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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@lww.com. Be sure to include a brief biography and photograph of each author. 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, April 24, 2019

​BY MECCA MADHUN, DO, & SHAZA AOUTHMANY, MD

We pulled up to the northern Lebanese-Syrian border after a two-and-a-half-hour ride from Beirut across bumpy dirt roads, and heard little voices singing, “Ahlan bil, dakatra!” (Welcome, doctors!)

We were dressed in our Syrian American Medical Society (SAMS) vests with stethoscopes around our necks, and made our way to the clinic, long alleys of white tarps covering tin walls and ceilings. It was barren and dark; we left the door open and set up our clinic space near the light from the door. We had six plastic chairs, a small plastic side table, an otoscope, alcohol pads, a thermometer, and a stack of blank paper to act as prescription pads.

Children started streaming in. Each family had anywhere from two to 10 kids. Some said there was something wrong just so they could visit us for the day. Other kids needed some ibuprofen to get them through the upper respiratory infection season.

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Between the URIs and coughs, we saw a 12-year-old girl who complained of hand dryness. Her fingertips were peeling extensively, and she had blisters on her palms. She said her hands bled most of the time. She said she worked to help provide for her family. Every day she would move wood from one place to another. She sometimes wore gloves, though at times there weren't enough for all of the workers. We applied bacitracin, wrapped open wounds, and prescribed lotion for long-term use. She was so thankful that she gave us hugs.

We saw more than 135 children, and at the end of the day they invited us to play with them. We played hopscotch, and one of the boys allowed the group to use his soccer ball. Most of the other kids wanted to play with our equipment. After letting one child try a stethoscope, a mob of children surrounded us, screaming, “Ana, ana!” (Me, me!) One by one, we let them hear their own heartbeats.

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The two of us and another resident, Suha Al-Shambari, MD, were enlightened by our experience in Lebanon. Our program under the University of Toledo Medical Center has always encouraged residents and faculty to travel on missions throughout the world. Our program mostly ventures to South America and Central America, and going to the Middle East required much research and planning. We all grew tremendously from the experience.

By being emergency physicians, we were able to provide care for many different types of presentations and chief complaints. These included pregnancy, women's health, geriatrics, diabetes, hypertension, infectious disease, and most importantly, pediatrics. More than half of the Syrian refugees are children. Our visit helped reassure them that there are people trying to bring them health care, an education, and a future.

Dr. Madhun is a second-year emergency medicine resident at the University of Toledo Medical Center in Ohio. Dr. Aouthmany is an assistant professor of emergency medicine and the associate emergency medicine residency program director at the University of Toledo Medical Center. She is also the global medical director at the University of Toledo.

Friday, December 21, 2018

BY ADERONKE SUSAN AKAPO, DO; KATHLEEN ANNE ROCCO, MD; EDWARD KAKISH, DO; & KRIS BRICKMAN, MD

Eswatini, known as Swaziland until April 2018, is a small South African country approximately the size of New Jersey. It has 1.3 million people, and is bordered by South Africa and Mozambique.

The country primarily comprises rural tribal areas with two major cities, Manzini and Mbabane, in the central portion of the country. Eswatini holds the unfortunate distinction of having the highest HIV rate in the world—approximately 26 percent of its population. Emergency medicine within this small country is clearly in its developmental stages—it is not recognized as a specialty, nor are there any training programs or requirements for emergency departments.

Roger Pachalka, MD, an emergency physician from Wright State University in Dayton, OH, initiated collaborative efforts with representatives from the University of Toledo's global health program and the department of emergency medicine along with pediatric physicians from Nationwide Children's Hospital. All were invited to meet with the Eswatini Ministry of Health in January 2018 to address the development of emergency medicine within the country. This initial exploratory visit and several meetings with the Ministry of Health and hospital officials at Raleigh Fitkin Memorial Hospital and Mbabane Government Hospital identified the need to develop a triage system, establish a true prioritization process to separate emergency department patients from outpatient clinic patients, and create emergency care standards that could be accepted throughout the country.

