few operating suites though they’re not currently used because they don’t have available staff. It also has a fast-track area, a low-acuity observation area, a secondary moderate-acuity rescue area, a high-acuity primary rescue area, and an emergency ICU. There is also a debridement room for procedures and a trauma area. Patients who come to the ED, primarily by private vehicle, are first seen in triage, where they are referred to the appropriate location depending on their acuity. The ED also has a cashier and a pharmacy; patients pay a-la-carte for tests, procedures, and medications.

 

 

ED triage

 

Dr. Cook and I spent the first week in China teaching an ultrasound course, with lectures and workshops for attendees to practice their skills. This course was a great success, and I stayed another month to work in the emergency department. I spent my time rounding with the teams in the morning, and I taught residents ultrasound scanning in the afternoon. Once a week, I gave a presentation on a particular area of ED point-of-care ultrasound (bedside echo, FAST exams, etc).

 

My first official week was spent in the observation unit. The day started at 8 a.m. with all of the residents, attendings, and nurses crowding into a lecture hall for daily morning rounds. Each unit in the ED gave a quick report on the events that transpired over the past 24 hours, plus information on any interesting patients. The unique part about these rounds was that they were delivered in English on Wednesdays and Fridays. One of my roles was to help the health care providers improve their English proficiency.

 

I reported to the observation unit after morning rounds and checkout. The observation unit at West China hospital fulfills a role that we do not really have in the United States. Most patients seen in this area are those we would simply discharge to follow-up. These patients, including many who have travelled from distant cities to be seen at West China, are kept in the observation unit for a few days until serious pathology is ruled out, however, because the primary care sector is essentially nonexistent in China.

 

Many Chinese people, especially in rural areas, do not have access to hospitals, and a lot of them seek practitioners of traditional Chinese medicine for their ailments. Consequently, physicians in China are much more familiar with herbal medications than health care providers in the West. One week I saw numerous patients with snakebites whose first treatment of choice was an herbal paste that they slathered over the affected extremity. It yielded positive results.

 

The observation area has the capacity to accommodate nearly 60 patients by doubling some of the beds with two seats. Some patients are kept there for days, and even weeks, as they wait for inpatient beds to become available. It is easy to imagine that many people get fed up with this scenario and would rather go home. As in America, these patients must sign AMA forms to leave. The ED has a list of those at home waiting for an inpatient room to become available; it is 3,000 to 5,000 names long at any given time.

 

Two attendings were responsible for the 40 to 60 patients in the observation area, and each was responsible for a team of about seven to 10 residents. Most of these residents were interns, though each team had one or two upper levels as well. I found it particularly interesting that I could immediately distinguish interns from upper-levels by the way they interacted with each other. Interns always looked a little lost and were questioned about findings, and they didn’t always have the answer. The senior resident let them flail for bit before rescuing them, just like in America. Rounding took most of the morning, after which the team split up to accomplish their tasks for the day.

 

 

Residents working in the ED

 

Many of the higher acuity patients were seen in the rescue area, and it was the largest and busiest area of the emergency department. It was split into primary and secondary rescue areas, the former having about 10 beds and the latter about 30. Overflow beds were everywhere. The 10 beds in the primary rescue area were staffed mostly by two or three senior residents, who were also responsible for incoming traumas. Stabilize patients were moved to the secondary rescue area or the EICU.

 

Three attendings with a team of five to seven residents did rounds on patients in the secondary rescue areas. The secondary rescue areas were similar to the observation unit; teams rounded on patients. Here, three attendings with a team of about five to seven residents each rounded on patients.

 

Admitting physicians at Palmetto Health Richland manage admitted patients even if they are still physically in the ED. The ED staff at West China manages all patients regardless of admission status. Patients are worked up as a result with tests like rheumatoid factors, ANCA, and other tests I have not seen since my medical school days. Rounding in the secondary rescue area felt like rounding on the floor. The closest we ever come to rounding in our ED is when we run the list, which takes less than five minutes.

