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, June 11, 2013

Making a Dream a Reality
By Joseph Kim, MD.
As a Korean-American, I have always been curious about exploring my heritage. Fortunately, I have had the opportunity to visit South Korea several times, including two trips during residency. Each time I visited, I realized that I had developed a desire to live in South Korea one day. But deciding to work in Korea as a physician was an enormous decision, and I did not want to make it lightly. I wanted to have the chance to explore the life of an emergency physician in South Korea before making such a life-altering decision.
 I began researching potential hospitals that might allow me to rotate through their hospital during my second year of residency. To my surprise, South Korea had several well-established international physician exchange programs at most of the large hospitals. I eventually settled on two of the largest hospitals in South Korea, the Asan medical complex and St. Mary’s Catholic Hospital. After a year of preparation, I boarded a plane in July and began my journey in South Korea.
Asan Hospital.
St. Mary’s Catholic Hospital.
Arrival at Incheon Airport.
After a 14 hour flight, I had finally arrived at Incheon, a city adjacent to Seoul that hosts the international airport for South Korea. If you have never visited Seoul, Incheon Airport is quite the sight. It has been acclaimed as one of the best airports in the world by several rating agencies. But what is more intriguing is the city Korea is currently building near Incheon airport named New Songdo City.
 It is a planned city being built on reclaimed land from the sea, and it is meant to attract foreign investors. Part of the project involves constructing an international hospital to be staffed by Korean and U.S. physicians. I did spend one day at New Songdo City, and it looks nearly complete. There are people living there, but it is still not nearly as populated as Seoul.
First Day at Asan
I had the opportunity to meet one of the emergency medicine attendings, Dr. Won Young Kim, on my first day at Asan hospital. We conversed about the differences in practices between South Korean and U.S. emergency medicine. He gave me a guided tour of the facility, and introduced me to all the faculty and residents.
Their emergency department is similar to the POD system we have in the United States. They divide the patient care areas into a fast track, the main ED (which has two resuscitation bays), a separate pediatric emergency department, a dedicated ED for cancer patients, and a fully equipped ICU/observation area called the acute care unit or "ACU." They graciously allowed me to observe in their main ED.
Just like any other emergency department, you would describe emergency medicine in South Korea as controlled chaos. The first patient I encountered was a middle-aged woman who had a known malignant effusion. She had presented because of worsening orthopnea, and was placed in the resuscitation bay. It just so happened that the patient was being worked up by the ultrasound fellow, and we noted a large pericardial effusion as she performed the bedside ultrasound. There was some question about whether there might be RV diastolic collapse. Her blood pressure dropped to 70s/50s despite IVF resuscitation during her clinical course. Cardiology was consulted.
EMS brought in a second patient, an elderly gentleman whose HR was in the 180s. The chief resident decided to manage this patient. He had a history of V-tach and had undergone ablation in the past, but he required ECMO during that hospitalization. The patient appeared to be diaphoretic, but his blood pressure was within normal range. An EKG suggested SVT, and adenosine was administered with no effect. It was decided to sedate the patient to attempt cardioversion. Unfortunately, the patient had no response to the attempts at cardioversion.
Cardiology was consulted, and they recommended an esmolol drip. The patient's HR climbed to 240, and eventually he lost his pulse during the interval period. CPR was being initiated when EMS brought in a third patient whose HR was in the 200s. They placed this patient in between the two other patients in the resuscitation room. Unfortunately, the ED was out of beds, and they had to place the patient on the floor of the resuscitation room. The R1 was managing this patient with assistance from the chief resident, who was going back and forth between the patients. She was apparently in SVT, and was successfully cardioverted with adenosine.
Once the storm settled down, I had the opportunity to ask the chief resident if it was always this busy. He said that day was a usual day. Asan essentially never goes on diversion, and ED crowding has become a huge issue. They find an area to place every patient who arrives at their ED.
First Week at Asan Hospital
The hospital was gracious enough to provide dorms for my stay at Asan, so I got to live right next to the hospital. The day usually starts with their morning conference at 7:30 a.m. All of the residents and attendings will run the list of all critical patients in the ED and then they hold a one-hour didactics session for residents. Many of the topics are quite informative. That month they focused on ATLS, but other interesting topics such as NSTEMI/USA and pulmonary embolisms were covered by Dr. Kim, who I found to be an excellent lecturer. I mostly observed at the main ED during that first week.
The faculty and residents were unbelievably gracious. One of the attendings, Dr. Ahn, went out of his way to make sure I was having fun. The first week, he took me to dinner, where we had grilled meat called "galbi." I really can't put into words how delicious "galbi" is; go to your local Korean restaurant to try it. The meat is grilled right at your table so it is always warm and practically melts in your mouth.
