EPI Issue #1

a new magazine by

+ The Future of IFEMan interview with

Drs. gautam bodiwala and Peter Cameron

Could The Netherlands be a template for EM

development in Europe?

EMERGENCY PHYSICIANSINTERNATIONAL

21EM DEvElopMEnT rEporTs FroM arounD ThE globE includingbhutanturkeyColombiahong kongVietnamSouth afriCaPanamakoreaSPainCroatiaghana

Issue One // Summer 2010 // epinternational.ning.com

2 Summer 2010 // Emergency Physicians International www.epinternational.ning.com 3 2 Summer 2010 // Emergency Physicians International www.epinternational.ning.com 3

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When I thInk of international emergency medicine, one of the first things to come to mind is my friendship with Professor Yitang Wang of nanjing, China. I first met Professor Wang in 1994 at an eM meeting in hyderabad, India. A cardiovascular surgeon by training, Wang became a

champion of eM specialty development and quickly developed a deep and complete understanding of the specialty. That trip we toured the taj Mahal together and began what became a long friendship. Over the years, Professor Wang made many trips to the U.S., attending various eM meetings, and then became one of the early presidents of the Chinese Association of eM. he has enabled me to undertake several extremely enjoyable and professionally productive trips across China. What’s more, he’s been a gracious host, giving me the opportunity to see China in a way that I never could otherwise – now I can say I’ve tried boiled ducks’ feet and puffer fish.

I’ve learned much from Professor Wang’s energy and enthusiasm for eM development, and yet he is just one of many individuals and organizations involved in development in this field. Emergency Physicians International (EPI) enters into this arena as a central platform, an open forum for cross-border communication. This inaugural issue of EPI began largely as the brainchild of Logan Plaster, the editor and Creative Director for Emergency Physicians Monthly. But it quickly grew in scope, garnering an editorial advisory board representing a wide range of countries and a depth and breadth of experience in international work. One of the central goals of this publication is to address the question: “What is international emergency medicine?” The phrase means different things to different people, but here are a few of the ways that we define it (see sidebar). If we’ve left something out, just let us know.

EPI is about open dialogue. to that end, we’ve also set up a social network (www.epinternational.ning.com) where physicians from around the world can gather, chat and share information on conferences or clinical updates. The site, which can be translated into nine languages with a click of a button, has already garnered hundreds of physician members, making it a robust tool for international communication.

Rather than go the route of an indexed, peer-reviewed journal, EPI is an open door, providing the opportunity for physicians from all over the world to submit articles. In the spirit of promoting free and open communications, EPI would like to receive and publish all types of articles (clinical, research, academic, political, business, etc.) from any country. We are hopeful that people will take advantage of EPI to publicize and promote their IeM activities or programs, and that EPI can foster and facilitate more international collaboration. The field of IeM has a bright future and EPI hopes to expand those opportunities and bring people together for collaboration. We very much welcome your input, advice, and suggestions. Welcome again to Emergency Physicians International!

C. James Holliman, MD, FACEP, FIFEM editorial director

What is int’l emergenCy mediCine?This new specialty means many things to many people. Here’s how we define it at Emergency Physicians International

1 Delivering clinical care for emergency patients in countries

other than one’s native country.

2 Developing and obtaining official recognition of the specialty of

emergency medicine in countries where it is not yet officially recognized.

3 Developing and conducting training courses in emergency care for

the public at large, non-physician healthcare workers, medical students, postgraduate residents, and physicians in practice in other countries.

4 Developing and operating prehospital care systems in other

countries.

5 Developing and conducting academic aspects of EM, including

research, faculty development, and educational program development and improvement.

6 Developing and equipping clinical facilities to provide emergency care.

7 Providing medical care in “repatriation services” which return

patients from one country back to their country of origin to receive additional or follow-up medical care.

8Operating travel medicine clinics.

9Conducting exchange programs for healthcare personnel from different

countries.

10Conducting international conferences on EM.

11Developing and operating specialty societies of EM

practitioners.

eDiTor’s Desk

Brave New Specialty


leTTer from THe PublisHer

EPI: An Introduction

publisher logan PlasTer

editorial director James Holliman, mD

executive editors PeTer Cameron, mD Terry mulligan, mD mark PlasTer, mD

editorial advisorsarif alPer Cevik, mD kaTe Douglass, mD HaywooD Hall, mD CHak-waH kam, mD greg larkin, mD Prof. DongPill lee sam-beom lee, mD glaDys loPez, mD alberTo maCHaDo, mD lee wallis, mD

associate editorsemily Debusk lonnie sTolTzfoos

to order reprints, contactgreg ruCker PARS Int’l253 W. 35th Street, 7th Floornew York, nY 10001p: 212.221.9595 ext. 105

advertisingmiCHelle ruCks [email protected] College AvenueAnnapolis, MD 21401

Submissions & LettersC/o logan PlasTer emergency Physicians International210 Columbia heightsBrooklyn, nY [email protected]

On A BeAUtIFUL evenIng two years ago, I arrived with my wife at the ICeM opening reception in San Francisco, California. I was covering my first international conference for Emergency Physicians Monthly and all I knew was that I was the guest of one Jim holliman.

Jim and I met, shook hands, and then it was off to the races. I quickly learned that when you’re with Jim – a man who has dedicated his life to the development of emergency medicine around the globe – you’re an honored guest. Over the course of the evening, Jim introduced me to literally dozens upon dozens of ePs with a passion for international eM development. Many of these men and women had worked tirelessly for years to lay the groundwork for the development of their specialty, often in places where it was previously nonexistent. Physicians gave me their reports on development, shared their stories from globetrotting adventures, and, towards the end of the evening, even extended warm invitations to visit their far-flung homes.

That night the seed was planted for Emergency Physicians International (EPI), the first issue of which you now hold in your hands. The goal of EPI is to accelerate emergency medicine development around the globe by bringing ePs together for an on-going dialogue. We hope this conversation will light the way to improved patient care and greater physician satisfaction. given the dedication and knowledge possessed by the IeM community, it is impossible to say what great developments are in store. But every building begins with a foundation, every book with an introduction. We at EPI look forward to helping tell that story. Along the way, I hope EPI captures a hint of that ICeM opening reception, with its excited talk of people, progress and new adventures.

Logan Plaster Publisher

connect with your international colleagues on ePi’s online networkwww.epinternational .ning.com

Join more than 400 current members from around the • globe

Create a professional profile for networking and • communicating internationally

Post international events and learn about new • conferences being held

Share photos, videos and educational materials with • colleagues

Join a discussion in progress or start a thread of your own•

Reconnect with old friends, or make new ones through • interest groups

on the web

cover illustration by tracey Jolliffetraceyjolliffe.com

EP International is a product of M.L. Plaster Publishing Co., LLC ©2010

Founder / CEO mark l. PlasTer, mD

Executive Vice President rebeCCa r. PlasTer


Partner with the company that knows emergency medicine. between emergency Physicians monthly (30,000 u.s. circulation) and epmonthly.com (90,000 impressions per month) Plaster Publishing has been reaching the emergency medicine market since 1992. now with the introduction of ePi, the ePi online network and custom regional publications, there are even more ways to build your em presence.

finD ouT How To ParTner wiTH PlasTer PublisHing by emailing [email protected]

A World of Possibilitieswith m. l. Plaster Publishing Co., llC

since 1992

inCrease aTTenDanCe at your next conference through targeted advertising

inCrease soCieTy revenue by building a regional em publication

inCrease em awareness and education through professional content

bring ePs TogeTHer online for networking and educational opportunities

use the strength of one of the largest eM publishing companies to help your eM society...

tech trendsautomated ed registration & other innovative game changers

in this issueManaging ManagersGetting complaints about your nurse manager? If mentoring doesn’t work, you may need to take it to the top >8

Visual DxThe eye cannot see what the mind does not know >5

Pediatric Journal ClubCan ultrasound-guided IV placement really help in those hard-to-stick pediat-

ric cases? Ghazala Sharieff knows and has the research to prove it. >16

Emergency Physicians Monthly | 5 College Avenue | Annapolis, MD 21401

“Those boys in The er” // An EP reflects on 37 years working in the same emergency department. page 3

May 2010 | Volume 17, Number 5 | www.epmonthly.com

continued on page 17

NightShift

A Couple Days This month Night Shift changes gears, publishing a post from one of our favorite medical blogs, StorytellERdoc.blogspot.com

I walked into Room 17 to see a sixty-ish woman who, by the

nurse’s triage note, had come to our ER for shortness of breath. A smoker, with a history of chronic obstructive pulmonary disease (COPD). The nurse’s note re-flected her suspicions that this

continued on page 9continued on page 18

Wal-Mart MedicineAre retail clinics eroding our business or are they the next

step toward cost containment? by richard bukata, MD


Oh heNry

Too Much Technology? Are gadgets gathering dust in your ED? Ask a few ques-tions before jumping on the next tech trend by Greg Henry, MD

“The philoso-phies of one age have become the absurdities of the next, and the

foolishness of yesterday has become the wisdom of tomorrow.” ~Sir William Osler.

I have no interest this month in sounding like a malignant Lud-

dite. I am not against all change; some change may actually be good. But, we cannot confuse change with progress. The two have noth-ing to do with each other. There are people who change for no good reason. There was time in the Unit-

Reading Between the LinesJeRoMe HoffMAn, MD on How To ReAD THe LiTeRATuRe

part i in a series 11

enter the iPad

14

The United States is a capitalist country in which entrepreneurs who see opportunities and are willing to take some risks can generally do

well. Finding the opportunities is the hardest part of the equation. One wide open market that would seem to be a slam-dunk opportunity is that of health clinics in retail stores. The concept seems compelling for several reasons. They are instantly credible because of the mega-businesses they are associated with (Wal-Mart, K-Mart, major grocery chains). They don’t require high cost physicians to provide the care – nurse practitioners can

in Case of emergency...Your ED is the saftety net for your community. But where

do you turn when YOU have a financial disaster? Here are four simple strategies for protecting your assets from life’s

worst case scenarios. by setu Mazumdar, MD

If I asked you to list the biggest risks to your assets, I’m sure malprac-tice lawsuits would appear near the top. But lawsuits are only one

of the many catastrophes that put your assets at risk. Whether you’re preparing for a natural disaster, a potential disability, or even death, you should seriously consider asset protection. Step one? Establish an emer-gency fund.

how Apple’s new tablet is already changing emergency medicine

by Nicholas Genes, MD

CME

your socIETy or

rEgIonal publIcaTIon


EVENT CALENDAR 2010/20111 2 m o n t h S o f I n t ’ l

c o n f e r e n c e S

EMERGENCY PHYSICIANSINTERNATIONAL

3 | editor’s Desk 7 | event calendar 47 | ieM Fellowship Directory

Features32 | Bridging the gap pCould The Netherlands serve as a template for emergency medicine development in Europe and beyond?

40 | the canadian head ct ruleIs the rule reliable enough for more litigious nations? Drs. Kevin Klauer & Christopher Carpenter square off.

42 | Disaster relief: haiti after action reportMSF deputy considers the weight of emergent amputations, plus Eight disaster relief lessons learned, by Mark Plaster, MD

ADVERTIsER DIRECToRy // medSpanish 2 emergency medical abstracts 8

the morgan lens 23 er Pocketbooks 27 em:raP 30 aCem Conference 51

ge Vscan 52

10 | interview pDrs. Gautam Bodiwala and Peter Cameron on the state of the International Federation for Emergency Medicine (IFEM).

11 | travelHow one physician used his profession to travel the globe

12 | academicsWant to take your interest in international emergency medicine to the next level? Get connected with one of many IEM fellowships.

13 | opinionHaywood Hall on the importance of having a community-based approach to EM development.

14 | case study qFlank pain with a twist. Test your ability to read bedside ultrasound.by Brady Pregerson, MD & Teresa Wu, MD

Source16 | DispatchesReader-generated updates on emergency medicine development around the globe.

18 | Bhutan p Emergency medicine takes strides forward high in the Himalayas with Jim Holliman, MD

21 | turkey Emergency medicine bridges continents

24 | Vietnam Emergency medicine takes strides forward through historic symposium

26 | colombia New growth through specialty societies and academic programs

28 | hong kong Towering city begins foray into EM subspecializations

18

32


EVENT CALENDAR 2010/20111 2 m o n t h S o f I n t ’ l

c o n f e r e n c e S

July / 2010PACEFEST // San Miguel de Allende, Mexico A multinational effort to develop and enhance the specialty of emergency medicine in Mexico and Latin America. July 10 – 18, 2010 www.pacemd.org Phone: 01 415 152 7532

augusT10th Asia Pacific Conference on Disaster Medicine // Sapporo, Japan A conference aimed at studying and im-proving regional disaster medicine and deepening relationships between Asian and Pacific Rim countries. August 26 – 28, 2010 www.sapmed.ac.jp/~disaster Official Language: English

sEpTEMbErLearning from Each Other: Civilian and Military Emergency Care // Birmingham, U.K. Sponsored by the U.K. College of Emergency Medicine and the Assoc. of Paediatric Emergency MedicineSeptember 13-15, 2010www.cembirmingham.co.uk

ACEP Scientific Assembly // Las Vegas, United States The annual meeting of the American College of Emergency Physicians. Large international section (1000+ members) plus numerous educational programs. September 26 – October 1, 2010 www.acep.org/SA

ocTobErThe 6th European Congress on Emergency Medicine (EuSEM) // Stockholm, Sweden A multi-faceted look at current advances in emergency medicine all over Europe. October 11 – 14, 2010 www.eusem2010.org Fees range from 4,950 to 7,250 SEK

8th International Conference of Emergency Nurses // Canberra, Austrailia Emergency nursing conference “emphasising the challenges of delivering emergency care in a global village.” October 14 – 16, 2010 www.cdesign.com.au/cena2010 Earn up to 15.75 RCNA CNE points

IAEM 2010 // Waterford, Ireland Ireland’s annual academic meeting will be held in Faithlegg House Hotel and Golf Club and will culminate in a black-tie gala. October 14 – 16, 2010 www.iaem2010.webs.com

ENAO Provincial Conference // Kingston, Ontario A provincial conference hosted by the Emergency Nurses Association of Ontario. October 21 – 22, 2010 http://enao.on.ca Held at the Confederation Place Hotel

2nd EurAsian Congress on Emergency Medicine // Antalya, Turkey EACEM is the biennial international congress of the Emergency Medicine Association of Turkey (EMAT) in col-laboration with SUNY Downstate and the Singapore Society of Emergency

Medicine (SSEM) October 28 – 31, 2010 www.eacem.org

1st International Critical Care Symposium // Chennai, India This meeting aims to “bring together world renowned speakers” in a “friendly environment allowing informal discus-sion,” while providing CME credits. October 29 – 30, 2010 www.critcaresymposium.co.uk

novEMbErCSEM Scientific Assembly // Antofagasta, Chile Academic conference hosted by the Chilean Society of Emergency Medicine November 10 – 13, 2010 www.medicina-intensiva.cl/urgencias Official Language: Spanish

ACEM International Conference // Bogota, Colombia Asociacon Colombiana de Medicina de Urgencias y Emergencias (ACEM) is hosting its 1st International EM Confer-ence, “New Horizons in Emergency Medicine” November 11 – 13, 2010 www.acemcolombia.org Spanish and English language tracks

JunE / 20111st IFEM Symposium on Resuscitation // San Miguel de Allende, Mexico An advanced international resuscitation symposium, held at a UNESCO World heritage site. June 22 – 24, 2011 [email protected] English with Spanish side events

EuSEM’s European Congress on EM will be held in Stockholm, Sweden in October, 2010

to have your international event l isted in an upcoming issue of ePi, email [email protected]

10 Summer 2010 // Emergency Physicians International

EpI: WhaT TrEnDs arE you sEEIng In InTErnaTIonal EMErgEncy MEDIcInE?