These efforts resulted in the development of the first provider conference for emergency medicine in Manzini in July. More than 130 prehospital personnel, nurses, physicians, and administrators traveled up to 120 miles to attend this introduction to emergency medicine.

The most prevalent emergent health care concerns identified in previous studies of Swaziland after HIV/AIDS include trauma care, infectious diarrheal disease, respiratory infections, tuberculosis, and stroke. Health care resources in Eswatini remain quite poor in spite of adequate literacy rates exceeding 85 percent and a middle-income population for Africa. Resources for appropriate trauma management, acute medical emergencies including cardiovascular and neurologic problems, and vascular access for managing dehydration and acute infectious diseases are quite limited. A major concern is the lack of a medical school within a country with a very limited number of physician resources. This, combined with the absence of a triage system, limited equipment and monitors, and limited ancillary support, indicates that the emergency care system of the country has opportunities for improvement.

This conference focused on the areas where we felt education and training could make an impact. Our Ohio-based faculty and residents from the University of Toledo Medical Center, Nationwide Children's Hospital, and Wright State University provided education and training on developing triage systems, adult and pediatric resuscitation stabilization, trauma care, and vascular access. The hands-on workshop component of the conference incorporated interosseous infusion education and training, pediatric and adult CPR resuscitation, and identification of cardiac arrhythmias. This was the first emergency medicine conference in Eswatini, and attendees said it was highly beneficial and educational.

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Eswatini medical professionals practicing basic life support.

This educational effort was also an academic experience for the emergency medicine residency at the University of Toledo Medical Center. Faculty and two EM residents were involved in developing and delivering this symposium. Global health has been a hallmark of Toledo's emergency medicine residency with initiatives in Central America, Africa, the Middle East, China, and Southwest Asia.

Further support, development, and resources for emergency medicine from the Ministry of Health will be necessary to achieve the goals of a state-of-the-art emergency care system within the country. We came away confident that the health care providers within the country are highly intelligent and fully capable of delivering a high level of emergency care if a standardized emergency care system can be supported by the local hospitals and the government. The initial starting point should be establishing triage systems at all hospitals in the country.

As EM residents, this experience in global health education and development was invaluable to us. It provided us a new perspective on health care and the opportunities for emergency care in other countries. We learned about the importance of honing our clinical skills and how to better utilize resources in patient care. We are grateful for the exposure to a cost-effective health care practice model that is essentially the norm outside of the United States where health care resources must be managed with appropriate restraint.


Dr. Brickman demonstrates the technique to obtain emergent intraosseous vascular access.

We hope to continue this relationship with the Eswatini health care teams to improve health care delivery and a long-term goal of establishing a true emergency medicine specialty in Eswatini that may be a model throughout Africa. This experience to participate in the health care system of a country at the local and national levels and in developing emergency medicine has become an invaluable part of our education.

Looking forward, our team is planning to return to Eswatini in six months to assess the development of the strategic mission that has been laid out for the country in standardizing emergency medicine. We have established ongoing communications between government and administrative officials at the hospitals to collaborate on the initiatives. We are highly encouraged by the response to this initial education and training effort, and are hopeful upon our return that we will find the bar for emergency care within the country higher than we left it.

Dr. Akapo and Dr. Rocco are second-year emergency medicine residents at the University of Toledo. Dr. Kakish is an assistant professor and the program director of the emergency medicine residency program, and Dr. Brickman is a professor and the chairman of emergency medicine and the director of the global health program there.

Tuesday, February 27, 2018

BY ZACH HARDY, MD, & DANIEL BAKER, MD

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.​

Dr. Hardy is a graduate of the Texas Tech School of Medicine, and Dr. Baker is a graduate of the Medical University of South Carolina. Both are members of the Palmetto Health EM Class of 2019.

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.​