I spent the first week exploring the hospital complex. It is like a small town. The complex houses a grocery store, several sit-down restaurants, a convenience store, and a bank. The medical complex also is home to the Ulsan School of Medicine and several research labs. The clinical portion of the complex is comprised of three large buildings, named the New building, the West Building, and the East building, which are connected by an underground passage.
Second Week at Asan Hospital
I decided to visit the cancer ED. I'm not sure if it’s because Asan is a large tertiary facility or whether it’s the sheer prevalence of cancer in South Korea, but I felt that a large proportion of the patients we saw in the ED had some form of cancer. Unlike the United States, gastric and hepatobiliary cancer is the most common, followed by lung cancer.
ED crowding has become a huge issue in South Korea, with the majority of the ED footprint and beds being consumed by ED admission holds. Asan hospital decided to build a separate ED designated specifically for cancer to alleviate some of the ED crowding. Cancer-related emergencies can be admitted to the cancer ED for 48 hours. This is supposedly the first of its kind, and it was quite impressive.
I normally ate lunch with either the faculty or attendings, and it was during this time that I could usually ask them about the Korean health care model. South Koreans benefit from a large public health care insurance system, but it does not cover all costs, and the percentage of coverage depends on the particular diagnosis. Private insurance covers the remaining costs.
I explored Seoul on my own during this second week there. Seoul possibly has the best subway and public transportation system in the world, and it was pretty easy to get around. Some of the subway stations are pretty incredible, and are practically shopping malls, with quite a few restaurants, stores, and, of course, the all-important air conditioning.
Exploring the streets of South Korea was amazing; there seems to be an overabundance of places to eat or shop. I've also never seen such a concentration of coffee shops; in fact, sometimes I would see two or three coffee shops right next to each other. Two of my favorite things to do are eat and read at coffee shops so South Korea was kind of a paradise for me. One of my favorite places to eat was the street food vendor carts. You can actually get a really filling meal for maybe $2. Starbucks has been incredibly successful in Seoul, but I actually preferred the Korean brands mainly because of the desserts. One dessert called a honey butter cake is so sweet and delicious that I felt I would get diabetes just looking at it.
Honey butter cake.
It was also during the second week that the faculty and residents invited me to something called "Hwe Sheek." Hwe Sheek is part of the company culture of South Korea. Once a month, the entire faculty and residents meet at a restaurant to have dinner and drinks together. It’s sort of a team-building event, and it’s really fun. It’s a really enjoyable atmosphere: people are telling jokes, laughing, and eating grilled pork called "Sam-gyeop-sal." I got to discuss the state of medical informatics with Dr. Jae Ho Lee during the Hwe Sheek.
Like at home, the push to implement computerized physician order entry was started in the emergency department in South Korea. Dr. Lee is an emergency medicine attending who taught himself computer science and informatics, and he is a leader in the informatics program at Asan. It might be because of the IT culture of South Korea, but some of the advances in informatics are well beyond what we have in the United States.
The staff at Asan has developed in-house iPhone and android apps that allow them to view CT scans and clinical notes and data. It’s much snappier than the remote log-in solutions we have in the United States. It was quite an exciting time because Dr. Lee is planning to roll out an informatics fellowship in a year or two, and actually invited me to apply. It’s actually a tempting offer; I think I could learn a lot about clinical informatics in South Korea, and I may take him up on it.
Third Week at Asan Hospital
I visited the acute care unit (ACU) and the pediatric ED at Asan hospital during my third week. The ACU is a fully equipped ICU run by the department of emergency medicine. It is staffed by a second-year resident, and an EM-critical care trained attending will round in the morning and afternoons. They also use this unit as an observation unit. Because the emergency medicine department staffs this ICU, the critical care training for the residents is quite amazing.
I asked why such a unit was built for the emergency department, and again it was because they needed a place where critical patients could receive quality care while awaiting an ICU bed. I found that the triage system they have complicates the matter. U.S. wait times can be measured in hours, but the longest anyone waits is 30 minutes at Asan, and the waiting room is often empty. They achieve this by finding a space for the patient immediately after triage, such as a chair or perhaps on the floor. The primary motivation for this type of triaging is that they are fearful that a critical patient in the waiting room won't be seen for hours. It’s not uncommon that they have to intubate on the floor, which they nick named "Tahng-tubation." "Tahng" means floor.
Pediatric emergency medicine is not really an established specialty in South Korea. Currently, no pediatric emergency medicine fellowship is available, and the pediatric ED is staffed primarily by pediatricians and one attending who is boarded in pediatrics and emergency medicine. The department of emergency medicine provides their first years with a one-month rotation in the pediatric ED, and also assists whenever there is a code or trauma case.