 

West China Hospital also serves as a regional referral center for the Sichuan province and much of western China because of its size, reputation, and resources. Many patients are transported there every day by ambulance from other facilities. Many more are individuals who have heard of West China’s reputation and have driven from thousands of miles away to be seen instead of going to their local hospitals. China has a shortage of physicians, and paradoxically many graduates cannot find jobs because the physician shortage is in underserved rural areas. These places have a difficult time attracting physicians, just like U.S. rural areas. The pay in these areas is also significantly less than in the cities.

 

The quality of physicians in rural China is not as high and medical licensing is not as standardized as it is in the United States, so someone who has not finished residency or has not passed the certification exam can still get a job in a rural area. Practitioners of traditional medicine often fill the dearth of physicians, which means most patients do not trust their local hospitals. This leads to physicians in rural hospitals having less clinical experience, further eroding the public’s trust in them. Attempts have been made to encourage people to visit their local hospitals instead of crowding into the overwhelmed regional referral centers like West China. We had many rural physicians rotating with us to gain more clinical experience and become more familiar with managing different diseases. The attendings in our department also visited satellite campuses, but people still swarm to West China, often with unrealistic expectations.

 

One of the most interesting patients I saw was a 15-year-old boy transferred from a regional Tibetan hospital. He had been thrown from his horse and had a massive skull fracture with an intracranial bleed. He was about a week out from the accident by the time he got to us, and he was intubated and his pupils were fixed and dilated, which did not bode well for his ultimate diagnosis. His family still seemed to hope that we were going to cure him, and all that was required was stepping up the level of care by transferring him to West China. The physicians there told me that this happens frequently, and families are disappointed when they find out nothing can be done for their loved ones.

 

On another afternoon, I stopped by the physician work area to ask if anyone needed a scan. One resident asked me to do an echo on bed 35. There I laid eyes on a young man strapped down in the bed. He spat and drooled onto the towel-bib laid over his chest. Straining against his restraints, he fought to lunge at me as I approached the bed. I cautiously placed the ultrasound probe on his chest as he continued to spit and snap his teeth in an effort to bite my hand. I assumed he had some kind of psychiatric disorder, so imagine my surprise when a passing resident said, “Be careful, he has rabies.” "WHAT?!" I thought, "Thanks, first resident, for leaving out that important piece of information."

 

Rabies is actually a rare disease in the United States, averaging only two reported cases per year, but it is common in rural China. I saw three cases during my month-long visit. This condition is usually fatal. Once doctors confirm the diagnosis, the family is informed, and they take the patient home to die. As in America, the ED at West China sees a number of suicide attempts. Many are ingestions, notably paraquat. This is never seen in the United States because it is banned, but paraquat seems to be the agent of choice for suicide in China. Ingestions above a certain threshold are inevitably fatal. We saw a few cases of paraquat poisonings each week. Treatment is usually supportive because toxic doses lead to multiorgan system failure. Experimental protocols are being tested at West China using CRRT, but it seems that even this simply prolongs the inevitable.

 

I had a few chances to go out with the ambulance to respond to some calls during my week in the rescue room. The chief residents took turns going out with a nurse instead of emergency responders. The ambulances are owned by the hospitals, and there does not seem to be a central command center, like the dispatch centers we have. West China’s ED has two vehicles that are converted vans with a stretcher in the back, oxygen, and an EKG machine. A nurse brings a jump bag with supplies to check vitals and blood sugar. The doctor also has a jump bag with airway equipment, among other necessities. My calls out included an elderly lady who had a syncopal episode while visiting her husband at one of our affiliated hospitals, and an elderly man experiencing post-stroke side effects. We tried to find beds for them in the rescue area.

 

My fourth week in China was spent in the emergency ICU. It makes sense to have a unit within the ED to manage critically ill patients while they wait for ICU bed. The West China emergency ICU has 15 beds and one private room with one-to-one nursing. The majority of patients in the ICU are intubated. EM residents, like in the United States, usually do their own intubations, with anesthesia as backup if necessary. Residents seemed very proficient from what I observed. I also saw a Blakemore tube used for the first time.