Dr. Peter Cameron: I think the positives are that emer-gency medicine is expanding into virtually every country in the world, in some form or another. It is still not a specialty in many countries, but roughly one-third of all countries have some formal emergency medicine organisation and training. Along with this, IFeM has been able to bring the disparate concepts around emergency care delivery into a more consistent approach through conferences, committees and most recently a curriculum that has been agreed to around the world. This is very exciting, even in comparison with other more established specialties. In addition to the expansion of emergency medicine as a specialty, there has been increasing interest in broadening the scope of subspecialization. now we have prehospital care, toxicology, disaster medicine, ultrasound and so on. I guess the other really big positive for IFeM is that it is the only true global emergency medicine organisation – this is most unusual in international medical specialties. It means that potentially IFeM can play a big role in advocating for improvements in emergency medicine systems around the world. +WhaT arE IFEM’s prIMary WEaknEssEs MovIng ForWarD?Cameron: The main negative for IFeM is that it is still es-sentially a loose conglomeration of national organisations with minimal funding. The IFeM Board has been examining ways to improve financial viability through conferences and so on. It is important that funding does not constrain the organization, either by association with large corporations or through lack of finance. It is a complicated path to follow. +Dr. boDIWala, hoW havE you sEEn InTEr- naTIonal EM changE DurIng your TErM In oFFIcE?Dr. Gautam Bodiwala: to start with statistics, there are now more than 40 national societies that are members of IFeM, not counting three regional ones covering Asia, europe and Latin America. There is more awareness in providing emergency

care and setting up emergency care systems around the world, particularly in countries where emergency medicine does not exist as a specialty and certainly where there is no eM national organisation. IFeM has brought awareness of the importance of organised eMS, delivery of quality emergency care and that too by trained staff. WhO now recognizes the importance of these aspects of medical care and with the help of IFeM and other interested parties has worked towards it. World health As-sembly has passed a resolution in favour of providing appropriate emergency care. There are more and more national and regional meetings exchanging science of eM and practice round the world. With IFeM producing undergraduate and postgraduate curriculum, it will promote the quality even further. +In rEgIons WhErE aTTEnDIng InTErnaTIonal conFErEncEs MIghT noT bE FEasIblE, WhaT FIrsT sTEps can bE TakEn ToWarDs IMprovIng EM sysTEMs?Cameron: One of the first steps is to get a group of interested people together – often we are all fighting the same battles with-out realising it. Once there is an organisation with local cham-pions, the group can learn from international experience. There is extensive help available online at no cost. Avoid making the same mistakes that everyone else has made. get a “jump start” by using the collective experience of 30-40 years of hard labour in other countries. visiting experts are also useful. They can say the same thing that the locals say, but have more authority because they are “experts” and they have no local vested interest. There are many people willing to help. vietnam, for example, recently hosted a conference in hue where 60 overseas emergency experts came at their own cost to assist in specialty implementation. +Is ThErE a rolE For IFEM In InTErnaTIonal DIsasTEr rElIEF EFForTs, In conJuncTIon WITh organIzaTIons lIkE DocTors WIThouT borDErs?Bodiwala: There is a definite role for IFeM in major disaster events. however, we must remember that as IFeM is still evolv-ing. It is limited to notifying member countries/associations

The Future of the Federation

INTERVIEW

This June, Dr. Peter Cameron (right) will succeed Dr. Gautam Bodiwala as president of the International Federation for Emergency Medicine (IFEM). EPI caught up with them to discuss the future of EM’s only global body. IntervIew by logan plaSter

Dr. Bodiwala vital stats

1943Born in Ahmedabad. He l ived there and qualif ied as a surgeon before moving to England in 1970.

1990Co-founded IFEM and becomes its f irst president

25+Years spent as head of the ED at the Leicester Royal Infirmary, Leicester, England

35Countries visited

OneNumber of emergency departments named after Dr. Bodiwala.

InterestsReading, travell ing and l istening to classical music


Dr. Cameron vital stats

1958Born in Austral ia.

Grew up on a farm 300 km east of Melbourne. He went to University

in Melbourne, Austral ia and was

one of the first group to do EM

as a specialty in Austral ia and NZ.

10+Countries visited

this year alone

Past President

of the Austral-asian College for

Emergency Medi-cine (ACEM)

Academic Director

of The Alfred Emergency and Trauma Centre

InterestsWalking and

tending his farm in the middle of

the bush.

where there is a need. After the recent earthquake in haiti, IFeM successfully circulated information about the need for medi-cal help. IFeM has established committees which are intended to create some basic, generic disaster management plans in due course. IFeM has also taken the first step by producing guidelines for pandemic flu.

Cameron: At this point, IFeM can’t be a relief agency like MSF. It is not organised to respond in this way and it is not part of its mission. however, by bringing groups together and develop-ing consistent approaches, IFeM can play a major role in assisting countries with training and planning for disasters. IFeM can also coordinate interested parties to get together and help after the immediate disaster relief operation. +gIvEn ThE DIFFIculTIEs oF global coMMunIca-TIon, hoW WoulD IFEM go abouT DIssEMInaTIng soMEThIng lIkE ThE panDEMIc Flu guIDElInEs? Cameron: Dissemination within the member societies is relatively easy; the larger organisations have their own internal structures. getting the message to the outside world in a cheap and effective manner is more difficult. however, I think the web makes this much easier – we just need to be smart in how we use it. Clearly conferences, papers and books etc… are supplementary methods.

Bodiwala: english remains the language of communication as it has become an international tool for communication. Once information is sent to national organisations, they disseminate it in their usual way to their members. electronic communication has made life easy. +DoEs IFEM prEFEr To casT a broaD or MorE nar-roW nET WhEn IT coMEs To DEFInIng “EMErgEncy MEDIcInE”? Cameron: The definition, as defined on the IFeM website, is fairly broad. I think within eM there is room for subspecialisa-tion. There is also the opportunity to collaborate with other specialty organisations. For example, in CPR training, ILCOR,

Dr. Gautam Bodiwala with HRH Princess Anne, at the inauguration of the College of Emergency Medicine in October 2008. M

y interest in international emergency medicine took form after I read Jonathan kaplan’s book, The Dressing Station. I had worked in germany three years by that time, and had moved back

to the United States where I picked up a copy of the book. After reading his stories of practicing emergency medicine in war zones throughout the world, I knew that I could never settle down. I had to keep moving. In the last few years, I’ve practiced emergency medicine as an expat in five countries, and I learned a few valuable lessons along the way.

// Know your home It is important to live and practice in your own country first before venturing abroad, in order to be grounded in medicine. This is the only way to appreciate the differences in the world, which may be cultural, scientific, spiritual, or simply a para-digm. If you aren’t sensitive to your paradigm and world view, you will be shucked and chucked like corn. That said, once you know where you are from, you can step out into the world and become an even better physician.

//Once an expat, always an expat If you spend any significant amount of time practicing medicine in another country, you’re going to want to go home and share your new insights with col-leagues and friends. The problem is, home isn’t where you left it. When you explain your adven-tures to your friends, their eyes may glaze over. They weren’t there and they simply don’t understand your enthusi-asm. An expat develops a world view that is unique, unrestricted by the indig-enous belief system they came from or live in. That

Your Passport Is Your ProfessionAdvice from an expat on using your profession to travel the globeby KeIth raymond, md

TRAVEL

United States 4 Germany 4 Saudi Arabia 4 Botswana 4 United Arab Emirates 4 ?

5 in 16continued on next page



flexibility in ideology can make it difficult for an expat to relate to folks who are ingrained in their lo-cal world view, constricted by the prevailing thought patterns.

//Don’t bother packing shampoo People are pretty much the same all around the world. everyone wears clothes, eats food and takes care of their health in one way or another. Once you are in country, you will be able to get by on what you have in common. In most of the world, banks aren’t necessary – over 90% of people live hand to mouth. Share your wealth and the people around you will share theirs. In Africa, I learned that living in a village

and being a tribal member is not ‘primitive.’ It is simply a different way to live. Their rites of passage might look different, for instance, but they serve the same function as those rituals played out the world over, from high school cliques to medical conferences.

//Learn the language, not the wordsThe nuances of social interaction are subtle. They vary from society to society, and you must pay at-tention. Learning these subtleties of communication is more impor-tant than memorizing vocabulary words. At the same time, do not simply mold yourself to the milieu. You have something from your own world to contribute that can enrich the lives of those around you. This

sharing of lives and cultures is what makes international medicine the amazing field that it is.

//Don’t dwell on the pastDo not think about what you left behind, and what it cost. As an expat you learn to give up a house full of furniture without looking back. If you are lucky you can sell it for 50% of what you bought it for, and if not, you pay to haul it to a dump, or a charity. You also learn that you needed it at the time, but in your next location you don’t. But it served you, for a time. What you received in return may not be material, but it is of great value. Letting go of possessions, the things that weigh us down, can be an ennobling process. I don’t mean abandoning all attachments. But by

defining ourselves by what we do, rather than what we own, we re-lease the flotsam and free ourselves to live a more generous life.

//Give free adviceIn most countries, people will give you a certain respect when they discover that you are a doctor. They will also tell about the medical problems they have. Your generos-ity will make them remember you kindly, and down the road they may help you. Once, I broke down in the middle of Saudi Arabia in the desert. A Bedouin driving by stopped and remembered that we’d met at a Souq, or market, and that I’d given him medical advice. In-stead of driving by, he stopped, and not only helped me fix my car, but took me to lunch!

In the last five years, there has been an explosion of International emergen-cy Medicine Fellowship Programs as-sociated with U.S. emergency Medi-

cine residency programs. This is in part due to the increasing recognition by academic institutions of the strong interest among medical students, residents, and faculty members in dedicating time and energy to international development work. The trend in medicine towards development

of global health institutions has fostered increasingly strong international relation-ships in the medical realm. emergency medicine as a specialty has been a leader in the development of formal post-residency training in international health, with more and more institutions starting their own International eM Fellowship programs. This is a great opportunity for eM residen-cy-trained physicians interested in global health and international development to

Should I Follow the Fellowship Road? International emergency medicine fellowships offer a range of opportunites to teach and learn, and to connect with like-minded physicians around the globe. by Kate douglaSS, md

ACADEMICS

TRAVEL

Passportwfrom page 11

jump into the field, gain experience and knowledge, have a great learning experience and accelerate their careers in International emergency Medicine.

The structure of IeM Fellowship programs varies depending on the institution. They typically last one or two years, and some – mainly two-year programs – offer master’s degrees. each pro-gram has a unique focus. For example, the fellowship program at harvard/Brigham & Women’s has a strong focus on international humanitarian relief programs. The fellowship program at george Washington University (gWU) has a strong focus on emergency medicine systems development and sustainable educational initia-tives. each program has a particular expertise, so it behooves po-tential fellows to do their research.

There is not a single formalized core curriculum that is required amongst the different fellowship programs, as there is not at this time a formal accreditation by the ACgMe. however, there has been some consensus movement among the IeM community and fellowship directors to standardize certain curricular components across programs. Most programs include exposure to, and educa-tion in areas including public health, emergency medical systems, international program development, and humanitarian aid. There is additional opportunity for collaboration across fellowship pro-grams to allow fellows to utilize resources that are a particular strength of a different program.

One fantastic thing about the International emergency Medi-cine fellowship community is the variety

“by defining ourselves by what we do, rather than what we own, we release the flotsam and free ourselves to live a more generous life.



There are many paths that support emergency medicine de-velopment around the world. One way is a more academic approach which supports the development of specialists in academic, often more urban, centers. While this is one of

our highest goals, in the developing world we also need to focus on basic emergency care training for the vast majority of providers. This large group, many of whom are general physicians, provide emergency care on a daily basis. If emergency medicine, as a new specialty, does not provide leadership in this area, we will lose significant moral au-thority and foster other alternatives to the development of the single-specialty model of emergency medicine that we all embrace.

Building a Specialty from the Ground UpWhile academic development in urban centers is important, a community-based approach, such as life support courses for existing emergency care workers, can be critical in the long-term establishment of emergency medicine as a specialty.

//How EM fits into devel-

oping systems is a crucial tactical issue. And these struggles occur as much

in the community as in academic centers.

OPINION

In Mexico, where I am currently in-volved in training programs, there are over 100,000,000 people and 11,000 new physicians are graduated every year. Only 15% of those ever receive any training beyond medical school. There have been about 2,500 emergency specialists desig-nated since 1991 and only a few hundred graduate from residency programs every year. The IMSS, which provides 60% of the care in Mexico, states that it needs 16,000 emergency physicians in its eDs. Mexico has about 1/30th the eM physician capac-ity per capita that the United States has, and Mexico is much better off than most of the rest of Latin America in this regard. general physicians provide the vast major-ity of medical care and emergency care in the country. There is a similar lack of train-ing throughout the health care system for all health care providers.

For emergency medicine – a new spe-cialty being introduced to a new environ-ment – there is typically a sensitive ecol-ogy which needs to be considered if we are to make advancements. There is the old

guard, legacy specialists (none of which want to give up turf to “the new kids in town”). There are the rank and file general physicians (typically a large number) who provide most of the labor force in emergen-cy care. given that in developed countries where eM is not yet an official specialty), our specialty is seen as of questionable value, how we fit into developing systems is a crucial tactical issue. And these struggles occur as much in the community as in aca-demic centers.

It is important to realize that historical-ly, when we say “emergency medicine” in Latin America, it is understood as “pre hos-pital medicine,” or worse, “first responders”. Additionally, the multi-specialty (“Franco-german”) model of emergency care, fur-ther lends itself to the identity crisis as a emerging specialty. Mastery and leadership in the full spectrum of life support courses helps to differentiate us from the multi-specialists while providing a valuable, high visibility service to the community.

Although emergency medicine special-ists often reject “merit badge medicine,” we

need to embrace life support courses for the existing emergency health care practitioners, especially for those working in com-munity hospitals. These courses are vitally important in develop-ing systems and assuring quality of care (in a completely different context from our own). It is critical that the emergency specialist provide leadership in these courses, since generations of generalists and specialists need this training and many lives will be lost if we can’t “train the system.” In the process, we increase our credibility and assure a place in the ecosystem as leaders in emergency care.

Of course, the whole needs to be greater than the sum of its parts. The emergency physician needs to integrate these life sup-port disciplines in a practical, highly valued way. Since we are “new,” our young leaders often don’t have the political power needed to overcome the obstacles of institutional change. Pro-grams which provide opportunities for the emergency physician to mingle with the health care system and to learn the language and culture (and the context of care) can be very valuable in terms of providing support to our fellow emergency physicians, but may also provide additional leverage and opportunities for these new specialists in their new settings. As a specialty, we have much to offer, not just in resuscitation, but in eMS development, toxicol-ogy, forensics, resource management, ultrasound training, to name a few. In the metro-centric academic centers, we need to fight the important battles to develop our credibility base. But let us not forget that in the community, at the grass roots level, emergency physicians have many tactical advantages for advancing the cause, be it through mission work, disaster response, infrastructure de-velopment, training and certification. It does not take much to convince the public that emergencies need to be managed well and that other problems can wait (by definition). Our efforts will provide deeper roots in the community and lend more force to development in academic and tertiary care centers. Let emergency medicine go forth in the world and multiply!

