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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, January 11, 2017

BY KEITH DOUGLASS WARNER, OFM, PHD

About 21 percent of Mexico's population lives in rural areas, according to the World Bank, yet only 2.3 percent of the country's 259,000 practicing physicians work there. That may seem like an insurmountable problem to some, but to Haywood Hall, MD, a high-school-dropout-turned-emergency-physician, it was a perfect opportunity to found PACE MD, a program that aims to enhance health care delivery in Mexico.

Mexico's fragmented health system with substantial but often poorly coordinated resources was crying out for someone to teach rural Mexican physicians, all of whom were fully qualified by their formal education but lacked practical training in emergency medicine. Enter Dr. Hall, who also recognized that many of the country's first responders would benefit from emergency medicine training.

PACE MD, started in 2002, weaves together disparate players and processes to foster a more responsive health system, save lives, provide better care, and establish a more inclusive health care system. Working closely with local partners such as the Red Cross, PACE MD organizes advanced training workshops across the range of Mexico's health care providers and institutions, linking emergency medicine to public health. The organization has trained some 30,000 health care providers in emergency cardiac care and obstetrics over the past 15 years.

I had the privilege of seeing PACE MD in action this past July during a PACE MD co-sponsored Advanced Life Support for Obstetrics (ALSO) workshop. PACE MD extended its reach to two students from Santa Clara University's Miller Center for Social Entrepreneurship, where I am the director of education and research. One day in the town square, PACE MD and its partners provided training to hundreds of ordinary citizens in the fundamentals of first aid. Four stations provided hands-on training, including effective responses for a person suffering a heart attack and for an infant who has stopped breathing. The trainers all regarded Dr. Hall with great respect, admiring his vision and leadership, which made me proud of the Miller Center's association with him and PACE MD.​


Dr. Hall teaching in the central Mexican city of San Miguel de Allende, where PACE MD co-sponsored an Advanced Life Support for Obstetrics workshop.

PACE MD also started a program — PACE Corps — that complements medical students' classroom learning with practical fieldwork. This program is designed in the spirit of the Miller Center's Global Social Benefit Institute fellowship, in which Santa Clara University undergraduates conduct field research with social enterprises in developing countries. Last year, PACE Corps medical student volunteers spent several weeks in Chiapas, one of the poorest states in Mexico, providing ALSO training for nurses and midwives.

Jesus "Chuy" Noguez Vega, currently in his last year of medical school, had his PACE Corps presentations translated from Spanish into two indigenous languages so that they would be more widely understood. Many of the midwives on the front lines in poor communities work far from clinics and hospitals, and he was able to provide training to help these health care workers. Mr. Vega said he shares Dr. Hall's vision of using social entrepreneurship to transform the nation's health care system and dreams of following in Dr. Hall's footsteps.

PACE MD's efforts to transform health care systems go well beyond its training workshops. The training programs bring together all the elements of emergency health care: transit police, firefighters, paramedics, midwives, nurses, and doctors. The participants learn skills and develop a common vocabulary. As these individuals collaborate on more sophisticated outreach and clinical projects, a continuum of emergency health care becomes possible. That triggers social change shifting the status quo from fragmentation toward coordination, an excellent example of how social entrepreneurial action can advance a more just and inclusive health care system.

Emergency physicians and nurses are generous with their time, sharing their expertise in volunteer activities, including medical missions to the developing world. PACE MD relies on physicians trained in ALSO to provide training, build local capacity for emergency health care, and foster a more integrated emergency health care system. If you want to volunteer your services internationally, contact Dr. Hall at Haywood.Hall@Centro-PACE.org. Read more about the program at http://www.centro-pace.org/en/, and read an EMN profile about Dr. Hall at http://bit.ly/DrHall.

Dr. Warner, a Franciscan friar, directs education, fellowship, grants, and action research activities at the Miller Center for Social Entrepreneurship at Santa Clara University (SCU) in California. He oversees the Global Social Benefit Institute fellowship, which provides a program of mentored, field-based study and research for SCU juniors within the center's worldwide network. More information is available at http://www.scu-social-entrepreneurship.org.


Friday, January 6, 2017

BY TIM DEPP, MD

No one knows when the first Samoans landed on what is now the Samoan Islands, the destination of our journey. The Samoans have most likely been there for several thousand years, since the Lapita people (ancestors of the Polynesians) migrated there between 1200 and 1000 BC, making Samoan culture, in a word, ancient.

