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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.

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.


Wednesday, November 18, 2015

BY RACHEL EDWARDS, MD

 

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

 

 

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

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

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

 

 

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

 

 

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

 

 

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

 

 

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

 
 

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

 

 

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


 


Monday, February 2, 2015

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

 

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

  

 

 

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

 

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

 

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

 

 

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

 

 

 

 

 

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

 

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

 

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

 

 

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Friday, January 9, 2015

By Christine Butts, MD

 

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

 

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

 

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

 

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

 

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

 

Surgical residents practicing FAST skills in Duhok, Iraq

 

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

 

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

 

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

 

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

 

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

 

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


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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.