Dr. Hall is the ACEP ambassador to Mexico and Cuba and is an Ashoka Fellow. He is the director of the Pan American Col-laborative Emergency Medicine Development (PACEMD) and MedSpanish Programs, as well as the co-founder of the UTSW International EM Fellowship program.

haywood hall, md


Flank Pain With a Twist

Your current patient is a 55-year-old obese diabetic male who presents with right flank pain that has been getting worse for about seven days. he was started on Bactrim three days ago for a urinary tract infection, but continues to worsen. he denies diarrhea, hematuria or dysuria, but has had fever and has been vomiting about once per day. his medications include glipizide, tylenol, and Bactrim.

On exam he is calm, nontoxic, and pleasant, but looks to be in mild distress. his vital signs aren’t bad. temperature is 97.4, blood pressure 98/58, pulse 108, and respiratory rate is 16 with

a pulse-ox of 98% on room air. eyes are anicteric. Oropharynx is moist. Lungs are clear. Abdomen is soft and non-tender, but the back has right-sided CvA tenderness. The remainder of the exam is normal.

Laboratory data showed a nondiagnostic urinalysis, possibly because he was already taking antibiotics. The metabolic panel was notable only for a glucose of 216 mg/dl, a sodium of 122 meq/L, and a creatinine of 1.6 mg/dl. The CBC had a white count that was elevated at 21,400. An ultrasound of the kidneys was normal, but the following image of the liver was also taken (above).

by brady pregerSon, md & tereSa wu, md

CASE STUDY

Y ou are working in a small, rural hospital in South America whose imaging modalities are limited to plain X-ray and a portable ultrasound machine.

There is a much larger hospital in the nearest city, but it is over a day’s journey away.

//What structures are shown in the image above? What abnormal finding is shown? Conclusion on page 50

Skills TestWhat structures are shown in the image? What abnormal finding is shown?

+Answers onpage 50

to sumbit a case study for publication in an upcoming issue of ePi, email [email protected]


bhutan 18

turkey 21

Vietnam 24

Colombia 26

hong kong 28

diSPatCheS 16

This past spring, Vietnam took a strong step towards greater EM development through a

historic international collaborationdetails on page 24

souRCEfirsTHanD rePorTs of

sPeCialTy DeveloPmenT arounD THe globe


sOURCE // DIsPATCHEsreaDer-submiTTeD uPDaTes aCross THe ConTinenTs

Nicaragua: Developments: Both residency pro-grams, Baptist Hospital of Nicaragua and the National University, continue, with ups and downs in recruitment.Challenges: To keep the powers that are in charge of allotting residents positions constantly aware of the need to prepare new EM residents. The graduates of EM have been recognized for their knowl-edge and abilities, and yet there doesn’t seem to be the awareness or sense of need to train new ones. Predictions: EM is here to stay in Nica-ragua, however, there needs to be more involvement of the graduates in public and prehospital affairs.-Nour E. Sirker, MD

PaNaMaDevelopments: Residency program established in 2002. Unique system of emergency care 9-1-1 started in 2009.Challenges: The adequate training of all who work in the emergency systemPredictions: There is much interest, so we expect a great technological and professional growth.-Elis E. Gonzalez Portugal, MD

argENTiNa:Developments: In Argentina, EM is not yet recognized as a specialty. The vast majority of doctors working in EDs are general practitioners, internists, cardiologists and intensivists. There are only about fourteen specific training programs in EM in the country, therefore trained specialists are scarce. Today, we who work in emergency services are responsible for encouraging the creation of more residencies in EM, with the intention that the majority of human capital which develops in the emergency area is increasingly better trained. -Alberto Machado, MD

Brazil: Developments: The 2nd EM residency program in Brazil is in its second year. The 2nd Brazilian EM Congress took place in 2009, and the Brazilian Association of Emergency Medicine

(ABRAMEDE - Associação Brasileira de Medicina de Emergência) has a new web site: www.abramede.com.br. Challenges: To become a recognized specialty. Our board of specialties is controlled by a few people who don’t know what EM is, or don’t want us to become a specialty for political reasons. Other people understand the impor-tance and support the idea but won’t fight for us. Predictions: We are in a crucial moment since we presented our intentions to become a specialty to the national board of medicine and we are about to be voted. The future is to become a specialty. When? Maybe now, maybe in the future. What matters is that we are growing in number, in knowledge and importance to our community.-Márcio da Silveira Rodrigues, MD

ghaNa:Developments: An EM residency training programme was started in 2009, with the first batch of 7 residents starting in Oct. 2010. The programme is run as partnership among Komfo Anokye Teaching Hospital (KATH), Kwame Nkrumah University of Science and Technology (KNUST), Ghana College of Physicians and Surgeons, Ministry of Health, the University Of Michigan Department of EM and the University of Utah Section of EM. Information at www.med.umich.edu/em/education/ghana/ghanacollabora-tive.htm

In 2009, a faculty of EM was formally established in the Ghana College of Physicians and Surgeons by the induc-tion of three new Foundation Fellows, all trained and currently working in UK. More info: www.ghcps.org OR email: [email protected]: Currently, EM faculty consists entirely of diasporan fellows. Efforts are being made for one of fellows to relocate to Ghana shortly. Also, the curriculum needs to evolve to suit Ghana. Currently, it’s based on IFEM model curriculum, with adapta-tion to American and UK curriculum. Also, Ghana needs to further refine the application and admission process for new residents applying for 2010 entry. Training of other emergency care health professionals (nurses, paramedics) is another challenge.Predictions: We’re optimistic that continued collabora-tion between foreign EM programmes

and Ghanaian colleagues will lead to development of an appropriate hybrid model of EM training for Ghana that can serve as model for other emerging EM training programmes in Africa. The next 3 to 5 years will see the graduation of first few batches of residents and this should provide much needed boost to the development of EM in Ghana and access to trained EPs in different parts of the country.

-Conrad Buckle, MD

SouTh africaDevelopments: EM recognised as a speciality in 2004, now we have over 60 specialists. This year added a 5th training site for registrars, in Kwazulu Natal. Critical Care officially recognised as a sub-speciality for EPs this year. Moved this year to a 4-year BTech for

paramedic training and 2-year diploma for Emergency Care Technician training – with a

new 2-tier EMS system replacing the old 3

trier (AKS ILS BLS). First PhDs in EM

registered in 2009.Challenges:

Resources, high trauma load,

high HIV TB load. Also, buy-in is a

challenge. EM is well established in 3 areas

only. Middle management capacity in health sector is

also an issue.Predictions: Health research

outputs, Peds EM as a sub-spe-ciality by 2011. Becoming the

training ground for “western”

What struggles does your country face in developing emergency medicine? What hurdles have been overcome? SourcE is your section for updating the world . . . and keeping up with the latest EM progress across the continents.

SPaiN:Developments: We are doing better in 3 fields: professionals, technology and Informatics/computers. Triage procedures have been implemented, and ED design (not “decoration” but architectural flow consid-erations) is also much more seriously considered.Challenges: That emergency medicine becomes a specialty like it is in U.S., UK, etc... Doctor scarcity makes it difficult to achieve quality.Predictions: In my opinion, we must shift towards a less “medicalised” model. Less MD and more techni-cians. I don’t think that paramedics will be considered in the system, so a mixed model with MD, RN and technicians seems the most convenient way.-Santi Ferrandiz

EcuadorDevelopments: The recent introduction of a compulsory insurance system for victims of traffic accidents is a major advance and has a favorable impact on the overall operation of emergency rooms in Ecuador. Challenges: Still pending is the task of putting into operation a plan for emergency response that achieves joint coordinated work of hospitals with prehospital care.Predictions: There is still much to do, but the outlook is favorable. The staffs are committed to improvement, and you can glimpse some increase in support from some institutions.-Byron Ruiz-Lapuerta MD


EM specialists to get into Africa to help develop EM there. Being the African leader in EM.-Lee Wallis, MD

iraNDevelopments: After the 4 EM residency programs were established, two other programs have become accredited by the National Board to start their

residency program. The 4th Iranian Emergency Medicine Congress took place in January, 2010.Challenges: Limited number of graduates and the current policy of the Ministry of Health to distribute them after graduation have led to some problems with the establishment of the new programs. There are few opportuni-ties for graduates to pursue toward a

subspecialty of fellowship.Predictions: With the number of graduates increasing and with more and more emergency rooms upgrad-ing to emergency departments with emergency medicine coverage round the clock, the benefit of this specialty for patients becomes more evident and unobjectionable.

PakiSTaNDevelopments: A department of EM has been established in an academic medical university. A new society for Pakistan EM has been formed with country-wide representation, as well as a wider understanding of the need for emergency medicine not seen before.Challenges: Lack of an exit examination for our residency graduates. The other challenge is making the practice of emergency medicine viable in terms of remuneration and practice opportuni-ties.Predictions: There is going to be a specialty certification examination in EM in near future. A practice model will be evolved which will make it feasible to practice emergency medicine in the country.-Junaid A. Razzak, MD, PhD

chiNa:Develop-

ments: In 2009, the

Ministry of Health published a national guide for the

construction and manage-

ment of hospital EDs. The 13th biannual

congress of the Chinese Association of Emergency

Medicince was held in April,

2010. Challenges: We are in short supply of well-trained EPs. We have too many patients visiting the EDs without emer-gency conditions.Predictions: EDs are hopefully less crowded with the modification of national policies for medical insurance. Postgraduate resident training programs will produce more well-trained EPs.-Haichen Sun, MD, PhD

auSTralia:Developments: Ultrasound is filtering in to EDs, as is video laryngoscopy. We already do most fracture reductions. Procedural sedation is rampant. More web-based resources. We’re looking forward to quality hand-held ultrasound devices. Successes: Doctors have a much more realistic workload here than in the United States. They are expected to see 2 to 3 pts per hour – interns 1 to 2. I can order any test/med/transfer and know that it is free to the patient. There is no ER bill generated, no ambulance bill. Everyone has a medicare card entitling them to ‘free care,’ which is a much lower stress model. My first malpractice bill for 2.5 years of coverage (a supplement to free

gov’t policy) was AU $145.00. Seriously. Challenges: It’s hard to recruit enough docs to treat this aging population. It’s also difficult to challenge each other and the specialty to grow and to evolve. Predications: Australia has a resource-based economy – a bit like Saudi Arabia in the 60s. We have enough iron ore to supply the entire world for 1000 years, as well as lots of gas, oil, gold, beaucoup uranium, coal and lots of land. Australia’s future is bright, and with it Australian EM. -Bruce Campbell, MD

Sri laNka:Developments: Attempts are being made to appoint junior doctors trained in EM to man emergency treat-ment units in the out-patient departments of hospitals and the intensive care units. Towards this end we have selected and conducted a training course working towards a diploma in critical care and emergency medicine. The first exam was completed last month. We are now working towards an MD in Critical care. The challenge would be to appoint consultant intensiv-ists to be in charge of these units. Challenges: Political pressures and political bungling as well as internal conflicts among the profession as to whether anesthetists or physicians should be in charge of these units has hampered the progress.-Kolitha Sellahewa, MD

SloVENia:Developments: Efficient prehospital network of physician-delivered emergency care has been built throughout the country over the past decade. Equally important is a recent start of EM as a primary medical specialty. Core-curriculum with a 5-year training schedule covering both prehospital and hospital competencies and skills started in 2008.Challenges: Successful integration of existing prehospital and in-hospital emergency care into uniform hospital-based Emergency Medical System.Predictions: With the recognition of EM as primary medical specialty and construc-tion of new EDs in many hospitals, Slovenia is hopefully entering a decade of completion of Emergency Medical System.-Matej Marinsek, MD

croaTia: Developments: Reform of EM in cooperation with the World Bank including reform of EMS, establishment of EDs in all hospitals, development of integrated dispatch and telemedicine and primary specialty in EM. Challenges: Switching the focus from autonomous out-of-hospital emergency medi-cine to emergency departments. Predictions: Integrated emergency medicine with involvement of EM specialists in all segments of emergency medicine: ED, out-of-hospital interventions (in ambulance cars, helicopters), education, research, education.-Fred Zeidler, MD

korEa:Developments: Korean EM is still developing after the Korean Society of Emer-gency Medicine (KSEM) was founded in 1989. (www.emergency.or.kr). There are over 100 emergency medical centers and EM residency programs in Korea. The spring Korean EM Conference was held in April in Daegu. The main topic was “Resuscitation – System of Care and Post-Resuscitation Care.” The Journal of the Korean Society of Emergency Medicine is bi-monthly published in Korean and English.Challenges: Subspecialty in EM is now a great challenge (Resuscitation, Toxicology, Traumatology, Critical care medicine, Disaster medicine, etc.) The difficulties in EM originate from ED overcrowding, long-staying time for hospi-talization and an insufficient number of nurses or doctors in the ED.Predictions: The continuing efforts for escalating financial support and intro-duction of new ED systems, short-term observation unit, trauma and critical care or sub-specialty care system is needed instead of conventional ED man-agement systems in the ED. We are now thinking about the introduction of simulation or CPX / OSCE on national board examination of EM in the future, which was already applied in Korean Doctor’s License Examination in 2009.-Sam-Beom Lee, MD


souRCE “It would seem from the outside that Bhutan’s kings have

successfully balanced modernization with preservation and enhancement of the country’s rich, unique culture.

In november, 2009, thanks to exten-sive logistical and financial arrange-ments by the Bhutan Foundation, Drs. kim Forman, Mike Owens

and myself, Jim holliman, traveled to the country of Bhutan to present two five-day emergency trauma care courses. Because of Bhutan’s relatively small population it does not have a medical school, so its doctors have had to go to other countries (mainly India, but also even Cuba) for medical and postgraduate training. The trauma course we presented was to be the first practi-cal course of its type offered to healthcare workers in the country.

When we were starting to make arrangements for this trip it became

apparent that many people have not heard of Bhutan. Most don’t even know where it is located. It is a landlocked country in the himalayas bordering China and India, with a population of about 700,000. The entire country is mountainous, with a number of peaks over 20,000 feet. What we found surprising was how thickly forested most of the country is, with dense forests even at altitudes exceeding 12,000 feet. even banana trees were growing above 10,000 feet. We were also surprised at the country’s climate: since it was november in the himalayas we were expecting bitter cold and lots of snow. however, most of the time the weather was like that of early fall in the northeast United States. Unlike

bhuTanTrauma care makes rapid advances in this isolated but modern Himalayan kingdom

BY DRS. JIm hollImAn, KIm FoRmAn & mIKe oWenS

the United States, in Bhutan, the trees had not lost their leaves yet or even started to change into fall colors.

Bhutan only started to open up to the outside world in the 1950s; prior to that the country had no roads, airports, or advanced healthcare facilities. Since the 1950s, the country, under the direction of its kings, has undertaken rapid but controlled develop-ment. Our trauma care education project is part of the Bhutan Foundation-sponsored plans to help develop improved healthcare for the country. hence the transition from sending healthcare workers away for train-ing to bringing a practical trauma course to the country itself.

Bhutan has a unique Buddhist-based culture certainly distinct from tibet. eng-lish is the main second language and is widely spoken, particularly by most of the medical professionals. Our courses were conducted entirely in english with obvi-ous complete comprehension by the course participants. It would seem from the out-side that Bhutan’s kings have successfully balanced modernization with preserva-tion and enhancement of the country’s rich, unique culture. One cultural aspect that took some getting used to was the ex-tensive use of very hot chili peppers in the diet. We made the mistake several times (to the amused attention of our Bhutanese col-leagues) of gulping down what we thought were string bean-like vegetables only to quickly discover that they were actually very hot chili peppers. All over the country you can see large amounts of chilies drying on roofs. Thankfully, to help wash the chil-ies down, Bhutan makes several excellent national beers.

