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Emergency Medicine between Continents

Palmer, Mary MD

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doi: 10.1097/01.EEM.0000288604.98426.f9


    My personal favorite among Icelandic patients was the man hit in the head by his tail gate after it flew off his vehicle in gale force winds. The next week it was the hood of another patient's car. I didn't have any such cases in my second winter in Iceland, which was much milder than back home in the U.S.

    And so it seems to go in Iceland, a rock in the north mid-Atlantic tangential to the Arctic Circle and the Gulf Stream. It is a complex of contradictions: volcanic fire and glacial ice, soft and hard, stunningly beautiful and starkly barren, innovative and rigid, kind and rude, dark and light.

    And here emergency medicine is trying to forge itself as a specialty. This began as a gleam in the eye of Jón Baldursson, MD. Dr. Baldursson realized almost two decades ago that what he really liked best — the acute care and prehospital work that he performed as a geology student with an interest in mountain rescue and later as a doctor in training working in the ambulance and helicopter — did not exist as a specialty.

    When a professor of social medicine took him aside as a medical student and informed him that the specialty of emergency medicine existed in the U.S., the gleam glowed brighter. It took two years to get an interview before he was accepted into the residency at the University of Cincinnati. As he stepped into his dream and its opportunities, a faculty member asked him a question that is virtually unknown to most interns: “Can't you stop smiling for a while?” But he smiled all the way through his chief residency. “It was fantastic. There was at least one person really good in everything there, and I learned so much.”

    Dr. Baldursson rightly expected his return to Iceland to be problematic because problems are frustrated dreams, and he is a big dreamer. His dream is to see an emergency department staffed by specialists in emergency medicine with focus on life and limb emergencies to serve as the anchoring interface between the community, prehospital services, and the hospital. Situated between the U.S. and Europe, Iceland has medical services heavily influenced by the European model that sends patients to various specialists. “But this organ system approach fails, ”said Dr. Baldursson. For instance, an overdose patient goes to medicine. If the coma does not resolve, etiology by trauma may only belatedly be entertained. Or consider the woman with abdominal pain who is triaged directly to the surgical intern, and the diagnosis of an ectopic pregnancy may not be entertained until too late.

    “It is about the delivery of a higher quality of patient care and resident education,” he said. While it is true that the slysadeild (emergency department), fondly known as the slyso, sees an inordinate number of orthopedic traumas, the potential of the specialty was for years limited as a subdivision of the orthopedics department and its subdiscipline of traumatology. These days it also sees an inordinate amount of patients, where last year the volume increased by 20 percent to 54,000 visits per year in a country with a population of only 285,000.

    As department status is becoming a reality, the next dream is to produce residency trained specialists with rotations to the U.S. and Europe to add the depth of training impossible with this population alone. But young physicians need to see specialization in emergency medicine as a viable option, and so the first step is to have a grandfathering process. Toward this goal the Icelandic Society of Accident and Emergency Medicine was formed last December.


    Reinforcements Arrive

    Along the way, reinforcements have entered the department. Dr. Baldursson left a deep impression on his colleagues in Cincinnati, which proved helpful in recruiting to his cause. Curtis Snook, MD, who trained in emergency medicine with Dr. Baldursson in Cincinnati and completed a toxicology fellowship there, moved with his family to Iceland in 1995. He came to work and teach in the emergency department, and help found a poison center for the country.

    Gudbjorg Pálsdóttir, RN, deviated from her original plan to work in oncology when she became “infected by this ED thing” in 1991. Along with another nurse from the department, Anna María Pórdardóttir, she left Iceland to obtain a master's degree in trauma critical care nursing at the University of Maryland in Baltimore where she specialized in pediatric trauma and disaster management. When Ms. Pálsdóttir returned to Iceland in 1997, she directed the nursing component of the emergency department with a vision synergistic with Dr. Baldursson's.

