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.

Friday, March 3, 2017

BY TIM DEPP, MD

Arriving in Port-au-Prince was like walking into another world. It was hot. The roads were dusty. In spite of reports of aid money being siphoned off and how little progress was being made in rebuilding, the parts of the city we drove through appeared improved since the earthquake. My first impressions of the city were positive, especially considering what I was expecting.


Despite Haiti's long and difficult history of slavery, revolution, poverty, violent dictators, overwhelming debt, failed development projects, deforestation, and natural disasters, including the earthquake of 2010 and the cholera epidemic introduced by the United Nations in 2016, Haitians demonstrate a great deal of pride. But still, they were surviving at the edge of survivability.

The Haitian community struggled with a significant lack of medical resources. Hospital Bernard Mevs in Port-Au-Prince is considered by many to be the best hospital in the country (with access to a CT scanner and specialists, including neurosurgeons). But profound challenges remain. With the grants and other funding for earthquake relief now drying up, the hospital had been forced to shift to a fee-for-service system. Unfortunately, for many people in Haiti, this puts care beyond their reach.

Individuals with symptoms concerning for acute MI may be unable to get an ECG until they pay at the registrar and return with a receipt. A man with a closed head injury may be unable to receive a head CT before his family pays for it. A conservative measure of intubating the same patient while observing for improvement in neurologic function may impoverish his family with the cost of placing him in the ICU. Placing him on a ventilator may mean there is only one ventilator left at the hospital and in the country. It is a difficult wager of resources, with many factors weighing in on the decision-making. It is a forced conscientiousness, very different from the defensive medicine we practice back home. Order a test, these patients won't have money for food and they will feel it in their stomachs.

Fifty-nine percent of six million Haitians live on less than $2.42 a day. (The World Bank. Sept. 16, 2016; http://bit.ly/2kDzrR2.) More than 20 percent of Haitians live on less than the national extreme poverty line of $1.23 per day. These resource limitations are not unique to Haiti, even though they are more dramatic there. The costs of unfunded care are assumed by an already overburdened system, squeezing the already slim operating margins even further.

Emergency physicians in Haiti face many challenges, but they who stay at it long-term appeared to be satisfied. Similar to successful physicians at home, they derived a deep sense of meaning and pride from their work. Knowing the environmental constraints and limitations inspires gratitude. The decision to withhold aggressive interventions (which at home would be provided unquestioned) was a reminder that we are not in control. In contrast, this close questioning of necessity and individual mortality was a real shock for many of us visiting.

But it is not cavalier when local physicians make decisions about the allocation of care. It is simply an acceptance of where Haiti is right now. Not everyone can have CT scans and stress tests or receive blood products. Most just can't afford it. There's no cardiac cath lab around the corner. Undiagnosed and debilitating illnesses are often sent home without the expectation of follow-ups.

At the same time, life is still precious.

Near the end of my third shift, an older woman was supported into the ED by her daughter. She had vague abdominal pain and severe fatigue. She handed me a several-day-old paper from a local diagnostics clinic that she couldn't read. The nurse registered her first systolic blood pressure in the 70s. Her imaging report said, "...malignant ascites...diffuse metastatic disease...." After discussing with the hospitalist, we decided the only option was to discuss comfort care with the family. Her daughters shed tears at the bedside, but were grateful for more information. It gave them some closure. Without any further aggressive measures, she died two hours after arrival.

Our team was there to provide some respite for the local EPs who provide 24/7 coverage. Packing up, we left behind our extra supplies for the ED, and took away with us the perennial question of what impact we made.

In the airport terminal in Port-au-Prince, minutes before departure, an old man collapsed in the bathroom. After checking his pulse and putting him in the recovery position, he was still unresponsive and hardly moving. His worn-out suit betrayed the lengths to which he had gone to buy his ticket. EMS carried him off to the hospital. Unconscious and poor, he is launched back into a strained medical system.​

Walking across the tarmac, the heat was still sweltering. The reflected sun was as blinding as the dust was suffocating and diesel fumes stifling. The air conditioning in the economy cabin seemed luxurious. The man's empty seat on the plane stayed with me. I realized that I had now left the majority world.


Dr. Depp is a graduate of the University of Pittsburgh School of Medicine and the Palmetto Health EM class of 2016. He is now a clinical assistant professor at Clinical University of the Greenville (SC) Health System.


Friday, February 3, 2017

BY LUKE HUSBY, DO

On a cool Monday afternoon, the plane to Dulles, then Frankfurt, and ultimately Bangalore took off. I landed two calendar days later in a place about 40°F warmer, with a weather forecast of "smoke."

I was greeted by a driver who only spoke Tamil. He took me to my hotel room less than a mile from the hospital where I was volunteering through congested traffic that held no regard for traffic lines or signs. The ED in Bangalore is essentially a 10-bed department, divided into a high-acuity and low-acuity sections.


The high-acuity section of the ED.

An entire herd of students flocked to see one patient in particular. The patient presented with shortness of breath, and was diagnosed with spontaneous pneumothorax. His chest x-ray prior to the placement of his "ICD," or chest thoracostomy tube, is shown below.


With an ED volume of only 23 to 25 patients per day, each patient is greeted by multiple students prepared to examine him.​


After three full days of lectures and bedside teaching, we went out for an evening of sari shopping and to try out the multitude of sweets and street vendors. After Bangalore, I landed in Madurai, "the temple city," home of one of the oldest and most impressive temples in the world. The emergency department there was more of the same: The four wings of the hospital were buzzing at all hours.​

The Meenakshi Amman Temple in Madurai was mentioned as far back as the 7th century and was built in honor of the goddess Meenakshi. The locals said the statue of Meenakshi has 1,001 pillars, which is mirrored in the Thousand Pillared Hall in the temple.


Within the temple were multiple towers, a central pool, and an amphitheater. There was a clearly marked cutoff area for anyone who was not there to worship, which barred me from passing through the central part of the temple. It was very busy because many people came from far away to visit the holy temple. The architecture was incredible, and there were intricate carvings everywhere.

The Meenakshi Amman Temple was not the only temple or historical building in the city. We visited another temple and the Gandhi Memorial Museum. I saw the various tenets of Hinduism as described by Gandhi. His nickname "Mahatma," means great soul, according to the museum.​

I hopped on another quick flight over to the coastal city of Chennai for three more days of lectures and bedside teaching. The residents would pick me up each day and take me to their facility to deliver their own presentations. Then we would review the topics of the month as we had at the previous two sites. We also had a suture lab where the residents practiced their skills on raw chickens.


I was there during the festival of Pongal, and we enjoyed some of the festivities on the beach and at many street-side restaurants. I visited one of the nice restaurants there and had the "non-veg" platter, something any Texas native would love.

After four days in Chennai, where I had a great time taking part in the festivities and fun, I enjoyed a 37-hour Monday traveling west to Columbia. Overall, it was a great experience during a great time of the year to be in the typically hot India. We all learned a lot from each other and enjoyed the holiday together.

Dr. Husby is the chief resident of the Palmetto Health EM Class of 2016 and a graduate of North Texas State Medical School.​


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.

clinicline.png

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.

cgraves3.jpg

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.​