Our first trauma course had 30 Bhuta-nese physician and nurse participants and

CHINA

INDIA

MongarThimphu

coMMon EMErgEncIEsAltitude illness, particularly in

tourists

Rabies, due to a

prevelance of stray dogs

Snake bites from one of

Bhutan’s poi-sonous snakes

Carbon monox-ide poisoning from indoor cooking fires

DzongkhaThe main national

language. English is widely spoken, however,

and most of Bhutan’s signage

is in English.


was conducted at the Royal Institute of health Sciences in Thimphu – a city fa-mous for being one of the world’s few na-tional capitals without a single traffic light. We also toured the small but new emer-gency department in the country’s main referral hospital.

In order to give the trauma course a second time, we then traveled to the city of Mongar. The 280-mile journey took two full days because the entire distance was nothing but tight switchbacks along mountain cliffs. While we were concerned about the lack of guardrails along much of the cliff edges, we had a very skilled driver who worked for the health Ministry, and we were amazed at his ability to pass on-coming vehicles despite the apparent sin-gle-car width of the road. We joked about the Bhutanese ability to defy the laws of physics in driving these tight roads, but the winding switchbacks certainly highlight a key obstacle to Bhutanese trauma care. transporting patients, particularly patients with spine injuries, from outlying areas to the main referral hospital in Thimphu, is extremely difficult.

Once we arrived in Mongar (after an overnight stay in the town of Bumthang) the nerve-wracking trip proved worth-

while. The mountain vistas were spectacu-lar and the town was starting its annual folk festival. Many people had traveled from all over the western part of the country to participate in the festival, which involved days of folk dancing, ornate costumes and singing. Our second trauma course again had 30 Bhutanese nurse and physician par-ticipants and was conducted at the newly built regional hospital. For a classroom we used the space allocated for the surgical ICU as it had not been activated yet due to lack of medical staff. We found our course participants to be energetic, enthusiastic, obviously interested, and, unlike in many countries, able to start on time and follow tight time schedules. The small group prac-tical skills sessions we conducted seemed to be the most popular and useful for the participants, and these sessions included basic and advanced airway management, radiograph interpretation, case manage-ment simulation, and ultrasound. One skill we introduced that was entirely new for Bhutan was intraosseous needle inser-tion. Due to customs and security issues we were unfortunately unable to bring the in-traosseous drill gun with us to demonstrate its use directly. however, even without the drill, the usefulness and practicality of the

intraosseous technique was immediately apparent to the course participants, partic-ularly those who work in outlying smaller healthcare facilities.

The Bhutanese have made great recent strides in their healthcare system develop-ment, but a number of major challenges remain. The extremely difficult geography causes long time delays in getting patients from outlying areas to the regional or cen-tral referral hospitals. There is a lack of healthcare personnel in some facilities, as well as shortages in equipment and sup-plies. There is a lack of advanced training for most of the ambulance personnel and there is the obstacle of transferring patients needing certain tertiary healthcare pro-cedures (such as cardiac valve surgery) to other countries. Many healthcare person-nel still have to travel out of the country for higher level medical training.

These obstacles notwithstanding, Bhu-tan has great strengths in its healthcare sys-tem. healthcare personnel are intelligent, energetic and enthusiastic. The government strongly supports healthcare for all its citi-zens, including complete immunizations, and has the support of organizations such as the Bhutan Foundation. With its cur-rently limited resources, the Bhutan health

1962First road built into Bhutan

by the In-dian Border

Roads Organization

1983Airport in

Paro opens

During our trip we observed folk dancers at a festival in Mongar, reminders of Bhutan’s unique Buddhist-based culture.


Ministry had decided to focus much of its healthcare de-livery system on preventive services and has organized very effective coverage of the population for immunizations and prenatal care. This cost-effective approach could act as a model for other national healthcare systems.

We would like to encourage readers of this article to con-sider being tourists in Bhutan – the scenery is spectacular and the people friendly and welcoming of visitors – or to consider becoming involved with healthcare system devel-opment in the country.

For tourist information, go to www.tourism.gov.bt

Tourists are charged a daily minimum fee.

u$165 per day for the offseason (January, June and July)

u$200 per day for all other months

u$40 per day surcharge for indi-viduals traveling by themselves

The fee must be prepaid through an approved Bhutanese travel agency, which also arranges the traveler’s visa.

This fee covers all travel, meals, and accommodations while in country.

A regional hospital in Mongar recently moved into a brand new building (right), which contains

an ED. Pictured above is the new resuscitation room in the ED of the

referral hospital in Thimphu.

Drs. Jim Holliman and Kim Forman are faculty in the Department of Military and Emergency Medicine at the Uniformed Services University of the Health Sciences in Bethesda, Maryland. Dr. Owens is faculty for the Emergency Medicine residency program at the Naval Medical Center in Portsmouth, Virginia. Dr. Owens is also developing the first International Emergency Medicine Fellowship Program in the U.S. military, to be based at his medical center in Portsmouth.

The king’s pal-ace in Thimpu

(above), has been the seat of

the Bhutanese government

since 1952

One cultural aspect that took some getting used to was the extensive use of very hot chili peppers in the diet (above). We made the mistake several times (to the amused attention of our Bhutanese colleagues) of gulping down what we thought were string bean-like vegetables only to quickly discover that they were ac-tually very hot chili peppers. Thankfully, to help wash the chilies down, Bhutan makes several excellent national beers.


The turkish Department of health runs the majority of the country's aproximately 1,200 major hospitals. University

hospitals and affiliated medical schools are a very important component of the healthcare system, and have access to the most modern triage and diagnostic systems. Private, for-profit specialty clinics do exist, but account for the smallest percentage of the country's healthcare providers.

A once chaotic structure, turkey's emergency medicine (eM) system has enjoyed a rise to prominence unprecedented for any medical specialty in the country's modern history. Over the last 10 years, emergency

medicine became one of the major health components of turkey's system.

eMergence oF MoDern eM in turkey

In the early 1990s, government and university leaders in turkey recognized that the nation of 72 million needed an improved emergency medical care system. They chose to adopt the mature and tested model of emergency medicine, which the Ministry of health declared an independent specialty in 1993. now, less than 20 years later, prehospital care remains well controlled by the government. turkey's dispatcher-based eMS system is known as the “112,” comprising 82

TurkEyThe dynamic, bi-continental country moves to unify its diverse, highly-stressed EM system

BY ARIF AlPeR CevIK, mD

souRCE

1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012

medical dispatch centers across the country. Most ambulances are covered by general practitioners. More recently, however, it is more common for paramedics to staff ambulances with or without doctors. The government has also shown great interest in air medical transport over the past two years, which were done previously by private organizations.

In 2009, the government declared a new regulation for emergency departments. The main idea of these regulations includes the categorization of departments by emergency medical care capabilities, architectural capabilities, facility resources, staff, equipment and supplies, etc. The regulations also gave notes for transfers and admissions to emergency department, hospital admissions, shifts and staff work recommendation in the eDs etc. With this regulation, the eM specialty has acquired a more powerful position than we held over the past 15 years. The annual census of patients already has a high effect on the system, considering over 500 cases daily in state hospital emergency departments (eDs) and over 200 cases in university hospital eDs. There are, however, problems applying these regulations in some cities and regions because of reluctant or defiant hospital medical directors. Obviously, a greater precedence for eM is challenging some long-held notions and authorities of the medical system.

lEmergency medicine is declared a separate specialty

lPrehospital care system nationalized widely in 81 cities

lOpening of the first EM residency program

lOrigina-tion of The Emergency Medicine Association of Turkey (EMAT)

lOrigination of the Emergency Medicine Physicians Association of Turkey (EPAT)

lThe first international EM Congress was held in Istanbul

lDuration of EM residency programs changed from 3 years to 5 years

lBoard of Emergency Medicine was built

lAir medical transport system was added more widely into the “112” system

lThe first Eurasian Congress on Emergency Medicine was held in Antalya

lEmergency Departments Regulation published by Ministry of Health

lOver 70 EM residency programs in Turkey

lThe 2nd Eurasian Congress will be held in Antalya

lEuSEM Congress to be held in Turkey with collaboration of EuSEM, EMAT and EPAT

lThe first EM specialists graduated from the EM residencies

A Brief Timeline of Emergency Medicine in Turkey

Worlds CollideThe Bosphorus Bridge in Istan-bul, connects Europe (to the left) to Asia (right).

“Before 1995, most medical students received no EM

lectures during their entire medical school experience.


eD statisticsThere are currently over 1,200 eDs in

turkey, but only about 400 emergency medicine specialists and about another 400 eM residents. Clearly, the limited number of emergency medicine specialists cannot fill these positions. Therefore, general practitioners provide most of the emergency medical care given in hospital eDs. emergency departments in big cities or select regional hospitals have an eM specialist to work with, but the majority of eDs are waiting for new eM specialists.

eD patient volumes in turkey depend on the category of hospital. State hospital eDs see 200-600 patients a day; state education and research hospitals see 500-1500 patients a day. These are bizarre numbers to most of us, but this is the reality. University hospital eDs see 100-300 patients a day. Admission rates vary between hospitals, but university hospitals and state education hospitals have higher admission rates. eM training anD resiDency PrograMs

Medical education in turkey is an adopted european system, as advised by French and german physicians who had been working in turkey during the last days of the Ottoman empire before its collapse during WWI. The european system remains today, with six years of medical school, starting immediately after high school. The final year is spent doing clinical

rotations of two months each in internal medicine, pediatrics, general surgery and/or emergency department, obstetrics and gynecology, and one month each in psychiatry and community health. Before 1995, most medical students received no eM lectures during their entire medical school experience. today, however, there are 50 academic emergency medicine departments in university medical centers. As a result, we can definitely say that the delivery of eM education to medical students is more efficient than in the early 90s.

Sixteen years after their formation, and 12 years since their first graduates emerged, there are now over 70 eM residency programs across turkey, 20 of which are in state education and research hospitals. The length of the residency is five years, which was recently increased from three years. The country has about 400 specialists and around 400 residents.

The first eM residency program (36 months in length) opened in 1994. In 1995, the emergency Medicine Association of turkey (eMAt) was established. The emergency Physicians Association of turkey (ePAt) was established in 1998 for the first residency's first graduates. The connection between departments is improving with annual meetings organized by eMAt and ePAt. In addition, eMAt is developing international collaboration in the Middle east and eurasian region.

The first collaborative congress was held in 2001 as the Middle eastern Conference on emergency Medicine. The 2nd eurasian Congress on emergency Medicine (eACeM) will take place this year on October 28-31, 2010 (www.eacem.org). The first eACeM was a success in 2008, with 565 participants from 15 different countries. The organizers are anticipating more than 600 participants for the 2nd eACeM, representing more than 20 countries.

the sPecialty that BriDges continents

The eACeM is the biennial international congress of the eMAt in collaboration with SUnY Downstate and the Singapore Society of emergency Medicine with endorsement by the International Federation for emergency Medicine and The Ministry of health of turkey. The scientific program will cover multiple aspects of emergency medicine. The congress will feature state-of-the-art lectures, workshops, panel discussions, as well as scientific oral, poster and video presentations. Most importantly, it will foster exchange with international leaders of emergency medicine. The congress will also include a trade exhibition on the latest technologies, pharmaceuticals and systems relevant to the specialty. As evidenced by the success of the first eACeM congress, we believe that eACeM 2010 will again create an atmosphere of superb networking opportunities for eM professionals and leaders of various continents and countries, as well as exposure to the newest eM technology in the region. eACeM will be at an exclusive golf resort in Antalya, one of the major tourist cities of turkey. The city is well connected to major airports and other

Istanbul

BLACK SEA

MEDITERRANEAN SEA

SYRIA

Ankara

The ED crew at the Emergency Medicine Residency Program in Eskisehir, Turkey. The program hosts 5 to 6 international rotators from abroad.

populaTIon DEnsITy

South Africa 40 people/km2

Turkey 93 people/km2

Hong Kong 6347 people/km2


places of interest. The climate is wonderful during that time of the year and there will be ample opportunity to explore the rich history and culture of its surroundings. Because of the bridging geographical location of turkey between europe and Asia, one of the missions of this meeting is to help foster connection and collaboration between european and Asian countries on the bridge of continents, “Anatolia.” eMAt looks forward to welcoming you to Antalya. conclusion

As indicated by recent developments, the success of the Ministry of health's strategy will depend on primary care systems and emergency medical care systems over the next 10 years. With this perspective, the family medicine system was changed to improve this category of medical care, and the new eM residency programs were opened in state education hospitals to graduate a more adequate number of eM specialists. today, there is a consensus that the system of eM is the correct way to follow to improve emergency medical care in turkey, although some specialty organizations have some questions about the process. The main issue facing the country's eM education system now is the government's strategy to open new programs in state education hospitals and in new universities without first preparing the facility for academic and structural meaning.

coMMon EMErgEncIEs

Poisonings: Mushroom,

carbon monox-ide & organo-

phosphate poisonings are

an issue

Crimean-Congo Hemorrhagic

Fever: A problem

during spring & summer months in recent years in small areas in the central

Anatolia region

9 out of 10 hospitals depend on

the Morgan Lens

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efficient and most effective solution for emergency eye

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The Medi-Duct® Fluid Management System makes the Morgan Lens even easier to use.

To learn more about EM development in Turkey, contact Arif Alper Cevik: [email protected]

An ambulance in the city of Izmir, Turkey, outside the Dokuz Eylul University Hospital, where Turkey’s first emergency medicine residency was started.


souRCE

T his past March, a historic event occurred in hue, vietnam. More than 60 physicians and nurses from the United States,

Australia, The netherlands, Canada and Thailand volunteered hundreds of hours and travel costs to deliver a series of sym-posia, workshops and conferences on dif-ferent aspects of emergency medicine to vietnamese audiences of physicians, nurs-es, medical school deans and government officials. This event was coordinated with the Ministry of health of vietnam and occurred concurrently with the approval process for hue College of Medicine and Pharmacy (hCMP) opening the first emergency medicine residency program in vietnam (titled Level 1 training over two years), anticipated to begin in September 2010.

These meetings and the move to devel-op this residency were the result of several

years and hundreds of hours of work by a number of U.S.-based physicians operat-ing independently and representing several universities and organizations. The inspira-tion and driving energy behind this proj-ect has come largely from two community physicians, Carter hill, MD, an emergency physician in Seattle and vien Doan, DO, a family physician in the Los Angeles area. Both of these physicians have been dedi-cated to developing medical capacity in vietnam for a number of years: Dr. hill through organizing emergency medicine training seminars in different cities and Dr. Doan through delivering medical care to rural communities in central vietnam via the good Samaritan Medical & Dental Ministry (gSMDM). Their paths crossed several years ago, bringing together the human and financial commitments that formed the seed for hue University Col-lege of Medicine and Pharmacy to apply

vIETnaMEmergency medicine takes strides forward through

historic symposia and international collaboration BY KRIS ARnolD, mD, mPh

& BoB SUTeR, Do

for the first emergency medicine residency and for the 2010 hue emergency Medi-cine Symposium and Conferences.

The gSMDM provided full financial support for the five-day symposium, the one-day Leadership and eMS/Disaster Response conferences and the two-day nursing conference, including stipend/travel support for vietnamese physicians attending. excellent simultaneous transla-tion was provided by several hanoi-based physicians practicing emergency medicine at Bach Mai hospital.

