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, August 9, 2017

BY JK FALLIN, MD

I had the opportunity to travel an extraordinarily long distance to Uganda last year on a mission with One World Heath, a nonprofit that aims to provide affordable health care to communities in need. The trip had a rather disjointed start because Delta forgot that they needed a computer to fly their airplane. After this minor hiccup, we embarked on our journey across the Atlantic, then Europe and Africa before landing in Entebbe, Uganda.

Entebbe is about 20 miles southwest of Kampala, the capital city of Uganda, but there is in reality little demarcation between the two towns. It's located along beautiful Lake Victoria, the largest lake in Africa, which is bordered by Uganda, Kenya, and Tanzania. The city is extremely energetic with surprising signs of modernization but a prevailing sense of a developing world culture still trying to find its identity.

Our travels were not yet finished. After landing, we met a representative of One World Health at the airport, who chauffeured us to our hotel for the evening. Our first night was spent coming to terms with how air conditioning was a privilege not experienced by the majority of the planet. After several cold showers and a wonderful breakfast, we loaded onto a mission van to go on the last leg of our journey.

After driving five hours north, up through the heart of the country, we made it to our destination of Masindi. This is a smaller town where One World Health has established a permanent clinic. The organization has designed a self-sustaining health care model that can staff and train its own workers, creating more efficiently run clinics compared with the local government-run facilities.​

They require cash payments, but the rates are unbelievably cheap, and they work with patients who absolutely cannot afford their services. They have actually been able to expand to several other clinics in nearby villages, and the goal is for these clinics all to be financially viable in the near future so they do not have to rely on donations permanently. They have an x-ray machine, a new ultrasound unit, primary care, and OB-GYN services in addition to general surgery. They also have rooms and lodging for overnight and long-term care.

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One World Health has an excellent relationship with a local inn, which is quite an anomaly for the region. Masindi itself is not a tourist destination, but several hours north of town is the famed Murchison Falls National Park, and the inn is a convenient pit stop for tourist groups traveling north. More recently, it's become the brief home of many mission groups in the area, including the United Nations and Doctors Without Borders. They provide excellent local dishes (i.e., carbs) and wonderfully cold showers at the end of long days in the heat.

During our stay in Masindi, we would travel to local villages by van every morning to provide health screenings and medicine to villagers where they lived. They would wait for hours, marinating in the hot sun without food or much water, just for a chance to be seen. They had many of the same health complaints we deal with on a regular basis in the United States, like heart burn and osteoarthritis. The main difference, however, was the numerous parasitic diseases that we don't have here, such as malaria, ringworm, and filarial disease.​

I was impressed by the influence the mission had in the area. Many patients were already on prescription medications, had received vaccinations, or had been diagnosed with some ailment. Unfortunately, much of the morbidity present in the area is due to poverty, lack of access to clean water, and general lack of knowledge of personal health and hygiene. Many of the patients' lives were greatly improved just by getting sunglasses to help with the long-term degeneration of their eyes due to a life spent toiling under the sun.


Most of our days were spent in patient care, but we did take the time to enjoy the stereotypical mission trip activities of taking pictures with adorable local children, comparing music and lifestyles with particularly fluent translators, and struggling to learn bits and pieces of the local dialects.

Each day we would climb reluctantly back on the vans, slightly more enlightened but much grungier, more odorous, and more exhausted for the trip home. Luckily, several in our group were blessed with unending enthusiasm and energy, and despite the somewhat cramped conditions, they were still able to make glib conversation during the commute, which would otherwise have been filled with silent pondering of what we had just experienced. Each night I would peel out of scrubs caked in a strong concoction of clay dust and sweat, clamber into the shower, and turn on the wonderfully cold water that erased my grimy farmer's tan. Afterward, we would have dinner and a moment of reflection and prayer prior to heading to our beds.

The last two days of the trip were spent on an excursion to the Murchison Falls National Park for a taste of what this area of Africa looked like prior to modern human influence. We got to spend the night at a resort in the park that had a pool!​

It was the greatest thing I had ever seen at that point in my life. We all impatiently waited for niceties to be exchanged between the resort staff and our group leaders before rushing off to don swimwear and plunge into the pool. After spending a relaxing afternoon floating, we prepared for our activities the next day, which would include a true African safari in the game reserve of the park. The safari was exactly what you'd expect and well worth the expense. We got to see the entire cast of the Lion King (except, of course, the lions, which decided to lay low) in their actual element. My only regret was not bringing a better camera; my phone camera just could not do the scenery justice.


After playing British explorers in the game lands, we traveled back to Masindi before heading back to Entebbe for our red-eye flight to Europe. I know it sounds cliché, but the trip was over way too soon. Friendships are best forged in such environments, and the sheer number of memories that develop from these types of trips makes me wonder why more of us go on them. It may be much easier, cheaper, and safer to avoid such undertakings, but by doing so we miss out on experiences that truly sculpt our worldviews and life stories.