    The return of Theodór Fridriksson, MD, in 1999 after completion of a fellowship in pediatric emergency medicine at the Medical College of Wisconsin and of other Icelanders trained in emergency nursing and prehospital care has given the department additional depth.

    When my husband was assigned to the U.S. Embassy in Reykjavík, I joined the team in late 1999 to complete a northern-bound momentum after training at George Washington University Medical School, Hahnemann-MCP School of Medicine for residency, and Bellevue/New York University for a fellowship in toxicology. Perhaps this general expansion in trained personnel influenced the recent decision to give the department independent status with the merger of the two major hospitals in Reykjavik. This department recently gained a new level of leadership when the former chairman of orthopedics, Brynjólfur Mogensen, MD, took on the chairmanship to advance care of trauma and to advocate this new specialty in Iceland.

    International Expansion

    I think our little group represents the general international expansion of the emergency medicine movement. As the specialty becomes saturated in the U.S., the adventurous personality types that go into emergency medicine are and will be looking for new frontiers. As the challenges of establishing the specialty in the U.S. are met, risk takers will attempt to meet the obstacles abroad. But as this U.S. specialty meets other cultures, it will need to be flexible, or even acknowledge that younger models from other cultures have something innovative to offer as well or at least be better suited to their own setting.

    Dr. Baldursson, for instance, looks to the Nordic reliance of helicopter service in prehospital care that operates on two levels: search and rescue and more advanced levels of prehospital care. He sees in Canada a tempting subspecialization of emergency medicine among primary care physicians serving rural areas. The patient mix in Europe is more similar to that found here.

    Ms. Pálsdóttir added that in Iceland there is a movement to centralize all resources for search and rescue that was previously scattered among civil defense, police, civil aviation, 911 administrations, and the network of 18,000 volunteers called Landsbjörg. The only service outside this center will be the Coast Guard. And she further explained that Landsbjörg makes possible otherwise difficult wilderness rescues through their technical skills, equipment, and snowmobiles. “Many rescues simply could not be done without these volunteers,” she said.

    Like the heat and cold of Iceland, the pros and cons of emergency medicine are not pure here. Each of us likes some things better about the Icelandic system than about U.S. practice and vice versa. For instance, Icelandic physicians are more involved in prehospital care, and that is believed to reduce the stress of the patient and offer wider immediate care options. In addition, medicolegal issues are not as overbearing. As Dr. Snook said, “There is the sense that reasonable care is reasonable even if the outcome is bad. Only flagrant malpractice becomes an issue.” This bears on the scope of practice where Dr. Baldursson found it difficult in the U.S. to send patients out for delayed orthopedic follow-up for conditions that he was used to treating definitively in the slyso, and noted that doctors provide better patient care than lawyers.

    We also enjoy in Iceland a more personal practice world that allows more individualized responses to patient care and crises and greater personal and family responsibility by patients who are also backed by the systemic safety net of guaranteed health care (40% of the national budget). I have rarely missed the absence of physical restraints here, including the pediatric papoose boards. The only gunshot wounds I have seen under gun control here are those inflicted by staple and nail guns.

    High-Quality Care

    Atmospheric dignity and gentility in the department are associated with the consistently high quality of nursing care. Ms. Pálsdóttir attributes this to an advanced level training and relative autonomy. “Instead of various degrees of training to practice nursing in the U.S., we are all university trained,” she said. “We do all the casting, and have the orthopedic background to know what we are doing.”

    In the U.S., I felt that if something was wrong with the respiratory system of my patient, I was supposed to get someone else to fix it: the respiratory therapist. Of course we work with respiratory therapists, but I do not like to work with patients broken down into different systems taken care of by various health care workers. “This chin-up spirit is reflected in the organization chart: Dr. Baldursson and Ms. Pálsdóttir are parallel.