The five-day clinical emergency medi-cine symposium was opened with remarks from Peter Cameron, president of the International Federation for emergency Medicine (IFeM), howard Blumstein, president of the American Academy of emergency Medicine (AAeM), Bob Suter, past president of the American College of emergency Physicians (ACeP) and of IFeM, the Deputy Chief of Mission from the U.S. embassy in vietnam and the viet-namese Deputy Minister of education and training to more than 200 vietnamese physicians from throughout the country. Lectures and skills workshops were attend-ed with enthusiasm. The physician attend-ees came from varied clinical settings from tertiary care facilities to commune out-patient village health centers. Dr. Joe Lex from temple University, the Symposium Chair, attracted a diverse faculty from the United States along with extensive material support from equipment manufacturers and digital/educational resource providers. The emergency department faculty from

sEpT 2010The Hue College of Medicine and Pharmacy is set to open the first EM residency

program in Vietnam

Special Delivery

Dr. Tam Chung uses a “cyclo”

to deliver a donated crash

cart to the Hue College of Medicine

and Pharmacy Emergency Department

LAOS

Hanoi

CAMBODIA

CHINA

The inspiration and driving energy behind this project has come largely from two community physicians, Carter Hill, an EP in Seattle and Vien Doan, DO, a

Family Physician in the Los Angeles area

“The central region of Vietnam experiences natural disasters,

such as typhoons, on an annual basis, with resultant flooding, mudslides and man made, multi-casualty road and rail crashes.


Bach Mai hospital in hanoi provided out-standing simultaneous/interactive transla-tion while providing local perspective to the organizing committee and conference attendees.

A parallel nursing symposium with hands-on training workshops, organized by Michele Suter, Rn, was delivered by American emergency medicine nurses to nurses from the hue College of Medicine and Pharmacy and hue Central hospi-tal emergency Departments. The faculty nurses were highly impressed by the clini-cal knowledge and enthusiasm of their vietnamese colleagues.

having recognized the national value of developing the resource of trained physicians to deliver emergency care, the Ministry of health co-sponsored a one-day conference for deans of other medical schools in vietnam and directors of pro-vincial departments of health. In coop-eration with the dean of the hCMP, Drs. tamara Thomas and kris Arnold brought together a group of physician leaders from around the world to review issues in devel-oping and managing emergency medicine residency programs. This conference was highlighted by the signing of a consensus statement by representatives of the national government affirming and recognizing the values of emergency medicine and cement-

ing their commitment to developing eM and training of ePs.

training physicians in emergency medi-cine is but one part of improving emer-gency medical care capacity. In recognizing and underscoring the role of emergency medical services (eMS) in response to disasters and other time-sensitive health conditions, the Thua Thien hue provincial Department of health sponsored a con-current one-day conference attended by 19 agencies involved in disaster response in the province. U.S. faculty organized by Dr. graham nichol from the Univer-sity of Washington’s Center for Prehospital emergency Care, delivered information on disaster management principles, eMS or-ganization and communication. The cen-tral region of vietnam experiences natural disasters, such as typhoons, on an annual basis with resultant flooding and mudslides along with man made multi-casualty road and rail crashes. The underlying theme for the conference was improved coordination of services among the different agencies. Following small group discussion among the agency representatives on the topics presented, there was general agreement that these agencies should continue to work to-gether to improve eMS in the region.

The events of this historic week have also been preceded by the hard work of several

academic and community eP colleagues, Drs. Sam Cloud, Craig Cooley, heather Crane, Richard guth and James Ramseier. Under the leadership of Prof. Cao ngoc Thanh, Dean of hCMP, Dr. nguyen Lo, Director of the hCMP emergency De-partment, a proposal had been submitted to the central Ministry of health and the Ministry of education to develop a clini-cal training program in emergency medi-cine using the U.S. “Model of the Clinical Practice of eM” as the foundation for their proposed curriculum.

The vietnamese medical system is cur-rently based on a government-funded in-surance scheme, a separate health insurance for the poor, and a fee-for-service system. Physicians with a basic 6-year post-high school medical education and no residency training provide the majority of health care. U.S. family physicians have been active in developing family medicine training in vietnam over the past 10 years with several active residencies and approximately 350 physicians having received this training.

vietnam is experiencing rapidly in-creasing economic activity. Along with this transition have come issues such as in-creased urbanization, increased motorized vehicular traffic encumbering roads with inadequate design for the multiple users from pedestrians to space-hogging tractor-

A symposium attendee practices ultrasound technique (top right). In the Advanced Airway Skills Lab (right), attendees inaugurated Hue

Central Hospital’s new clinical training center, using mannequins supplied by the Japanese International Cooperation Agency.

3


trailers and tourist buses playing chicken. Although a national helmet law went into force in 1997 with a marked reduction in head injuries, motorbike crashes still con-tribute a significant amount of trauma to the overall health burden. Coupling these development factors with the decreased childhood mortality, greater longevity out-pacing global advances, increased personal purchasing power and a high percentage of tobacco smoking is leading to a rapid in-crease in chronic diseases of developed so-cieties such as COPD, CAD and diabetes.

As was brought to attention in the Disaster Management/eMS conference, further development of infrastructure for mitigation of the effects of natural disasters such as dams and other hydrologic control projects are advancing slowly. It was also recognized by vietnamese participants at all levels that improved out-of-hospital emergency medical care is urgently needed to alleviate the burden of diseases. Addi-tionally, the point was made that, despite needs for more and more capable mate-rial support such as equipped ambulances, the foundation for improving out-of and in-hospital emergency medical care and disaster response will be in training and developing increased coordination among stakeholders, including the general public.

This week of teaching, learning and bonding between a multinational visiting faculty and local practitioners is a mile-stone in the development of emergency medicine as a distinct medical specialty in vietnam. Much hard work remains to be done, but the eagerness and dedication of the vietnamese physicians to serve their people with improved healthcare despite the poor base salaries of physicians will, undoubtedly, make a significant improve-ment. Through the consensus statement signed at the Leadership Conference, of-ficially proclaiming government support as well as recognition of a desire to work with visiting faculty, an invitation for participa-tion in the future development of eM in vietnam has been sent forth. In support of future participation of visiting faculty and residents, the gSMDM has leased a house – a multi-story, air-conditioned, fully-equipped and renovated home – just 10 minutes from the hCMP and the hCh.

tFor more info on assist-ing with this project through donations or volunteering as faculty, contact Carter Hill, MD, at [email protected]

souRCE

Colombia is a difficult coun-try to categorize. It has the highest rates of traumatic injury-related deaths, includ-

ing injuries from landmines, in all of Latin America. At the same time, it ranked third – after Denmark and Iceland – when na-tion news scored the “World’s happiest Countries.” Colombia is the second most biodiverse country in the world and is the second largest coffee and flower exporter in Latin America. Most importantly for this article, however, Colombia was the fourth Latin American country to create an emer-gency Medicine (eM) academic program.

A Brief HistoryPrehospital care and Disaster Medicine,

the precursors to academic emergency medicine, really began in the mid-70s in Colombia with the rapid growth of Co-lombian cities. This growth increased all indexes of traffic accidents and violence, social changes that demanded the develop-ment of a well-designed medical specialty

to take care of these specific issues. During the 80s, Colombia faced chal-

lenges very similar to the ones faced by the United States in the late 60s. Families felt they needed two full-time wage earn-ers in order to increase their income and economic status. A large population was displaced from rural settings to urban areas because of unsafe living conditions. There were guerrilla attacks in small towns and there was a shrinking market for agricul-tural products. Jobs were also easier to find in Colombia’s biggest cities. Uniquely for Colombia, the 80s also saw an increased rate in violence throughout the country because of the blooming of the narcotraf-ficking business.

The national health System, instituted in Colombia in 1993, separated the popu-lation into two groups. The “contributive group” comprised workers that could pay for their health insurance coverage (similar to the U.S. model) while the “subsidized group” contained the population unable to pay for coverage because of severe poverty.

coloMbIaNew specialty societies and academic programs

enrich the training of dedicated emergency physicians in Colombia

BY GlADYS h. loPez, mD, mPh & lUIS eDo vARGAS, mD

**Academic Focus

Funducion de Bogota is one

of the coun-try’s premier

emergency care training facilities

3

The combination of trauma and subsidized insurance for 80% of the nation’s poorest patients led to a flooding of

the country’s emergency departments.

The combination of trauma and subsidized insurance for 80% of the nation’s poorest patients led to a flood of patients in the country’s emergency departments.


This health reform (Ley 100) was far from being a perfect model, having been based on several national health care reforms in higher income countries. But it has helped to support health coverage for up to 80% of the poorest citizens (subsidized group) up to the present day. emergency depart-ments got flooded with patients that finally obtained “some” health coverage and this phenomenon persists even today.

The Birth of a Specialtyemergency medicine as a specialty in

Colombia was initiated by CeS University in Medellin in 1996. This three-year pro-gram used the American model as a basic blue-print but it also included the specific feature to train emergency medicine lead-ers in the eD administrative realm. These new leaders were given tools beyond the theoretical, clinical and practical skills of the eM physician.

In 2003, a graduate from CeS Univer-sity’s program supported the creation of the second program by the Universidad del Rosario in Bogota. Universidad del Rosa-rio, in consortium with Fundacion Santa Fe de Bogota, supported and currently hosts this second program in emergency medicine with special rotations in inten-sive care units (including burn units) and prehospital care.

The third eM program, launched in 2004 and supported by Antioquia Univer-sity, marked the very first public university in the country opening a residency training in emergency medicine. Antioquia Univer-sity was the first institution to “grandfa-ther” physicians from other specialties into emergency medicine as part of their own faculty. One year later, the CeS University opened a new eM program in Cali, the third most important city in the country. The program, designed in conjuction with Fundacion valle del Lili, had a special in-terest in trauma care and research. In 2009, two more three-year eM programs opened in Bogota, one at Fundacion Universitaria de Ciencias de la Salud and the other at Universidad Javeriana.

Overcrowding, multispecialty care and lack of training in the eM specialty are currently the most concerning issues that the country is trying to resolve in its eD setting.

The SocietiesThree Colombian eM associations were

founded within the last six years and have hosted more than ten international eM conferences. One association has even been working with the Ministry of health to create emergency Care and eMS guide-lines for the entire country. Colombia has been an active member of the Interna-tional Federation of emergency Medicine (IFeM) since 2006, only the second Latin American country to have this distinction. IFeM membership kicked off the expan-sion of the Colombian eM group in the international arena.

A select group of Colombian eM spe-cialists has had the opportunity to expand their learning and experience at new York University ∕ new York Poison Control Cen-ter, Pittsburgh University and at george Washington University in Washington, D.C., over the last 6 years. however, there are not currently enough U.S. clinical rota-tion sites to satisfy the thirst of knowledge

Acceptance of Academic EM in Latin

AmericaMEXICO

1986

COSTA RICA 1990

PERU 1993

COLOMBIA 1996

and further need for experienced interna-tional mentors which has characterized this initial cluster of fine and newly trained Colombian eM specialists.

As you could see, there is still a lot to do. But a great foundation has been laid, and new, intelligent emergency physicians are taking up the call in Colombia every year to be dedicated emergency physicians.

Gladys H. Lopez, MD, MPHInternational ACEP Ambassador, Past International EM Fellow at George Washington University. EM attending at Holy Cross Hospital, Maryland.

Luis Eduardo Vargas, MDEM Residency Program Director, Univer-sidad del Rosario-Fundacion Santafe de Bogota. Co-founder of the Asociacion Colombiana de Especialistas de Emer-gencia y Urgencias (ACEM)


souRCE

Emergency medicine is a spe-cialty of breadth and selected depths. More than 30 years ago in hong kong, the emergency

department – formerly the casualty depart-ment – provided simple wound manage-ment and treated minor ailments. Most pa-tients with moderate to severe conditions were transferred to the in-patient ward for care.

traditionally, the casualty department or emergency room was known as the gate-keeper or watchman of the hospital. The 1980s saw the appointment of eD consultants and the formation of the hong kong Society for emergency Medicine and Surgery – a title indicative of the specialty’s mixed parenthood. In 1996, the creden-tialing body of the hong kong College of emergency Medicine (hkCeM) was established). The breadth and depth of emergency medicine expertise have rapidly evolved to meet not only the expectation of the professionals but the needs of the community.

The hkCeM has promptly developed the three levels of Fellowship examination to attain maturity and international recog-nition.

There is one element to emergency care in hong kong that is quite different from overseas counterparts. Whereas many emergency departments have a conven-tional observational approach – a more passive methodology – hong kong has created something called emergency Med-icine Ward (eMW) Services. eMW ser-vices “treat and actively review” rather than

hong kongThis densely-populated city maintains an

excellent EM delivery structure as it forays into EM subspecialization

BY C.W. KAm, mD

waiting to see if patients are deteriorating. According to Dr. Lau Chor-Chiu, the

clinical service co-ordinator of the hos-pital Authority’s hong kong east cluster, eMWs relieve pressure on inpatient wards. Patients who need treatment for only a few days may stay in the eMWs instead of the general or specialised wards. emergency physicians diagnose and treat these pa-tients, with the help of specialists.

“We will gradually increase the man-power to meet the heavier workload,” said Dr. Lau. “I think the supply of doctors is Ok, but it is quite difficult to hire nurses as there is an overall shortage in the city.”

emergency medicine in hong kong, as in many overseas cities, has taken a major leadership role in collaborating with other related specialties. The specialty has estab-lished the Clinical toxicology Services

populaTIon7 Million

ED annual aTTEnDancE/

cEnsus2.1 Million

languagECantonese (a Chi-nese dialect) with patients. Written

records in English.

# oF EpsAround 250 fellows

& 200 trainees

CHINA

SOUTH CHINA SEA

New Territories

Hong Kong Island

0 10 mi

Dr. Chak-Wah Kam (middle) in 1995, soon after the establishment of Hong Kong’s EM society, journal, and certification exam process.

Levels Aim to Test Format

PEEM(Primary Exam in EM)

Applied Clinical Science Automated (Computerized) MCQ & OSCE

IEEM(Intermediate Exam in EM) – Conjoint with RCSEd till 2008 & with CEM of UK since 2009

Clinical Knowledge & Skills -Written Short Answer Questions-Clinical OSCE

PEEM(Exit Exam in EM)

Clinical Maturity & Resourcefulness

-Written OSCE-Oral Exam

l


and Poison Info Centre, for instance. A major proportion of toxicology cases are now treated in the eD or on the eMW. Many post-ICU treatment toxicology patients are now transferred to the eMW for subsequent management and follow-up instead of the conventional in-patient wards. herbal poisoning is a special issue in hong kong owing to the proximity to the mainland of China.

USg has become the regular visual stethoscope of the eP for about 10 yrs. The POCt has transformed the clinical management and disposition of patients from gynae, traumatology, acute abdo-men, calculous diseases, chest pain of car-diopulmony conditions, shock to cardiac arrest.

There two arenas will probably be in-

corporated into the Subspecialty Fellow-ship exam of the College in the coming five years.

Prehospital emergency care including aeromedics and sports medicine (mass gathering medicine) are gaining popular-ity.

Clinical simulation training is currently an international and local trend to prepare the novice, to train the registrars and to re-consolidate the expertise of the specialists with the aviation crew resource manage-ment fashion.