The burden that the mission has undertaken is humbling in scale when you consider the number of villages that are still unreachable in this one region in this one country on this one continent. Money donated to the mission, unlike many other organizations, is not just going into a bottomless pit. The self-sustaining model that they have developed will likely be reproducible in many other underserved areas. This enables the reach of the mission to expand while still receiving the same financial backing. The trip was a great opportunity to experience and be a part of the mission and a culture that is so foreign to us.

Dr. Fallin is a graduate of the West Virginia University School of Medicine and a member of the Palmetto Health EM class of 2017.​


Friday, May 5, 2017

BY CHLOE MCCOY, MD

I knew I wanted a global health experience that offered the opportunity to have an impact on patients but also on the health care infrastructure and local physicians. This led me to research trips that involved teaching opportunities, specifically ones involving ultrasound.

As a resident at Palmetto Health Richland, we learn how to use ultrasound in our daily practice to make quick and accurate decisions about clinical care. Our program's emphasis on its use made ultrasound a standard-of-care component of emergency medicine for me over the past several years. Teaching ultrasound seemed like a great opportunity not only to hone my skills as a resident but also to share my knowledge and training with others in resource-limited settings that would benefit greatly from that skill.​

The Mbeya Zonal Referral Hospital in Southwestern Tanzania has been making strides toward improving emergency medical care, including expanding access to emergency ultrasound. Mbeya Hospital serves as a tertiary referral facility overseeing the care for more than six million people. Mbeya Hospital has inpatient services for medical, pediatrics, obstetrics and gynecology, surgical, and trauma care, but it is not equipped with a CT scanner.


Patients requiring CT imaging or a higher level of care must be transferred 12 hours on the ground to the coastal city of Dar es Salaam. This barrier permits only a small number of patients from this area to get CT scans and never on an urgent basis. That makes ultrasound a desirable diagnostic tool for this setting because it offers an affordable, accurate alternative to CT, and it can be used and interpreted by physicians who are not radiologists.​


Mbeya Hospital, in partnership with Muhimbili National Hospital in Dar es Salaam and the departments of family medicine and emergency medicine at the University of South Carolina School of Medicine, hosted a group of U.S. physicians for a five-day practical emergency ultrasound course with an emphasis on the focused assessment with sonography for trauma (FAST) exam. This course served as a study of the execution and initial impact of this training on providers' confidence, skills, attitudes related to ultrasound, and a learning experience for me.​


The course was planned so it could also serve as an informal study of how best to teach ultrasound to health care providers in underdeveloped countries with limited hospital resources. We designed the curriculum, obtained IRB approval, and brought V-scans with us to aid with teaching. We focused on teaching how to use ultrasound for trauma and critical care patients, which is enormously helpful when making simple decisions like whether a patient needs to go to the operating room when CT scans are not available. We prepared and presented lectures on the FAST exam's science, and spent a considerable amount of time teaching the participants one-on-one during their regular work days in their respective wards and departments. We wrote up our findings and published them in a peer-reviewed ultrasound journal to share with the international community how we approached teaching ultrasound in a resource-limited country. (J Ultrasound Med 2017;36[3]:515.)​


We also spent some time networking with local physicians in Mbeya and Dar es Salaam to see how to make a lasting and sustainable impact at the hospital where we were teaching. Dar es Salaam is a coastal city in Tanzania that has the only EM training program in the country. Observing how the residents and EPs practice in this setting was eye-opening and incredibly helpful for designing our ultrasound course to meet the needs of the physicians in this country.

The residents practice the same medicine we do in the United States (with the routine use of ultrasound), but medicine is carried out under very different circumstances and with much more limited resources. Many patients presenting to the ED wait until their illness has progressed before going to the hospital, and residents often see textbook presentations of common medical ailments that we do not see in America. The second big difference is the availability of specialties and resources for treating illnesses that can only be temporized in the ED. Aortic dissection? There are no cardiothoracic surgeons. Heart attack? The nearest catheterization lab is hours away by car, and no air transit is available. Patients with these conditions may not be treated with the same urgency as in the United States simply because there is no capability to cure or treat the conditions.

Their limited resources, however, has helped ultrasound emerge as a key diagnostic tool in the emergency medicine program. Ultrasound's portability, ease of use, and accuracy of diagnosing make it possible to treat many internal illnesses, such as cardiac tamponade, intussusception, pulmonary edema, pleural effusions, cholecystitis, and intraabdominal bleeding.

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Tanzania is a country that, though relatively small, has all varieties of landscape and terrain. When we weren't teaching or working, we were traveling and sightseeing. Mbeya is filled with rural highlands with lazy dirt roads, a friendly community feel, rundown looking makeshift shops and hidden treasure stores, and open-air hospitals and main buildings. We visited during the dry season, so everything was dusty and cool. The country also has the well-known Serengeti National Park, Ngorongoro crater, Mount Kilimanjaro, and Zanzibar Island. All of which have many opportunities for safari, and we took full advantage while we were there.

Dr. McCoy is a graduate of the University of Wisconsin School of Medicine and a member of the Palmetto Health EM class of 2017, which is under the direction of Thomas Cook, MD.​


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.