    I must add that I love my commute. I can be in the thermal waters or home in 10 to 15 minutes with views of old world charm or modern city chic set before mountains and fjörds that still consistently drop my jaw. It is a comfortable place to live with fantastic services for kids and a small pond for fish to swim in. Dr. Snook has been Nordic champion in several events in master's swimming.

    On the other side of the ledger, we all miss terribly the value of emergency medicine as a specialty. We are suffocating here on sprained ankles because the acute non-trauma cases usually go to other services. Our colleagues have not accepted the broad scope of services of our profession. We miss the diversity of clinical practice found in the U.S. where acceptance of our specialty led to quality teaching and training and later the evolution of academic emergency medicine research.

    Slow but Sure

    This specialty-education-academic trajectory is a sequence that Dr. Baldursson hopes to follow, but it seems exceedingly slow. Ms. Pálsdóttir added that the standards of care in the U.S. are more universally accepted, and this quality transmits to the patients in the U.S. This transcends “the kings and queens” of personality, ego, and styles found everywhere including Iceland despite the deceptive casualness that everyone is on a first-name basis. We miss the “stimulation of dynamic exchange and timely access to medical information in the U.S.,” Dr. Snook said.

    Dr. Baldursson reminisced that “it was hard to come back because there was no respect for an emergency medicine attending. In my first weeks back, I watched a resident take a patient off for an x-ray with a clamped chest tube, blatantly ignoring my advice to put it to water seal. I also was told that the residents didn't need ACLS training because they had already had what turns out to be an equivalent of a course in CPR. Interestingly, no one but me (an idealist) mentioned the better financial benefits of practice in the U.S.

    A number of these pros and cons come down to the immutable fact that Iceland is an island, now suddenly volcanic not only in its geology but also in its prosperity and growth. Iceland is hot, and tourism abounds in this discovery. Compared with times before World War II without air access when many lived in unspeakable conditions, seeking out subsistence in sod homes shared with the animals, peat fires, and mold.

    You don't hear much about the details of this history, but you do hear a lot about the major historical institution in Iceland: its language. Viking settlers competed not only in combat but also in verse and Iceland's genealogy and history is preserved by a unique literary form called the Saga, which modern day Icelanders are still able to read by virtue of centuries of isolation. This blend of Viking brawn and brain has generated incredible talent concentrated in a population comparable with that of my hometown. The list includes two medallists in the last Olympics, the chess player Bobby Fischer, physicians and lawyers to staff the health care and legal systems, journalists, movie producers, dignitaries and politicians, more authors per capita than any other place in the world, and universal literacy. This is a culture of incredible innovation, intimacy, strength, and intelligence. They do not know that they can't do things.

    But this tight sense of cultural identity and magnificent ancient language are threatened by and threatening to diversity and change. Even Dr. Snook, who is described by Ms. Pálsdóttir as “abnormal” in his extraordinary ability to rapidly achieve fluency in the complex Icelandic language, misses knowing that he is a part of the culture he is living in. People who have lived here for decades remain an “utlendingur,” or outsider, in this tough nugget of a close culture. I was recently insulted by a patient who called me a cleaning person because people with poor language skills is often members of Iceland's new underclass.

    Extroverted Americans

    Dr. Snook was once physically assaulted simply because he is an American. I got wind of reserve after I first came when a British woman complained to me that the Icelanders were aloof, cold, and not reciprocal in friendship. I rather liked teasing that they were off thinking about the correct grammatical form for their next word (there can be 120 forms for a given adjective depending on its context). But Dr. Snook more expertly assesses this as “a clash of extroversion with introversion.” Americans are as a group extremely extroverted as compared with Icelanders and most other Europeans.

    I was wired to find my worth and direction in part through feedback from others, and I found myself in a place where that feedback rarely came. The other major difference with Iceland in particular is the relative lack of what Americans would consider common courtesies. We have had to learn not to take offense when cut in front of in line, carelessly kicked in the pool, or not acknowledged with a smile on the street. Be that as it may, there is nothing better than a slyso party, and I have noted eyes go appreciatively misty on the topic of Dr. Snook's years of contribution and his mastery of Icelandic. Fire and ice.