In line with the common international mission of eM to upkeep the community emergency illness treatment and health maintenance by continuously upgrad-ing and sustaining the service standards through the provision of well-trained, high-

With a population density several times that of most other cities, Hong Kong emergency physicians cannot afford to ‘wait and watch’ their patients. Instead, they have had to develop special skills to ‘treat and actively review’ emergency patients.

Developing EM Subspecialties in Hong Kong

1. Resuscitology 7. Sports Medicine

2. Traumatology 8. Disaster, Catastrophe, HazMAT & Conflict Medicine

3. EM Cardiology 9. EM Short-stay Therapy

4. Toxicology 10. Interhospital Transport Medicine

5. EM USG 11. EBEM (Evidence-Based Emergency Medicine)

6. PHEC & Aeromedics

quality emergency physicians in collaboration with other stake-holders by utilizing the modern, robust, competence-aligned and outcome-based education, training and examination, hong kong is going to be formulate the new milestones of the evolving fron-tiers to create landmarks for this new millennium!

Dr. C.W. Kam is the Director, Clinical Skills Training Centre, Tuen Mun Hospital, Hong Kong.Chairman, Examination Committee, Hong Kong Col-lege of Emergency MedicineEditor, Hong Kong Journal of Emergency Medicine

Q. What is unique about emergency medicine

development in 2010?

One interesting thing about emergency medicine

developing in Hong Kong is how western medicine

has met the eastern traditional herbal medicine.

Take toxicology, for instance. Chinese herbal poi-

soning can be grouped into the following 5 major

groups:

a) Aconitine Group - cardiotoxicity (ventricular arrhythmia &

hypotension)

b) Podophyllin Group - neurotoxicology (convulsion & coma)

c) Anticholinergic Group - tachy-arrhythmia & change in

sensorium

d) Digoxin-liked agents

e) Others


EMERGENCY MEDICINE: Reviews and Perspectives Experience the monthly series enjoyed by more than 8,000 of your colleagues.

the topic-based, upbeat, provocative audio program, specifi cally designed for emergency medicine professionals

WHO ARE THE HOSTS OF EM:RAP?Each month EM:RAP is hosted by two internationally recognized Emergency Physicians, Mel Herbert

and Stuart Swadron. Both are award-winning educators and innovators and full-time faculty at the Los Angeles-County/USC Medicine Residency. Both have been recipients of awards from ACEP and AAEM,

as well as from the University of Southern California and the University of California, Los Angeles. They have participated as faculty at CME conferences on the national and international level, and are generally

recognized as two of the brightest lights in Emergency Medicine today. Their style is fresh, up-beat and often politically incorrect, but always targeted at delivering the best, most focused and thoughtful information

possible!

EMRAP.TVEach month subscribers to EM:RAP will be able to access EMRAP.TV online, with videos linked to the audio portion of the program. X-rays, ECGs, ultrasounds and other components that require visual demonstration are covered in this segment of the program to enhance the material presented on the audio CDs.In addition EMRAP.TV presents bonus videos that include round table discussions of clinical EM topics by some of the most respected EM faculty in this country, focusing on relevant x-rays, ultrasound images, ECGs and other visual components, as well as presentation of bedside clinical cases, pictures and videos from the cadaver lab, new product reviews, procedures and much more.

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WHAT IS EM:RAP?EM:RAP is a truly unique monthly audio program designed to give listeners an in-depth review of specifi c EM-related topics in a format especially designed for easy listening. Each month, EM:RAP provides its listeners with two tightly edited CDs (or equivalent MP3s or iPod fi les) providing information from leading-edge conferences, grand rounds presentations, phone and SKYPE interviews, and in studio presentations with authorities and news makers in Emergency Medicine and beyond.

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brIDgIng ThE gap// why emergency medicine in The netherlands could serve as a template for comprehensive em development around the world

by Terrence Mulligan, DO, MPH

Erasmusbrug (Erasmus Bridge) in Rotterdam, a towering symbol of Dutch modernization


Emergency Medicine (eM) is a burgeoning medical specialty that is rapidly developing worldwide. Focused on the recognition, stabilization and treatment of life- and limb-threatening conditions, eM is established

as a fully “mature” specialty in only a handful of nations, with 45+ countries in the early stages of development, including the netherlands. [Arnold, Smith, 2005; IFeM website] nevertheless, in the netherlands, emergency medicine (called spoedeisende hulp in Dutch—“quick, urgent help”) has developed at an in-tentionally quick pace, and has achieved many of the landmarks of eM development in just over 10 years. This article examines the development of eM in the netherlands and elsewhere, and attempts to explain how regional-specific elements of emergency medicine development in the netherlands embody a reasoned, deliberate approach to national development that can be used as a template for eM development strategies in the rest of europe and the world.

the need for global eM developmentepidemiologic and demographic public health data reveal

an already overwhelming need for emergency Medicine (eM), trauma and acute care development. According to 2006 WhO studies on the global Burden of Disease [WhO 2006], the worldwide forces of demographic and epidemiologic shift have elevated non-communicable diseases to the single largest cause of morbidity and mortality worldwide. The non-communicable diseases of trauma, cardiovascular disease, stroke and cancer have surpassed traditional communicable diseases as the major global causes of death for the first time in history. The so-called “diseases of Western Society” have become global, are increasing at a much faster pace than earlier anticipated, and in precisely those areas with the least-developed health care systems [WhO 2006].

Through first-hand and shared experiences in international medicine development, many in the IeM field have realized

ABSTrACT

There is nothing more difficult to take in hand, more perilous to conduct, or more

uncertain in its success, than to take the lead in the introduction of a new order of things.

Because the innovator has for enemies all those who have done well under the old

conditions, and lukewarm defenders in those who may do well under the new.”

–Machiavelli

“


the difficulties and complexities of emergency medicine and acute care system development, and ensuring longevity of provision of high quality, affordable care. Collectively, the emerging discipline of international emergency medicine is learning that national and international medical development require expertise in many areas outside the field of medicine, and that any successful development of health care delivery systems, be it in emergency medicine or in other areas, requires extensive collaboration between the sometimes disconnected fields of clinical and academic medicine, administration and management, health economics, health law, health policy and public health.

As study of the evolution of eM development in the USA has shown, and as extensive study of eM development in the 45+ other countries in the world where eM is currently in early or intermediate stages of development has reinforced, national and international eM development has (at least) 3 areas of focus:

Primary development: academic and clinical medicine (undergraduate, training and graduate physicians), patient care systems development, setting up residencies, teaching students and other health professionals, etc...Secondary development: administrative and managerial training, financial and economic systems development, reimbursement, systems analysis, andTertiary development: health legislation, health policy and public health systems / agendas, patient safety, acute health care as a human right.

Over the short 10-15 year history of organized international emergency medicine development, most of our collaborations, projects and exchanges have focused on primary stages of eM Development. Until recently, this focus has been natural and well-reasoned: eM development depends heavily on the knowledge and skills of emergency physicians and other medical professionals, and on their ability to provide high-quality, focused care of acute patients.

In general, we have had much less collaboration and exchanges focusing on non-clinical secondary and tertiary stages of eM, despite evidence that these stages of development are often as important or more so than clinical and academic stages, especially as rate-limiting steps in mature eM system formation. Many new and emerging eM systems have focused solely or mostly on building

the primary stages of eM in their systems, only to later encounter blockages and barriers to further development which might have been avoided if time had also been spent developing secondary and tertiary stages. For example, an examination of the mature eM systems from Canada to Singapore, as well as the quickly-maturing eM systems like Poland and Mexico, shows emergency medicine developing into the areas of eM administration and management, eM finance and health economics, health insurance expansions, emergency health care legislation, and public health.

This multi-level, multi-disciplinary approach is absolutely essential to ensure successful medical development, and to ensure program longevity, resilience and self-generation. eM development strategies should include training and development in each of these areas to facilitate capacity-building in local eM expertise.

overview of international emergency Medicine

“Among the most important factors affecting health system convergence are the dynamic

character of medical knowledge and technology and the forces that sustain it;

the effect of medical demand on national

economies; changing demography and, particularly, the aging of populations;

changing disease patterns; and increasingly rapid mass communication coupled with

rising public expectations.” [Mechanic and Rochefort, 1996]

Over the past twenty years, emergency physicians (ePs) have begun to examine the scope of eM and its extension into the fields of public health and primary care. Specifically, ePs have increasingly looked beyond their borders to learn how emergency medicine is practiced in other parts of the world. The emerging field of International emergency Medicine (IeM) is concerned with the development of emergency medicine and acute care systems development in countries and regions where eM development is needed, and can be viewed as a subspecialty of eM; it allows emergency physicians and other health professionals who are involved in emergency medical care to learn from each other, and involves the educating and training of emergency care providers throughout the world. [Rupke, 1993]

eM is established as a fully “mature” specialty in only a handful of nations, and another 45+ countries are in the early stages of development, including the netherlands. In

Figure I: Despite local cultural, socioeconomic and political differences, most evolving patient care systems (for example, acute care / emergency medicine) pass through similar developmental stages. Development often follows a commonly shared structure regardless of national or cultural differences. The sequence of development experienced in advanced systems is useful as a template for development in other countries.

brIDgIng ThE gap//

SECONDARY STAGESManagement systemsEconomic Structure

TERTIARY STAGES

Legislative Structure National Health Policy

PRIMARY STAGESSpecialty systems; Academic development

Education / Patient-care systems

LocalVariations

The EM Development

Pyramid


many underdeveloped and developing countries, the emergency medical care systems are much less established, with often regional clinics, local general practitioners, nurses or other local healers providing the bulk of emergency medical and primary care. In more developed regions where hospitals provide primary, secondary and tertiary care, very often there is only a rudimentary emergency department, often staffed by under trained and inexperienced physicians, often with no dedicated 24-hour coverage of the emergency room, and rarely with emergency medicine specialty training. Usually the eMS/prehospital system is highly variable, understaffed and underdeveloped, and there is in general vastly inadequate training for emergency care providers, for doctors, nurses and medics alike. While the need for emergency medical care is as large or larger in these developing areas, too often these countries have inadequate or overwhelmed emergency medical care systems [Alagappan and holliman, 2005]. In some regions, such as sub-Saharan Africa, eM is mistakenly seen as less pressing than more traditional primary health concerns such as infectious diseases, maternal and child health and other public health issues. In fact, eM can still play a role in underdeveloped regions in supplying acute episodic care and a much-needed link to the public health care system, as well as supply care for the emerging chronic diseases as depicted by the data supporting epidemiologic and demographic shift.

overview of emergency Medicine in the netherlands

In the netherlands, emergency medicine does not yet exist as an official, fully-developed medical specialty. health care delivery in the netherlands is organized in a two-tiered system with a network of community-based general practitioners (gPs) providing primary care and acting as gatekeepers to hospital-based specialists. These gPs refer chronic problems to specialty clinics based in the hospital and acute problems to the emergency department for specialist consultation. Patients can also go to the emergency department on their own (self-referral). to date, of the 126 hospitals in the netherlands, 106 have emergency departments (RIvM, 2007). As described by elshove-Bolk, Mencl, Simons, et al in the european Journal of emergency Medicine:

[these emergency departments] are staffed by loosely supervised interns and junior

residents, without any specific training and are employed as emergency physicians. The specialists’ consults are also often conducted by loosely supervised residents, with varying

degrees of training. It is these doctors who are responsible for the initial evaluation and treatment of the approximately two

million patients treated in Dutch emergency departments annually. [Elshove-Bolk, 2005]

Most patients presenting to emergency departments in The netherlands are received by the most inexperienced young doctors: so-called artsen-neit-in-opleiding [doctors not in residency: first-year doctors waiting for residency opportunities elsewhere], together with older non-emergency residents in family practice, surgery and other specialties. This model of allowing the youngest, most inexperienced doctors tend to the sickest, most urgent patients is unfortunately not uncommon in most parts of the world, and is not particular to The netherlands.

In recognition of this problem, in the 1990s, several Dutch medical professionals laid plans for training programs for emergency physicians in the netherlands, and in 1999, the first national emergency medicine society was formed, the nederlandse vereniging van Spoedeisende hulp Artsen. In 2003, the Stichting Opleiding Spoedeisende geneeskunde was formed—the Foundation for education in emergency Medicine, which, until recently, acted as a certifying body of emergency medicine training programs. As of October 13, 2008, the Medical Specialist Review Committee (the national certifying body for new specialties) declared emergency Medicine a “medical specialty profile”—a temporary intermediate-level specialty designation. Presently, there exist 16 accredited emergency medicine training programs in the netherlands, with 10+ more currently in the process of obtaining accreditation. These

...during my em residency in the bronx, new york. i

had long been interested in international emergency

medicine (iem) as a career, and witnessed the huge

need and opportunity in this arena. i realized that

while my em residency training showed me how

to practice em in a health care system where em

already exists, it did not teach me how to develop

em systems where they don’t exist or exist only in

pieces.

deciding to gain as much understanding and

expert training in this new field as possible, i

completed an international emergency medicine

(iem) fellowship at george Washington university

in 2003 (their first iem fellow), an mPh in 2003 as

part of the iem fellowship, and a one-year health

Policy fellowship in 2006 and immediately began

looking for a full-time iem position to practice

what i had learned. after introductions and interviews with dutch

trauma faculty who were looking for an experienced eP at the 3rd

mediterranean em Congress in nice, france in 2005,

i decided to accept their offer. in July 2006, my new

wife and i moved to rotterdam, where i started as

the first ed director and the director of the new em

residency at erasmus medical Center in rotterdam,

one of the initial em residencies in the netherlands.

Since July 2006, i have been living and working in the

netherlands as a fully-licensed, practicing emergency

physician, helping to establish em residencies and em

as a full specialty in that country, and have continued

working in the worldwide iem community in multiple

fashions: as chair of the aCeP Section for international

emergency medicine, as Committee member for the

international federation for emergency medicine

(ifem), as director and organizer for multiple national

and international em conferences and teaching

programs, as board member for the newly-formed

african federation for emergency medicine (afem), and as a

member of multiple national and international em societies.

About the Author // I first became interested in a career in international emergency medicine...

Dr. Terry Mulligan, in The Netherlands with his daughter Louisa.


programs have graduated approximately 120+ trained emergency physicians and approximately 150+ residents are currently in training.

eM administration and Management Fellowships in the netherlands

Currently, the training program for Spoedeisende hulp artsen as recognized by the SOSg and the nL Board of Medical Specialists is only three years in length. This short training program length does not allow for full instruction in advanced, essential elements of clinical, academic, administrative, managerial and specialized areas of emergency medicine. During the presentation at the 1st nvShA conference, I mentioned that I was in the process of formulating a 1-2 year post-residency “Fellowship” training program in administration and management in eM. Immediately after the lecture was over, I was pleased to notice that 20-30 individual ePs and residents came up to me to ask for more information on this Fellowship training program and how they could take part in it. From this initial outpouring of interest, I began to dedicate my time to designing a shorter Fellowship training program to meet the needs of this large group of Dutch emergency physicians.

to these ends, we developed the Administration and Management Fellowship in eM, which draws its rationale from the eM Development Pyramid concept illustrated above: that eM development needs to include more than just clinical and academic eM, and that emergency physicians in societies with newly developing eM systems need to gain training, expertise and experience in these areas.