 

Many patients in the ICU succumb to their illnesses, so emergency physicians are often required to have end-of-life conversations with families. I generally felt families seemed more accepting of death as a part of life, and once they were faced with the inevitability of death, they chose to take their loved ones home to die. The Chinese feel it is better to die at home than in a hospital. Perhaps a part of this is that they must pay for health care services. Physicians also are reluctant to pursue heroic measures in patients that are terminally ill.

 

One interesting case I had was a foreigner from the Netherlands who was visiting China when she developed abdominal pain and persistent diarrhea; she came into the ED in septic shock. She had a complicated medical history of multiple abdominal surgeries for abdominal cancer and numerous other comorbidities. Fortunately, I was able to talk to the repatriation doctor of the Netherlands, who had spoken with her primary care physician and specialists to compile an extensive list of her medical history and everything else we could possibly need. Moral #1 of this story: Don’t get sick when traveling abroad. Moral #2: Make sure you have international insurance.

 

I bade the ED farewell during my last week in China to spend time in the operating rooms to work on intubations. I got 11 tubes on my first day, and was reminded why anesthesiologists are airway experts — they do so many! I feel fairly comfortable with most simple airways after two years of residency, but I still dread difficult airways. I felt really fortunate to have this opportunity to spend an entire week refining my airway skills. I even picked up a few tricks for better bag ventilation while learning one-on-one with the anesthesia attendings.

 

The Chinese anesthesiologists preferred MAC blades; nearly every uncomplicated airway I did was with a MAC 3. They explained that they only use the Miller blade for pediatric patients. They tend to go for an Airtraq first for difficult airways. This intubating device was purportedly invented by an Italian emergency physician; it provides direct visualization of the vocal cords via a mechanism similar to a periscope. Once the cords are visualized, the preloaded ET tube is simply advanced along the track and it goes right in. I used it a few times, and felt that it was bulky and not as maneuverable as the GlideScope, but I can see its appeal and definitely think that with some practice, it can be just as effective.

 

One day I accompanied one of our ED attendings to an affiliated hospital in the countryside. I imagined a tiny rural clinic from what all the residents were saying about this hospital, but it was a 500-bed, 10-story hospital that had an ED with ambulance bays and surgery suites. I guess everything else seems like a rural clinic when you work in the largest hospital in the world. A handful of residents worked at this affiliated hospital, and it did not seem that the ED was being used to its full capacity. Even the floor beds were somewhat empty, and the hallways seemed deserted. The hospital had opened just three months earlier, so I hope it is simply a matter of time before people start going to it. I could not shake the image of empty rural hospitals as sick people bypass them to crowd into the regional referral centers.

 

 

A 500-bed, 10-story “rural” hospital

 

The remainder of the week was spent intubating patients in the operating rooms. The tubes were easier than in America for the most part, which I think is in large part because of thinner body habitus of patients in China. That doesn’t mean there weren’t a few difficult patients, though. One that stands out in my mind was a 15-year-old with TB, Pott’s disease, and numerous abscesses on his back that needed to be opened up and drained. He could not be placed on his back, so he had to be intubated in the lateral decubitus position. The week ended with a night out with a few of the anesthesia attendings for hotpot and to catch a local movie (The Vanishing Bullet; I give it 4.5/5 stars).

 

I spent my last weekend in China going to SongXiao Qiao, a collection of stalls and stores selling “antiques” and artwork. I planned a walking tour to get to the city, which was about an hour away. On my way back, I ran into the infamous fainting vagrant.

 

The fainting vagrant is a young man in his 20s who found his way to Chengdu a few weeks after I did. I first heard about him during a morning report checkout when the chief resident complained about how she had to respond to five calls the previous day on this one person. Like most vagrants, he did not have any money nor did he have his government-issued ID giving him a hukou (a kind of residency permit that, among other things, gives you access to social services in your area). He would have fainting spells during which he would clutch his chest.

 

Concerned bystanders would call the ambulance, and he would then refuse to go to the hospital. This happened five or more times a day, and always play out the same way. As I was walking back that last weekend, I ran into a crowd surrounding this person. Wanting to see whether the situation would play out as I had heard, I hung around and, sure enough, someone in the crowd of bystanders called 120 (911), and an ambulance rolled up eight minutes later (pretty good response time). One of the chiefs came out, tried to examine the patient despite his refusal to cooperate, and they went back to the hospital empty-handed after 30 minutes of attempting to convince him to come to the hospital.

