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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.

Friday, December 1, 2017

EDs in Different Parts of the World but the Same Stories

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.​