Spaniards, pirates, and missionaries came and went. And "fa'asamoa," the Samoan way, has continued, albeit somewhat changed. Important distinctions are maintained, including the divide between the sovereign nation of Samoa (formerly Western Samoa) and American Samoa (a U.S. protectorate). Its population is now more than 198,000, and the dominant religion of the Samoan Islands is Christianity, with 76 percent identifying as Catholic or Protestant. Despite the island's proximity to New Zealand, which is only a few hours away by plane, the Samoan Islands remain geographically sequestered and receive relatively little traffic from other countries.


It might then come as a surprise that a group of South Carolinians has had ongoing contact with and visits to Samoa for many years. The key player is Vaifanua Pele, a retired resident of Cayce, SC, who was born in Samoa. Pele joined the military after finishing his secondary education and spent the remainder of his career in the army. He became a pastor after retiring and has continued his role as a local leader in leveraging resources for outreach to his fellow Samoans as one of the bloodline leaders of his village in American Samoa. He leads a yearly trip to the Samoan Islands with a team of physicians, pharmacists, and nursing staff from South Carolina.

During our two-week trip, we had six day-long clinics in villages throughout the Samoan Islands. Samoans are naturally a robust people, but the introduction of a western diet high in refined sugar has led to an epidemic of obesity, diabetes, hypertension, and coronary artery disease. A mixture of traditional remedies and poor health literacy often lead to delayed care and poor health outcomes.

Many patients presented to the walk-in clinics with general malaise and blood glucose levels over 500. Many people seem to live in this range (for how long?) and did not feel they needed further care, so we offered them oral antihyperglycemics and strongly encouraged follow-up. Most patients would likely benefit from a combination lipid-glycemic-hypertension pill, which is hopefully on the horizon for the WHO formulary.

Patients were grateful for simple interventions like acetaminophen or refills of their pharmaceutical regimen. Interesting cases included fish handler's disease, Mycobacterium marinum infections, mucocutaneous lesions with chronic nosebleeds, and a high incidence of perforated eardrums from chronic pediatric ear infections.


Logistics for short-term medical clinics are resource-intensive and complex. The trip's visionary is Pele, and Steve is his right-hand man who executes the complex logistical plan. Shortly after arriving home from the trip, preparations for the following year begin almost immediately. Every year several tons of medications and durable medical equipment are shipped in boxes to the islands ahead of the team's arrival. Each day requires an assembly of the supplies, personnel, and advertisement through local communities for exchanges of the medical resources. If any piece falls out of place, through lost supplies or poor advertising or weather, the efforts can be a wash. Our trip was largely successful by historic standards with daily clinic visits in the hundreds.

Short-term trips have a specific set of challenges: Impact barriers such as language, local familiarity, follow-up, and lack of continuity after the trip were significant. Sometimes we succeeded, such as immediate referral of a pediatric incarcerated hernia to a local hospital, but other times we floundered. An 11-year-old girl with severe club feet who was barely able to walk, came to our clinic. She had been seen by well-intentioned medical teams for several years without much benefit. She had been previously evaluated by a Shriners Hospital pediatric orthopedic team and was promised corrective surgery, but that plan had not materialized.

We emailed with Shriners after the trip, and discovered they required legal consent from her parents, who were working in New Zealand and couldn't be reached. Our team offered her pain medication for a week or two, but we had little else to offer. Her crippling deformities seemed to be a visible representation of the chronic medical conditions that our short-term team was unable to treat.

Overall, it was a fun trip. Medically we brought about some good outcomes. The best part was getting to know our Samoan hosts. It is a culture of deep generosity and respect, and I was very grateful to have been able to take part in it.

Dr. Depp is a graduate of the University of Pittsburgh School of Medicine and a member of the Palmetto Health EM Class of 2016.



Monday, December 5, 2016

By CASEY GRAVES​, MD

The Northeast Presbyterian Church (NEPC) has been organizing mission trips to Nicaragua for many years. These trips generally comprise operating roving clinics and performing ministry work in different parts of the country each year. Recently, they added a new option: The church began sending volunteers to a newly established clinic in an extremely poor community to provide affordable care, and I was one of them.   

Cristo Rey was a community formed from the good intentions of the Spanish government, which carries out a significant amount of humanitarian work in Nicaragua. Many people previously lived in the city dump of Managua (Nicaragua's capital city), where they subsisted off other people's garbage and from selling anything salvageable. The dump was closed, and people living there were moved to an area on the outskirts of the city and given materials to build small structures in which to live. These people have remained impoverished, however, and subsequently, many went back to their old way of life when a new trash dump was established adjacent to Cristo Rey.