    Language problems — most focusing on the sexual organs— have made for some of our funnier transcultural moments. Ms. Pálsdóttir gave a presentation in her U.S. master's program and spoke specifically on disseminated intravascular coagulopathy (DIC). She did not understand why her dry lecture in shock pathophysiology was so funny because she had never heard the acronym spoken phonetically except in her own head: dick. And back in Iceland, Dr. Snook also came up with the Icelandic equivalent for the male genital organ when trying to create a word for the midfoot region. In another example, he attempted to express the thought “to calm down” and stated the verb “to masturbate.” I watched a patient flush red after I put an accent over the letter “i” which changed the meaning of an Icelandic word for “dizziness” to a vulgar word for sexual intercourse.

    Dr. Baldursson's transcultural difficulties, however, were more highbrow as he had to adjust to a form of education that he now decidedly prefers. In the Icelandic part of his training, if you said, “I don't know” you would be rebuked, “Well, aren't you a doctor? Go somewhere else and learn.” The assessment of patients is more intuitive, and this is associated with looser standards in charting and communication among specialties. Although that is changing as more physicians are returning after training in the U.S., there is an apparent discomfort with the Socratic method and with discussion of quality assurance issues. This harkens back to Dr. Snook's assessment of cultural differences where “American assertiveness intended to be proactive and to open discussion can instead be perceived as preemptive and renders dialogue impossible because of discomfort with open disagreement or problems.”

    Being an Outsider

    At first this outsider stuff depressed me, especially when it became apparent in the deepest dark of winter. My time as a diplomatic spouse will long be over before I can escape the infantilization of not being able to complete and understand sentences much less the cultural nuances and politics of a different health care system, itself in flux between fiefdoms, socialism, and the private sector. That said, I am proud of my basic patient interviews and limited dictations so kindly tolerated and carefully edited by the medical secretaries, but these do not help me in my goal to help Dr. Baldursson from the inside with his dream that I share with Dr. Snook, Ms. Pálsdóttir, and the other few.

    Instead, I have decided to just accept the difficulty and bring in more reinforcements. Why not strut the seductive stuff of emergency medicine before the Icelanders and other members of the international medical community? Why not invite residents to come for elective rotations to share the excitement and quality of their profession with their Icelandic peers? And why not bring in some of the best and brightest of the profession to Iceland, especially because so many of these leaders have already come so far in their own fights to advance the specialty in the U.S.?

    Although I faltered with doubt in the second dark albeit less windy winter, by spring's exquisite light I had both feet inexpertly planted into emergency medicine conference planning. They should come preferably during the light part of the year when salmon run, glaciers, ice caves, and sea kayaking look inviting, alpine flowers and green grass cover the hiking hills, and golf can be played anytime of day. And so June 9–13, 2002, close to the vernal equinox, we will host the emergency medicine conference, Iceland 2002: Emergency Medicine between Continents (

    I have found new energy in this effort, aided by the interest of working in a small pond. I find myself speaking with the president's office, donning my pumps to go hat in hand to corporations and granting agencies, asking my friends from the symphony to help us with music for the reception. In short, I find myself networking in unaccustomed veins with our organizing committee to pull together the resources that will make this a world class international event.

    My own bold dream is for this event to be more than just four days in June. My dream is that we not only will break even but also make money for the new Society of Accident and Emergency Medicine to support Iceland's partnerships, exchanges, and training of grandfathering physicians and residents into our new specialty. Maybe this contagious desire to advance emergency medicine in Iceland will escape its island quarantine and spread. In a land of heavy metal blowing in the wind and swims in warm, thermal waters during blizzards, why not? After all, the sum total of daylight hours in Iceland is greater than in most other places in the world.

    © 2001 Lippincott Williams & Wilkins, Inc.