I had the opportunity to have lunch with one of the EM attending who staffed the pediatric ED, and he concurred that Korea does need a pediatric EM fellowship. He said the pediatricians do an excellent job, but the mindset and philosophy needed to practice emergency medicine efficiently differs tremendously from what one receives with pediatric training. He did tell me that there are plans to institute a pediatric emergency medicine fellowship in the near future.
I also explored an area of Korea called Myeong-dong. It’s really famous for its theaters and shopping, and attracts quite a few tourists. The best way to describe Myeong-dong would be to mix an outdoor shopping mall, a flea market, and theaters in Manhattan. It was quite the experience. I was able to catch a performance called Nanta, which is an acrobatic comedy.
Nanta performance.
Fourth Week at Asan
The fourth week at Asan involved visiting the fast track. I actually enjoyed this portion of my observation the best. The fast track area is a collection of five rooms, each with a desk, computer, and a bed. Unlike the United States, each room is stationed by a physician, and the patients are brought to each room to be seen. I actually see this as a more efficient way of seeing fast-track patients. I have found that the bottleneck to seeing more patients is often a lack of beds. I felt I was able to learn Korean patient-doctor etiquette in the fast track area the best.
Given South Korea's Confucianism background, I always thought that the patient-doctor etiquette would be paternalistic. It was quite the opposite, to my surprise. The physician typically acts an advisor, so the doctor will often present his analysis, several solutions, the pros and cons of each solution, and finally a recommendation. Nevertheless, there were some subtle differences. Both parties often use the honorific form of speech, and they bow instead of shaking hands. I was quite impressed with the level of politeness exhibited by both the patient and doctor during these exchanges.
This week I decided to check out the largest Korean palace called Gyeongbokgung. The original palace was apparently burned down during the Japanese occupation, and is currently being reconstructed. It’s really neat, and it has an attached museum.
Throne room.
Fifth Week at Asan Hospital
The fifth week involved spending time in the Asan MICU, which is comprised of two separate areas. Much of the practice of critical care medicine is similar to that seen in the United States. It might be because of Asan being a large research center, but I felt that Asan was quicker to adopt more cutting-edge practices. Therapeutic hypothermia and post-cardiac arrest ECMO were used with much more frequency than what I saw in the United States. There were quite a few interesting cases, including a woman who had Takotsubo, which I have never seen.
I had about five days before my next rotation started at St. Mary Catholic's hospital. I arranged to stay at a home-stay, which was an experience. The family that hosted me was quite friendly, and I got to learn what it’s like to live as a family in South Korea. People do work quite hard in South Korea; often people do not return home till 10-11 p.m., a 13-14-hour work day. And I thought I worked hard.
Sixth and Seventh Weeks
My last two weeks were spent at St. Mary’s Catholic Hospital in the department of radiology. I was lucky to be chosen to participate in an international ultrasound fellowship sponsored by the Korean Society of Ultrasound in Medicine. My goal was to become more familiar with pediatric abdominal and hepatobiliary ultrasound. The radiologists here do their own ultrasound scans. This was really helpful for me; I received a lot of one-on-one teaching from the radiologist on how to obtain certain views. I was also surprised that one can make inferences on certain diagnoses based on ultrasound, such as fatty liver disease.
The faculty and staff were amazingly kind. On the last day, I got to meet the president of the hospital, who presented me with a certificate for completing their course.
Dr. Kim, right, with the president of St. Mary's Catholic Hospital.
I spent the last weekend visiting my aunt and cousins in a different city called Daejeon. Daejeon is not nearly as large as Seoul, but it is one of the larger cities in South Korea. The last time I had seen my family in Korea was six years ago, and it was amazing how much they changed. I also took this time to visit an area in Seoul called Insa-dong, which is a street filled with traditional restaurants, stores, and teashops. I ate traditional bibimbap, and it was amazing!
I had an amazing time in South Korea. Not only did I make invaluable contacts and new friendships, but I also gained a greater understanding of the Korean medical system. I feel that I have been extremely lucky to be able to attend a residency that makes it a point to allow their residents to experience something as unique as rotating through South Korean hospitals.
I'm grateful for all the support that my residency, the Palmetto Health Alumni Association, Asan Hospital, St, Mary's Catholic Hospital, and Palmetto Health has provided to make this happen.
Have I made a decision about practicing in South Korea? After all that I experienced, I think the answer is yes! There is still a lot of work ahead of me to make that dream a reality, so check in on me in a few years, and I'll tell you whether I made it happen.
Read more about the Asan International Visiting Scholars Program at http://bit.ly/1107ikb and the Korean Society for Ultrasound in Medicine at http://ultrasound.or.kr/eng.