Fellowship overviewto date, the Administration and Management

Fellowship in emergency Medicine for emergency physicians and emergency medicine residents in the netherlands has been run successfully three times, with 29 Dutch ePs having successfully completed the Fellowship, earning the designation of Fellow of the nvShA (FnvShA). This Fellowship Program has involved Dutch and international eM faculty and others, and has focused on a “train-the-trainer” model, where Fellows obtain both mastery levels of the course content, as well as specific instruction on how to conduct identical courses at their institutions. This teaching model has been very successful at disseminating the information presented to the Fellows by giving them reading, teaching and instruction materials to use and

expand on their own. The Fellowships also focus on the production of individually-catered Fellowship Projects, which are specific, problem-oriented projects that Fellows bring back to their sponsoring institutions for immediate action and implementation. Past Fellowship Projects have included:

9 the formulation of an eM curriculum for Dutch medical schools9 the development of an e-Portfolio for the newly released Dutch Curriculum in eM9 the formation of national quality indicators for Dutch eM (which were officially accepted by the Dutch Ministry of health)9 investigations into formal feedback systems for eM education and practice9 the establishment of eM Student organizations at every Dutch medical school.

On-going consultation by Dutch faculty, nvShA and national and international faculty has been made available on-site, on-line and via telephone, and through advanced video telemedicine linkages before, during and after all forms of training.

The Fellowships have consisted of conferences, didactic lectures and academic teaching, reading and writing assignments and the completion of individual Projects for each Fellow.

academic lectures, readings and didactic material:

The following areas are covered in conference, lecture, readings and other academic assignments:

9 Administrative Principles in eM 9 Management Principles in eM9 hospital Management9 Academic and training Principles in eM9 Patient Safety and Quality in emergency Medicine9 Research in eM9 Development of the Specialty of eM9 emergency Department Operations9 health economics, Policy and Law in eM Development9 Special topics in eM (global Burden of Disease, Acute health Care as a human Right, eM and global health Institute Consortia)

This is the first comprehensive international eM training program of its kind. While certain elements of our Fellowship have been taught in pieces for only the most advanced eM systems, our program is unique in that it is the first to bring together all of these requisite development

topic areas into one training program, and is first in offering it to ePs working in developing and underdeveloped eM systems.

Interest in the non-clinical topics of Administration and Management and in this course has been large. The first Fellowship class in 2008 was extremely successful and prompted a second to follow in 2009, and then a third in 2010. Interest has also spread outside of The netherlands. Our particular Fellowship course has been conducted in many places around the world, in developed, developing and underdeveloped regions alike. So far, in addition to the netherlands, we’ve conducted region-specific courses in South Africa, Australia, Poland and Spain. We have plans for programs in hong kong, Botswana, the USA, Canada and elsewhere.

The european Society of emergency Medicine has also validated the program, devoting three days to eM Administration and Management in the 5th Mediterranean eM Congress in valencia, Spain in October 2009, and will sponsor a 3-day pre-conference on these topics at the euSeM Congress this October 2010 in Stockholm, Sweden.

Many eM systems are struggling with these non-clinical aspects of eM development, and could benefit from concentrated training. There is a general lack of didactic material on the secondary and tertiary elements of eM development in nearly all national eM curricula, and a limited understanding of these traditionally non-medical areas by most physicians. Indeed, many of the international teaching faculty involved in our courses in The netherlands have remarked about the conspicuous absence of such comprehensive, non-clinical training even for their own residents back home at their “mature” eM systems. It is one of the goals of this program for these non-clinical topics to formally be placed into national and international eM teaching curricula, and for the broader IeM community to become more involved in comprehensive eM development on many different levels.

Future directions for emergency medicine in the netherlands

As described by Jeff Arnold in 1999, international eM development stages can be roughly divided into three major groups: underdeveloped, developing and mature. The so-called “mature” group includes the countries that many would consider having a fully-developed acute care system, such as the United States,

brIDgIng ThE gap//


Australia and Singapore. The “developing” group now includes 45+ countries that have officially recognized eM as a medical specialty but that are in various states of eM development.

In many aspects of its medical and health care system, The netherlands is one of the best developed nations in the world. They lead the world in transplant medicine, genetic mapping, gene therapy and genomics, and hematology / oncology. They are even among the local european leaders in trauma care, prehospital care and critical care. however, for many historical, cultural, medical and political reasons, The netherlands is arguably in the “developing” group with respect to its level of eM and acute care systems. It’s as if the Dutch health care system were a modern city skyline filled with skyscrapers, representing multiple areas of medical achievement and clinical excellence. In the middle of that impressive skyline sits a humble, four-story building representing the literal and comparative underdevelopment of eM and acute care delivery systems.

Among the 45 or so countries in this “developing” group, however, The netherlands is emerging as one of the local leaders in national eM development in the eU community. In the short 10 years or so of Dutch eM development, they have achieved what has taken some other countries 30-40 years to develop:

In particular, the nvShA development of the first Dutch national eM curriculum in 2006, now in its 2nd edition, is one of the most advanced and sophisticated national eM curricula so far, having studied and adopted the best pieces of the existing national eM curricula from Canada, the Uk, Australia and the USA, and offering region-specific additions and improvements. This eM curriculum has proved to be one of the major influences on the structure and format of the euSeM-authored “european Curriculum in emergency Medicine” that was approved by the european Union of Medical Specialists in 2009. In addition, there is large and growing interest in more advanced eM development programs, such as the Administration and Management Fellowship, along with other eM teaching and development programs in Patient Safety, Medical Decision-Making, eD Design and eM Finance that are coming out of the eM development community in the netherlands.

Through the elements in figure II and other examples, the eM community in The netherlands is intentionally and deliberately addressing national eM development using particular focus on those eM development strategies that have been tried (with or without success) elsewhere. In

The establishment of a national em society (the nvsHa—nederlands vereniging van spoedeisende Hulp artsen / The Dutch society for emergency Physicians)

The establishment of 16+ accredited em residency training programs, with 10+ more in the process of accreditation

The gradation of 120+ Dutch emergency physicians from these programs, with 150+ emergency medicine residents currently in training

formal recognition by the Dutch medical specialist review Committee as a medical specialty profile

The formation and publication of the national Dutch Curriculum in emergency medicine (the first of its kind in any specialty in The netherlands)

The development of a national e-Portfolio, allowing all Dutch em residents to register and monitor their training centrally and electronically (also the first of its kind in The netherlands)

The incorporation of many elements of the Dutch em Curriculum in em into the european Curriculum for emergency medicine

The formation and administration of national in-service examinations for evaluation and comparison of em residencies (also the first of its kind in The netherlands)

efforts towards a comprehensive “board certification” exam in em (the first of its kind in any specialty in The netherlands)

Three national em conferences (called the Dutch north sea em Conferences) in 2007, 2008 and 2009, with 2010’s taking place in June

many local, regional and national onderwijsdagen, or em teaching days

The establishment of em-student organizations at all eight Dutch schools of medicine, with the eventual formation of a student chapter of the Dutch society for emergency Physicians

The development of a national institute for Dutch em fellowships, which, in addition to handling this current administration and management fellowship, is forming other training programs and fellowships in research, in academic em, in international em, and in many other areas, and is concentrating on collaborations in research and education

Fast tRaCK // since the mid-1990s, the EM community in The Netherlands has been a model of rapid specialty acceleration, accomplishing the following landmark achievements:

this fashion, Dutch eM development is following templates for development as much as creating one.

By focusing on comprehensive eM development techniques, by concentrating on the eM development experiences of fellow countries and regions, and by gaining education and experience in multiple areas outside the field of medicine, The netherlands is historically and politically well-positioned to offer its experience in successful eM development as a template for development outside its borders.

conclusionemergency medicine is a new and expanding

field in The netherlands. given the recent developmental steps that have taken place, the state of Dutch eM is growing and shows all prospects of flowering into full development in the near future. Further, the successes of eM development in The netherlands will continue to spread to and influence eM systems in neighboring countries in the eU and elsewhere, and can be used as a guide and template for eM development abroad. As one of the “success stories” of goal-directed, intentional national eM development, The netherlands has the opportunity to establish itself as one of the global leaders in national and international eM development.

REFERENCESArnold, J. International Emergency Medicine and the Recent Development of Emergency Medicine Worldwide. Ann Emerg Med. 1999;33(1):97-103.

Arnold, K, Smith J. Emergency Medicine Clinics of North America – International Emergency Medicine. Elsevier, 2005;23(1).

Elshove-Bolk J, Mencl F, van Rijswijck BT, et al. Emergency department patient characteristics: potential impact on emergency medicine residency programs in the Netherlands. Eur J Emerg Med. 2006;13(6):325-329.

The European Society of Emergency Medicine (EuSEM). www.eusem.org

International Federation for Emergency Medicine. www.ifem.cc

Holmes J. Emergency Medicine in the Netherlands. Emerg Med Australas. 2010;22(1):75-81.

Mechanic D, Rochefort D. Comparative Medical Systems. Annu Rev Sociol. 1996;22:239-70.

Nederlandse Vereniging van Spoedeisende Hulp Artsen [Dutch National EM Physicians Society] http://www.nvsha.nl

RIVM Rijksinstituut voor Volksgezondheid en Milieu [Dutch: National Institute for Public Health and the Environment.] http://www.rivm.nl/

Rupke John, ed. American College of Emergency Medicine: 25 years on the front line the ACEP anniversary 1968-1993 (Dulles: ACEP, 1993) 10.

SOSG: Stichting Opleiding Spoedeisende Geneeskunde [Dutch EM Certifying Body]. http://www.sosg.nl/

The World Health Report, 2006. (World Health Organization) http://www.who.int/whr/en/

brIDgIng ThE gap//

Figure ii: elements to the success of emergency medicine development in The Netherlands

1. champions: mavericks, transformational leaders, network facilitators

individuals who have shown constant support and tireless effort of the

em movement, particularly on the flat part of the sigmoidal development

curve, without whom Dutch em development would most likely be much

less developed

2. concentration outside the field of medicine

i.e. simultaneous and deliberate development strategies in administration

and management, economics and finance, legislation and health law,

public health and health policy

3. concentration outside their borders

using emergency medicine development patterns elsewhere as templates

for their own development

4. socio-economic appropriateness

emergency medicine and acute care are currently the largest burden of

disease on the health care system in The netherlands, and the time is right

for em development

5. the Fluke concept, or the “serendipitous accident”: the accidental

or intentional ‘spark’ that instigates and aligns the movement culturally,

historically, economically or contextually

between 2000 and 2006, and especially recently, there have many

national stories in the media revealing the current state of em in The

netherlands, along with changes in national medical financing and

insurance practices, causing national concern and the alignment of social,

cultural and economic forces in support of em development

examples of the “Fluke Concept” around the world:President ozal of Turkey died of a suspicious heart attack in 1993, •

which provided national attention on the state of acute care in Turkey,

and spurred a national focus on em development

The olympics, world forum, world Cup and/or other major world •

sporting or economic events, that crystallize attention on emergency

medicine development

major economic, industrial or private business development that •

supports em systems development for economic returns in addition

to public health benefits



The Canadian Head CT Ruleis the rule reliable enough for more litigious nations?

a pro/con debate

YESuse the rule to cut costs and radiation

without litigation exposure. by Christopher Carpenter, MD, MSc

Per capita, the US currently spends twice as much as Canada and every other first-world economy in the world, yet ranks behind on many qual-

ity measures. Undoubtedly, the US malpractice environment contributes to this fiscal conundrum. In caring for anyone, anyplace, anytime eM physi-cians sit at the forefront of the defensive medicine frontier. Rarely, do eM physicians benefit from well-established science to augment clinical gestalt. Deciding whether or not to obtain a cranial Ct on head injured patients is one exception.

Mild traumatic brain injury can be defined as loss of consciousness (LOC), amnesia, or witnessed disorientation with initial gCS ≥ 13. The Canadian head Ct (ChCt) rule was developed to guide decision making about the use of Ct-head ordering excluding those less than16 years old, pregnant, on Coumadin, suffering seizures, lacking clear trauma, LOC, obvious skull fracture, or hemodynamic instability. The primary outcome was the need for an intervention (craniotomy, skull fracture elevation, ICP monitoring, intubation for head injury), while the secondary outcome was clinically im-portant brain injury on Ct as defined by a consensus of 129 neurosurgeons, radiologists, and eM physicians. Insignificant Ct findings included: soli-tary cerebral contusion < 5mm; localized subarachnoid blood < 1mm; thick smear subdural hematoma <4 mm; isolated pneumocephaly; and closed depressed skull fracture not extending through the inner table. After being derived and validated on over 3000 Canadian patients, the ChCt rule has subsequently been validated in germany and england. Ironically, in contrast to the US debate about whether to utilize the ChCt rule to decrease head Ct ordering, British physicians debated whether to incorporate it into their guidelines fearing it might increase Ct use! Other blunt head injury clinical decision rules (CDR) have been developed, but none explicitly followed the guidelines for CDR development and subsequently none have been exter-nally validated.

While the ChCt rule has not been demonstrated cost-effective or widely acceptable, no US legal literature demonstrates appropriate use of the ChCt rule missing a clinically significant, successfully litigated intracranial injury. nonetheless, no sane physician wants to be the first. Therefore, the ChCt rule should not replace clinical judgment. Instead, the rule should augment the intuition experience garners. If a seasoned eM physician’s in-sight suggests that central nervous system imaging is merited despite a nega-tive ChCt rule, the patient should definitely be scanned. If the clinician’s gestalt is that no significant intracranial injury exists, concern about the medical-legal implications of the rare (0.6% neurosurgically significant – all detected by the ChCt Rule) clinically significant injury should not drive decision making. Practicing knee-jerk, counterintuitive, defensive medicine drives up the cost of health care for everyone and negates the value of clinical expertise.

the Canadians have demonstrated a unique expertise in developing ev-idence-based rules that make sense. however, as a risk manager, board

member of our group’s risk retention group and a practicing emergency physi-cian, clinical application is where the rubber meets the road.

At journal club, this is an academic discussion. In the eD, we need to make certain we are practicing safe, appropriate and efficient, risk-averse emergency medicine. Which would you prefer to do? Avoid a lawsuit and all the fun this will add to your life for 18 months; or use an evidence-based guideline to convince a jury of laypersons why it was Ok to miss a small subdural.

We could have an academic discussion. however, how does that help the average doc working a shift? Many research-oriented discussions focus on the quality of the research. Unfortunately, they fall short with how or if the in-cluded recommendations should be implemented clinically and how to do so.

For most of us, this is not an academic discussion. It’s a matter of how to get through the next shift, practicing high quality emergency medicine, avoiding a lawsuit, walking away with some sense of gratification for the care we provide.

The issues I have with the Canadian Ct head rule are a lack of external validity, the exclusion of “clinically unimportant” lesions and the use of a uti-lization reduction tool that may result in missed intracranial injuries.

external validity is key. Can the study results be reproduced elsewhere, or is it only valid in the environment in which the original study was conducted. In example, an excellent head Ct rule was studied at Louisiana State Univer-sity (LSU) in 2000. It reduced Ct utilization without any additional missed injuries. Unfortunately, attempts to reproduce the same results in other en-vironments have been unsuccessful. Thus, rendering application of their rule to LSU only.

