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, February 27, 2018

Going on a medical mission with the Himalayan Health Exchange to the Himachal Pradesh region of India allowed me to see a part of the world that I had never experienced before. The patient population that we were seeing had very little access, if any, to medical care throughout the year. We had to travel on foot to their villages to provide care because of their remote location. But the trip was quite unforgettable—we spent all our off days hiking through the Himalayas, had night-time views of the Milky Way, and ate more Indian food than we could have ever imagined.

The flight from Delhi to Leh was incredible. We could see the mountains peeking through the clouds, giving us our first view of the Himalayas. We landed in Leh, a small town in Himachal Pradesh, after more than 24 hours of flying from Atlanta, and met with our companions while we recovered from our flights and attempted to adjust to the altitude.

We left Leh the next morning to drive to our first clinic site, Sarchu. The road there consisted of nine hours of cringe-inducing single-lane roads bordered by treacherous drops. We crossed the Taglang La pass (17,582 feet), the second highest pass in the world, according to the sign at the top. This rapid elevation gain made a number of members on our team feel the effects of altitude sickness, so we were happy to make it down to the relatively low elevation of Sarchu, where we would be camping (13,500 feet). Sarchu itself consisted only of about 50 yards of shacks set on either side of the highway. Each one had a big sign repeating the same offer: "Breakfast Lunch Dinner. Bed available!"



Our first clinic day was an eye-opening exposure to the challenges of providing health care in remote settings. We were limited significantly in our ability to diagnose and treat, given the minimal stock of tools and medicine we had. The majority of the patients presented for gastroesophageal reflux disease, eye complaints, and chronic musculoskeletal issues. Many patients we saw in Sarchu were road workers who had only come to the area for work. The uncertainty of follow-up care weighed heavily on our decision process. We had to decide what limited supplies to pack and bring on our trek for the next three weeks.

The next day, we packed up for the first time and headed out on foot with a local monk, «Lama G,« as our guide. We hiked for the next five days, working our way toward the Phriste La pass (18,250 feet). It was quite a momentous achievement when we crossed; this was the highest elevation most of us had ever reached. Sadly, we were only allowed 10 minutes at the top to take pictures before descending so we didn't develop altitude sickness. On the other side of the pass, we dropped down into the valley where we would spend the next two weeks.

The Toll of Everyday Life

Going into the valley felt like being transported back in time. Each village we came to consisted of fewer than 100 people. The lifestyle they lead is incredibly physically demanding. They would work from sunup to sundown performing physical labor such as carrying bushels of grain or making mud bricks by hand. They worked with only minimal tools, and relied entirely on the glacial snow melt for irrigation and drinking water.

It was apparent how much this lifestyle took a toll on their health in the clinic. Nearly every older woman we saw had diffuse chronic pain from carrying these heavy loads on their backs for so many years. We saw a man who presented with dry eyes and hoped to obtain sunglasses. We noticed, however, he was walking with a limp, so we asked to take a look at his leg. When he pulled up his pant leg, we were shocked to see what looked clearly like a complete knee dislocation. Apparently, he had injured it in a fall 30 years prior, and had walked with that limp his whole life.



We would gather around for didactics after each clinic day. Each of us had to prepare a 15- to 20-minute lecture for the group. These helped us place the issues we were seeing into context. We discussed various topics, including altitude-related disease, rheumatic fever, sexually transmitted diseases, peptic ulcer disease, acute hepatitis A, and more. We also had enlightening conversations about the ethics of medical missions as well as the social issues and dynamics of India.

We had nine clinic days and saw more than 300 patients. We were able to help with a variety of acute issues, including eye irritation, GERD, musculoskeletal pain, and viral and bacterial infections. We also found several worrisome findings, including a man with possible tuberculosis, a young man with what seemed to be heart failure, and a woman with signs of liver cancer. We were not able to do much for them in the field, but we were able to help somewhat by having them follow up in the city. Overall, it was an amazing experience that showed the positives and negatives of global health and allowed us to work with a great group of people.​

Tuesday, December 12, 2017

BY KATE BANKS, MD

The Himalayan Health Exchange (HHE) is an organization that assembles volunteers and health care providers from all over the world to deliver care in underserved areas in northern India. I had the amazing opportunity in my second year of residency to spend a month delivering medical care with HHE in the beautiful inner Himalayan mountains. The month was full of exploring, trekking, camping, learning, doctoring, and personal and professional growth.

The clinics were scattered throughout different areas in the state of Himachal Pradesh. Our convoy of interpreters, cooks, volunteers, and health care professionals made camp in remote villages or in the mountains near small towns. Clinics were generally held in the areas close to our campsite. HHE visits these sites several times a year, so the local residents are familiar with their group and there is a small degree of continuity. Patients came from all over to see the physicians at our clinics. One patient, who was in the second trimester of pregnancy, walked more than 18 kilometers through the mountainous terrain to see a doctor. We also held clinics at schools and orphanages. After clinic, we had educational sessions about hygiene and dental care.

Luckily for our patients, physicians and government hospitals will see them for free or at reduced rates. Access to health care, however, can be quite far geographically, and may require a one- or two-day trip. Most people cannot afford the transportation fare or missing several days of farming or work to see a physician, unless it is very serious. Most patients had benign complaints such as poor vision, arthritis, or gastritis. These people were so thankful when we provided them with simple remedies such as reading glasses, ibuprofen, or Zantac. It was refreshing to see how grateful they were for medications that we have readily available in the United States and take for granted.