 

Later, one of the chiefs asked me if I wanted a tube, "Of course,” I said. “Who needs one?" "Sit tight, we're still waiting for the family to decide if they want to pay for it."

 

That was a conversation I had in China that I have never had in America, and it highlights one of the fundamental differences between the two countries about who bears the burden of health care. The West China ED initiates treatment including code drugs, resuscitation, and intubation for all critically ill patients before sorting out payment. This particular patient was terminally ill and near the end of life, and the real question was whether the family wanted to pay for heroic measures in what might have been a futile resuscitation attempt leading to a prolonged vent wean if he made it to the ICU.

 

The way in which this scenario is framed as a cost-of-futile-care issue contrasts sharply with the attitude in America, where discussion of cost (and by extension resource allocation) is almost a taboo discussion. This particular patient’s code status would have been couched in the language of what his wishes would be. If a patient came to the ED with respiratory failure and no advance directives dictating his code status in America, we would intubate him or do whatever we felt necessary, almost always without considering the costs of the procedures or tests. EMTALA essentially mandates that every patient get a workup and any life-saving treatment necessary, and it incomprehensible to many of us who grew up or trained in America to withhold therapeutic interventions or even diagnostic tests from a patient who obviously needs it.

 

We in America have come to view health care as a right, and the preservation of life trumps everything else. The patient’s ability to pay is not usually something that is part of the decision-making process. The Chinese way is a fee-for-service model where a patient’s family is responsible for paying prior to services being rendered, whether those services are administration of medications, blood draws for tests, or intubations. The physician writes a prescription for a medicine, test, or imaging study that needs to be done. A family member then takes this prescription to a cashier, and brings back the medicine or a receipt that allows for the medicine to be given or the test to be done. Many physicians in China have told me that the way we practice medicine in America would bankrupt hospitals in China. Hospitals in America stay afloat and remain quite profitable through a variety of methods, such as cost-shifting and government reimbursements for taking care of the indigent.

 

As a physician who trained in America, I feel uncomfortable withholding life-saving treatment from someone simply because they cannot pay. This would have implications on the way we practice as well. Instead, for example, of relying on the gold standard tests for diagnosis or rule outs, we would have to tailor each patient’s management based on his financial status. These alternative tests or medications may not have the same sensitivities/efficacy as more expensive alternatives, and may ultimately result in different standards of care. I feel this would go against most Americans’ ideal of egalitarianism (though many would argue that this scenario is, in fact, already an unspoken reality). There is also the concern that someone would be allowed to die simply because family was not around such as in cases of trauma where the next of kin is often not present.

 

All things considered, I feel a very compelling argument can be made for a fee-for-service model. The biggest benefit I think this type of model would offer is more judicious use of resources. This is obviously a bigger issue in the developing world than in developed nations, but even in America, I think most doctors would agree that we order too many unnecessary tests. Of course, this would have to go hand-in-hand with changes in the litigious environment of medical practice and tort reform. Speaking of which, is the practice of medicine in China fraught with fear of litigation? Yes and no. Throughout my rotation in China, I often witnessed attendings reminding residents to document carefully and obtain consents for everything in case there was a bad outcome.

 

One week, I even witnessed a local camera crew covering the poor outcome of a patient’s case. At the same time, the legislative process does not seem as developed as in America, and residents in China recount numerous cases of family members taking matters into their own hands and physically attacking doctors. A few years ago, an ENT physician at West China was stabbed after a patient was unhappy with his surgery. Another time a medical student was fatally stabbed when she was at the wrong place at the wrong time, and a disgruntled family member went on a rampage. Even while I was there, I witnessed multiple confrontations between overworked doctors and stressed-out family members.

 

Dr. Chao graduated from the Palmetto Health Richland emergency medicine residency in 2013, and is now a fellow in emergency ultrasound there.


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. (http://missionofhope-us.org.) 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.
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