It is here that the new clinic, Clinica Betesda, was established to help people most in need but lack access to health care. The clinic is open daily, but there is only one doctor who attends regularly. They are severely limited in what medications and services they can provide. The goal of the NEPC mission trip is to meet some of these needs and draw the community into the clinic to encourage them to receive preventive care.​

Our team consisted of U.S.-trained doctors and nurses as well as the Clinica Betesda staff and Nicaraguan doctors who had volunteered their time to be a part of the project. In addition, two dentists joined us to attend to the many dental issues in the community. 

clinic.jpg

Reading glasses were also made available to those who needed them. Medications transported from South Carolina or purchased in Nicaragua were arranged into a makeshift pharmacy and offered to patients at no cost with the prescriptions our physician team gave them. Each day, there was a long line of people waiting. Five physicians would see 200-250 patients a day in addition to the 30-40 patients seen in the dental clinic. Pictured below are our patients lining up for medical and dental care each morning prior to our arrival.

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Though we saw many different complaints, one of the major ones I addressed had to do with the community's location, which is right next to a landfill where trash is burned continuously. Almost every patient had some sort of respiratory complaint, whether it was coughs, rhinitis, shortness of breath, or wheezing. Post-chikungunya arthralgia was also common among this population.

Even the simplest treatments were cost-prohibitive for these people given their limited resources, and they were incredibly grateful to receive free medical care and medications. In addition to chronic medical conditions, some patients presented with skin abscesses that needed to be drained and lacerations; one man even had a traumatic lens dislocation.

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These clinics ran for a week in tandem with children's ministry and construction work. All in all, I believe it was an effective trip. By partnering with an established clinic, we were able to draw the community into a medical home where they can have their chronic conditions cared for year-round instead of working in isolation and leaving the community with an ongoing problem of poor access to medical care. I learned a lot from the local doctors about tropical diseases uncommon in the United States and about how the medical system in Nicaragua functions. I would encourage anyone to join this trip and help serve the people of Nicaragua.

Dr. Graves is a graduate of the University of Michigan Medical School and a member of the Palmetto Health EM Class of 2018.​



Tuesday, March 1, 2016

By Luke Husby, DO, and Heather Brown, MD

We arrived in rural Masindi, Uganda, after more than 24 hours of air travel and a five-hour van ride over the only two paved roads in the country. The travel was fairly exhausting.

The Masindi-Kitara Medical Centre (MKMC) is a fully functional hospital in Masindi, Uganda, run by Palmetto Medical Initiative (PMI), a nonprofit organization based in Charleston, SC. MKMC has multiple nurses, an inpatient ward, and obstetrics, gynecologic, surgical, and outpatient wards. It recently established itself as a low-cost, self-sustainable, private clinic to offset the two opposing ends of the spectrum with higher end private clinics on one end and sometimes difficult-to-access, free government-run clinics on the other. PMI conducts mobile clinics quarterly in the communities surrounding MKMC. Pictured below is their donated ambulance. It is likely the most highly equipped ambulance in Uganda, because it includes oxygen tanks.​



The first two clinic days began at a primary school near the Masindi Hotel where we were staying. A long line greeted us when we arrived. We saw roughly 350 patients on those two days.


Four providers and their interpreters sat at desks to see the patients before they went to the pharmacy or the physical therapy/occupational therapy clinic room. All services were free. Referrals were given to MKMC whenever needed for follow-up.

​A couple of hundred people waited outside another primary school to be seen on the third day. All of the translators, pastors, and Ugandan assistants were seen in return for volunteering with us. The child below was found to have difficulty sitting up because of her cerebral palsy. The occupational team created a seat with some foam and cloth so that she could sit upright on her own.

 

The child pictured below came to us with a fever and a swollen knee she had had for 10 days. She was ultimately diagnosed with a septic joint. We gave her antibiotics and immediately sent her by ambulance to MKMC, where her knee was washed out the following day by a local physician.

 

Pictured on the left below is Dr. Brown with her translator, Armstrong, seeing patients during one of our last of five clinic days at another primary school.

 

After a long week of clinic, we were treated with a day of relaxation by the Nile River and a sunset safari in Murchison Falls National Park. A male elephant, who immediately prior to being photographed began to charge the vehicle, turned away huffing and puffing. We returned home after a 40 hours of travel.



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.

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.