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The simplicity of medicine in India was sometimes invigorating, but I found myself yearning for modern technology several times. I had a teenager with mastoiditis who could not go to a hospital for several weeks, so I placed him on an oral third-generation cephalosporin. I still agonize over that case, and wish I'd done a CT scan to determine if the patient needed surgical debridement or if antibiotics were sufficient to treat his condition. Another patient presented with a benign complaint, but had a pulsatile abdominal mass on exam. I wanted to perform a bedside ultrasound so badly to confirm my suspicion of an abdominal aortic aneurysm, but that was impossible. We stressed the importance of going to a hospital for evaluation of this potential ticking time bomb, but I don't know if she was able to make it.

Besides treating Indian and Himalayan patients, our trip also provided care to Tibetan refugees. Many Tibetan refugees followed the Dalai Lama to northern India when he was exiled. Because of this, a large Tibetan and Buddhist population mixed with the traditional Indian Hindu population in Himachal Pradesh. This made for a very interesting and varied cultural experience. We held clinics at Buddhist nunneries, monasteries, and schools where Tibetan children study while preserving their language and culture.

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Our group consisted of undergraduate students, medical students, residents, and attending physicians from all over the world. We had people from the United States, England, Australia, Italy, Canada, and India. It was so interesting to learn the way medical education and health care work in each of these diverse countries. We would often sit around the campfire and talk about our respective cultures. I learned a lot about these different cultures' philosophies, food, language, and so much more.

This trip was truly once in a lifetime. Looking back on my residency, I will always remember my month-long journey trekking through the Himalayas and providing care to such wonderful patients. I am blessed that the Himalayan Health Exchange and my residency program allowed me to have such a gratifying and life-changing experience.​

Dr. Banks is a graduate of the University of Kentucky College of Medicine and a member of the Palmetto Health EM class of 2018.

Friday, December 1, 2017

BY TIM DEPP, MD

I spent two weeks in India and another two weeks at the Centers for Disease Control and Prevention in Minnesota during my global health elective month. It was a great time to reflect on sustainability in developing world medicine and on my medical education and career goals.​

Emergency medicine in India is still in its infancy. Some might say it's only just been conceived, still waiting to be born. India is growing incredibly in numerous sectors, and several universities, including George Washington University (GWU), have partnered with established hospitals there to grow the specialty. After completing their MBBS training (the British and Indian equivalent of medical school), physicians can specialize as we do in the United States, or take positions with the military, hospitals, or in other areas. GWU, among others, has help set up a program for emergency training, which is a three-year master's program. Candidates are selected from diverse backgrounds. Faculty and senior residents are recruited from U.S. emergency medicine programs to visit and teach. Many of the physicians have had broad-ranging experiences, from working at rural military posts in Kashmir to having completed a cardiology fellowship. It is an extremely dynamic group, and the future of emergency medicine in India is bright.


The model is effective—most residents are driven to achieve—and there seems to be a clear exit strategy for GWU as the programs grow and develop their own faculty members.

One of the key challenges for trainees at different centers was variability in patient volume. I visited and taught at four hospitals—three in New Delhi and one in Kolkata. It was a great experience. Residents at some centers saw lots of patients; others saw only four or five per shift. Even at the sites with less throughput, however, it was exciting to see the group discussions of interesting patients and true intellectual curiosity.

Another interesting challenge in resident education was the number of subspecialty hospitals. Because of the large size of the population in these cities, eye, kidney, and heart hospitals have emerged, and some pathologies were rarely encountered at different training sites, not to mention that many of the hospitals were not trauma centers. We were in the head, neck, and ophthalmology module of their curriculum, and many of the residents had little experience with eye pathology because the vast majority of these patients go straight to eye hospitals. These rules fell apart as they do in the United States at centers on the outskirts of the cities or at those serving poorer populations. People often just go to the closest hospital or emergency department.

It was a lot of fun working with the residents. It was no different from the ED in South Carolina in many way: People sometimes got stuck in the ED for days because the hospital was full, lots of people came to the ED because they couldn't get an appointment with their primary care physicians, nursing ratios were out of control, and lots of people also waited way too long to come to the ED and were critical by the time they finally walked through the door.

Teaching was also rewarding. I learned as much as I taught. Conditions such as kala azar or spinal tuberculosis are commonplace, but we would need to pull a reference text back home to know how to begin treating it. Most of the EDs don't have slit lamps, so we spent time at different facilities honing bedside exam techniques and ultrasound skills for evaluating intraocular pathology.

It was a great two weeks, and I would definitely consider going back. After wrapping up my teaching in Kolkata, I flew to Minneapolis for a welcome break from the 100-degree temperatures.

The Certificate of Knowledge in Clinical Tropical Medicine and Traveler's Health Course through the University of Minnesota and the CDC is a great introduction to developing knowledge of world medicine. I was introduced to it by Nate Ramsey, MD, and really enjoyed it. It consists of seven online modules covering topics like refugee health and migrant populations, human trafficking, virology, microscopy, parasitology, disaster response, and Ebola. All the modules combined were about 300 hours of lecture, and the portion in Minneapolis was a two-week in-person segment focused on more in-depth parasitology and simulation medicine.

It was a phenomenal opportunity to take the course. Once I complete the course, I will be eligible to sit for the American Society of Tropical Medicine and Hygiene exam. The best part of the course was networking and hanging out with the other participants. It was a great group, split evenly between trainees and fellows and clinicians getting additional training for international aid and clinical work. Participants included faculty from universities around the country, NGO executives, physicians working with Médecins Sans Frontières and the CDC, first responders to the Ebola outbreak, and physician leaders from Nigeria and Tanzania. It was a great opportunity to learn from each other and discuss ongoing challenges in global health work like the ethics of short-term work, scope of practice, and crisis relief.

As I continue to focus my career on international emergency medicine, it was a great capstone to accomplish in the last months of residency. This is a course I would recommend to anyone who wants to become more responsible and offer value to the places and people they visit..

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

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.​