Some might say that the Canadian Ct head rule has stood the test of ex-ternal validity. Well, the devil is in the details. Boyle, et al., British investiga-tors, noted a substantial increase in utilization of Cts, without any additional benefit. In Australia, the new Orleans criteria and the Canadian Ct head rule were tested. neither performed well. Rosengren, et al., from down under, reported that if the high-risk Canadian criteria were utilized, 74% of the nor-

NOA miss is a miss. Juries don’t care

if you’re saving cost. by Kevin Klauer, DO

The issues I have with the Canadian CT Head rule are a lack of external validity,

the exclusion of “clinically unimport-ant” lesions and the use of a utilization

reduction tool that may result in missed intracranial injuries.


con

The clinically insignificant Ct findings represent the central argument against the ChCt rule. Dr. klauer has argued that if one of these injuries is missed by one physician only to be found by another physician, a lawyer will portray the patient as a major corporate CeO if only the first physician had ordered the scan even if few surgeons in the world would intervene on the injury. If detecting any abnormality regardless of the cost to the individual or society is top priority, recognize that a brain injury can exist despite a normal head Ct. If we are to take a fully defensive posture and toss the evidence out with the tort reform, should we not order more sensitive head injury tests such as MRI, Pet scans, serum biomarkers, and formal cognitive testing before any of these patients leave the eD? Most eM physicians would not advocate this extreme viewpoint, but what distinguishes unnecessary head Ct ordering from other unnecessary brain injury testing?

tort reform is past due to alleviate counterintuitive over-testing. Intrac-ranial injuries, missed or recognized, often have devastating results for indi-viduals and families. The ChCt rule, or future worthy substitutes, ought to continue to be the focus of research until cost-effectiveness and acceptability can be demonstrated. If physicians are being legally persecuted for appropri-ately applying these rules, the case details and testimony should be reported in venues such as eP Monthly. Lacking an effective alternative, cost-conscious, evidence-based physicians are left with two choices: augmenting clinical deci-sion making with the ChCt rule or substituting best-evidence practice for uniform testing of all head injury victims at tremendous cost to society with no proven benefit to the individual patient.

Christopher Carpenter, MD, is an Assistant Professor at Wash-ington University School of Medicine.

mal scans could have been avoided, and the one patient requiring “neurosur-gical intervention” would have been identified. however, with addition of the medium-risk (2 additional) criteria were used, only a 46.7% reduction in scans would be noted. Unfortunately, two “clinically significant” abnormali-ties would have been missed. Their conclusion was that such studies have no applicability outside the environment in which they were developed. hence, they lack external validity. I agree with them!

If you feel external validity has been proven by these studies, conducted in europe and Australia, how does that apply to apply to those of us practicing in the U.S.? When’s your next shift in Canada, england or Australia?

A fundamental challenge applying the many utilization-driven guidelines, generated by Canadian researchers, to eDs in the United States is that our medical malpractice climate does not afford any forgiveness for medical er-ror. The Canadian Ct head rule was 92% sensitive for identifying traumatic neurosurgical lesions. Ct utilization could have been reduced to 32%. Un-fortunately, only 320 of the 348 patients with positive Ct scans would have been identified. Stiell was proud to report that they did not miss any of the lesions requiring neurosurgical intervention. however, they don’t talk much about the 28 “clinically important” and “clinically unimportant” lesions the rule would have missed.

In the malpractice climate in the United States, there is no such thing as a “clinically unimportant” intracranial injury. Any such miss is an opportunity for a lawsuit. If a claim is made, convincing a jury of laypersons that the lesion was “unimportant” will be nearly impossible. Furthermore, average defense costs will be at least $100,000, and that’s just to get you to your first day of trial.

great concept. But, it falls way short on practical application. Plaintiffs and jurors don’t commend a physician for reducing utilization and saving healthcare costs when they have an injured patient in front of them. I agree that we spend far too much on unnecessary tests in this country. however, until our legal system accepts misses in exchange for controlling costs, we can’t put ourselves at risk.

Kevin Klauer, DO, is the Director of Quality and Clinical Educa-tion at EMP & the Director of the Center for Emergency Medi-cine Education

While the CHCT rule has not been dem-onstrated cost-effective or widely accept-able, ...no US legal literature demonstrates appropriate use of the CHCT rule missing a clinically significant, successfully litigat-ed intracranial injury.

pro

vCLINICAL uPDATEin 2009 trial, prediction rule safely stratifies children with minor head injuries, gauging which need CT

Kuppermann, et al., published an excel-lent article in 2009. This study helped

to address the question of which children with “minor head injury” require a CT scan and in which patients can a CT be safely be avoided. 42,412 children, younger than age 18 yrs, with a GCS of 14 or 15 were studied in 25 North American Emergency Departments. Both groups included deri-vation and validation populations. The pa-tients were divided into two subcategories, less than 2 years and 2 to 18 years.

CTs were obtained in 14,969 (35.3%) patients, identifying clinically important traumatic brain injury (ciTBI) in 376 (0.9%) patients, 60 requiring neurosurgery.

ciTBI was defined as, “death from trau-matic brain injury, neurosurgery, intubation >24 h or hospital admission > 2 nights.” The prediction rule for children less than two years of age, “normal mental status, no scalp hematoma except frontal, no loss of consciousness or loss of consciousness for less than 5 s, non-severe injury mecha-nism, no palpable skull fracture and acting normally according to the parents,” had a negative predictive value of 100%. The prediction rule for the older group, 2 years and older, “normal mental status, no loss of consciousness, no vomiting, non-severe

injury mechanism, no signs of basilar skull fracture, and no severe headache,” yielded a negative predictive value of 99.95%. No neurosurgical lesions were missed in the validation groups.

Although no decision rule is perfect, these validated prediction rules provide an excellent guideline with respect to identify-ing patients at very low risk for clinically- important traumatic brain injuries and in which patients a head CT may be safely avoided.

Kuppermann N., Identification of children at very low risk of clinically-important brain injuries after head trauma: a prospective cohort study. Lancet. 2009 oct 3;374(9696):1160-70.


u facing the Difficult reality of emergent amputations

by dr. greg elder, mSf-uSa’S deputy operatIonS manager

In the days following the earthquake in haiti, I was asked in a Cnn interview about the rescue of an 11-year-old girl who was partially trapped under a build-ing. It was a compelling story: an inno-

cent victim crying in pain, newly-arrived search-and-rescue teams racing against the clock in an apocalyptic cityscape, and an ethical dilemma over whether to risk the girl’s life by performing a crude amputation or attempting a slow rescue. It was an awkward question for a doctor to face on national television. I wondered if I was being asked to comment on the scene or to give a pro-fessional opinion on what should be done.

Later in the day, I was dealing with the events ongoing at MSF’s centers in Port-au-Prince. Our hospitals had been damaged and staff members were missing. Our traumatized teams were strug-gling with the overwhelming numbers of patients flooding into the facilities they’d established where our trauma center once stood. Our emer-gency response team was plotting out our phased response strategy and calling high-level contacts in regional governments to request facilitation of our efforts. My mind drifted back to the little girl and I wondered if anything I’d said might have been construed as professional advice to ampu-tate her leg and to move to the next case.

Doctors are trained to make these decisions and to live with their consequences. As a doctor working for a humanitarian organization, I am buffered from the personal impact of such choic-

es. At headquarters level, patients can become abstract categories: victims, displaced, refugees, and so on. MSF conducts more than 8 million consultations a year in nearly 70 countries. That’s 8 million individual conversations between a health worker and a patient. They could happen under a tent in a mobile clinic in Darfur, at an

hIv center in Malawi, or in a trauma hospital in Port-au-Prince. This is the measure of MSF’s hu-man reach. This is the “human” in humanitarian. And, from time to time, even for those of us at headquarters, one patient can alter that abstract relationship and make the decisions very real.

What could be the future of this little girl? What are the implications of my advice? her leg

was probably crushed. Pulling her out with her leg intact was unlikely. Reperfusion of her dam-aged limb could provoke crush syndrome and put her in mortal danger. Sepsis, gangrene, and tetanus are also risks. But amputating her leg

would be only the first chapter. She would sub-sequently need intensive medical management —surgical debridement of her wound, fashion-ing of the stump, physiotherapy and planning for an artificial limb–that would require specialists and long-term follow-up care. She would need several new prostheses as she grows, and she will also almost certainly need psychological support to cope with the loss of her limb, the trauma and post-trauma of her experience, and the grief asso-ciated with losing friends and family.

Services such as these were extremely limited in haiti even before the earthquake (and almost wholly inaccessible if one didn’t have money). MSF set up trinité hospital in 2005, when urban warfare was raging in Port-au-Prince. For the last two years, it’s been the capital’s sole trauma cen-ter, treating fewer war-wounded and rape victims but increasing numbers of people for motor vehi-cle, domestic, and workplace accidents. MSF also ran the city’s primary obstetric unit—providing obstetric care to some 25,000 pregnant women since 2006, almost 60 percent of whom were fac-ing potentially life-threatening complications—while also providing primary and basic secondary health services in several city slums.

On top of this girl’s short-term and long-term medical needs, one wonders how a young woman—possibly on her own, with a significant physical disability—will negotiate a crowded marketplace in a poor country that still lacks meaningful social safety nets despite the billions that have been invested in development aid and a Un peacekeeping operation.

The proposed amputation to save this girl’s life is a calculated surgical act, at once aggressive and compassionate. A similarly aggressive and targeted approach is needed for the long-overdue reconstruction of haiti’s health system. If it can be done, this young woman might not have to bear the burden of her collapsed house for the rest of her life

DisasTer relief

haiti earthquake

Aggressive Compassion

at headquarters level, patients can become abstract catego-ries: victims, displaced, refu-gees, and so on.

. . . from time to time, even for those of us at headquar-ters, one patient can alter that abstract relationship and make the decisions very real.

“

Originally from New Zealand, Dr. Greg Elder (middle, in Sudan) is MSF-USA’s Deputy Operations Manager. Photo by Caroline Livio/MSF

l


Problem: People need help in the immedi-ate hours and days after and event. however, big organizations take days if not weeks to respond. emergency physicians need to be prepared to re-spond quickly to maximize their impact.

As soon as I saw the scale of disaster in haiti I, like many others, knew I wanted to respond. Be-ing a part of the US navy’s Rapid Response team, I assumed we would be some of the first in coun-try. But it took over a week to work through the government bureaucracy. eventually I gave up on going through the military and joined an ngO (non-governmental organization) called team Rubicon. The first team members had already been in country over a week.

lessoN leArNed: If you want to be able to respond in the first wave of relief, have a rela-tionship with a team of like-minded individuals or an organization that is ready to respond on a moment’s notice.

Problem: With infrastructure gone, would-be rescuers can be a drain on scarce local supplies if not self sustaining. Obtaining medical supplies in country, especially narcotics, may be impos-sible.

team Rubicon was made up of former military doctors, nurses, paramedics and firefighters, all with an ‘expeditionary mentality’. As such, team members were responsible for providing our own tents, food, and medical equipment. Most of the team Rubicon members were able to obtain sup-plies on short notice through the medical facili-ties where they worked, but these supplies were quickly exhausted and had to be obtained from the scarce local supply. A second team was able to resupply by contacting large suppliers, but only after a lag period.

lessoN leArNed: While most equip-ment and personal gear can be stockpiled for use on a moment’s notice, medicines, especially nar-cotics must be obtained at the last minute. have a predetermined supply line for meds that can be tapped quickly and maintained. time is of the es-

sence, but have a plan for a rapid resupply.

Problem: Regardless of how thoroughly you plan, teams who travel light will have need of purchasing goods and services in country where banks may not be functioning. So cash will have to be carried. This can present a security issue.

Daily expenditures for the entire team could reach $1000. Carrying that much cash, sleeping outdoors or in an unsecured environment can be a real risk. team Rubicon, being made up a mostly former military had planned for and was prepared for such. But this might escape the plan-ning of a naive and trusting group.

lessoN leArNed: team members must have access to and be willing to carry large sums of cash. You must also reserve cash and a plan for getting home.

Problem: getting the necessary paperwork for admission to a country takes more than hav-ing a good heart and desire to help.

haiti was a unique situation in that the gov-ernment was virtually disabled. The initial teams were able to come into the country with little more than a letter from an official source in the US, far short of a visa. Other countries, however will likely keep national border security tight even in times of disaster. Medical teams must be prepared with current passports and letters of

introduction from the country’s own embassy in the US. This is where affiliating with a larger organization might be helpful. One of the team Rubicon members had recently worked with the United nations. Those contacts proved invalu-able.

lessoN leArNed: have current pass-ports for all members. have a list of contacts for countries to which you are willing to travel, who can provide the needed documents on an expe-dited timeline. Consider obtaining some type of affiliation with widely recognized world relief organizations.

Problem: Who is your first contact once you arrive at ground zero?

By chance, team Rubicon had a contact with a Jesuit mission in Port-au- Prince. Jim Boynton, a Jesuit brother affiliated with the mission proved invaluable to the group. Other physicians who went to help had contacts with other religious and benevolent organizations. having a local contact that can be trusted in absolutely impera-tive. Lacking such a connection, precious time would have been wasted with a multitude of team sustainment issues. Since the mission was secure and set up with its own power, water, and internet access, the team was free to immediately begin providing much needed care.

lessoN leArNed: Build a list of contacts for places you are willing to go. The more informa-tion the better as communication may be limited in a disaster. Religious ngOs are good contacts for this. They commonly have the trust of the lo-cals and basic facilities from which to work.

Problem: What happens when you out run your referral base?

A disaster, by definition, is where the resources are overwhelmed. emergency physicians who expect to refer serious cases on to other special-ists may find that there are none, or that they are overwhelmed. In the case of haiti, first respond-ers found themselves handling crush injuries and

Last January, the world watched as a massive earthquake hit Port-au-Prince, Haiti, virtually leveling the city and the surrounding

towns. It is estimated that almost a quarter million people died in the initial quake and the ensuing medical disaster. I was privileged

to be one of hundreds of emergency physicians who responded by going to Haiti to treat the thousands of injured. I encountered

physicians like myself from all over the world. As we labored together to relieve the suffering, we learned a few things about

international disaster response. by marK plaSter, md

Mark Plaster, MD (R), rides through downtown Port-au-Prince with Brother Jim Boynton

DisasTer relief

haiti earthquake

8 Things i learned in Haiti


open fractures with no hope of immediate fol-lowup by surgeons. Many field amputations were performed by physicians who had never done such procedures. even when orthopedic surgeons began arriving they were quickly overwhelmed and soon out of orthopedic appliances. When the USnS COMFORt arrived on station, there were 1200 patients waiting to be air lifted to ter-tiary care. needless to say it didn’t happen over night.

lessoN leArNed: especially for physi-cians from the developed world where practices are limited to speciality practice, go back to the basics and re-learn how to give basic care to any-thing. Plan on bringing supplies to clean wounds, splint the worst kinds of open fractures, provide prophylactic antibiotic coverage, and pain con-trol for several days. Then develop priorities for handling once secondary help begins to arrive.

If you want to help in a disaster, spend some time with your local general surgeons and ortho-pedic surgeons brushing up on basic wound and fracture care. If you haven’t already mastered the skill, learn regional anesthesia. And be prepared to step out of your first area of expertise to apply skills that you may know but seldom practice.

Problem: how do I keep from making en-emies of the locals?

Physicians from the developed world can seem arrogant and condescending to the locals, especially local health care providers. Decisions, ostensibly made in the patients best interest, can fail to take into account the social situation of the patient and the local medical providers. health care workers from the ‘outside’ can even be seen as an affront and ultimately resisted. In the case of haiti, because some early physicians who spoke no Creole, simply did what they thought right and amputated crushed limbs without consulting anyone, patients became afraid to seek care.

to make matters worse, many from our group, being former military, had very functional mili-tary clothing. But wearing it made us look like we were foreign invaders. I found that by wearing scrub tops, or a lab coat, even dirty ones, I was seen as a doctor, a universal symbol and given re-spect and assistance.

Most situations were resolved with better communications. But these situations could have been avoided by taking time with each patient and bringing in the local medical providers, at whatever level, whenever possible.

lessoN leArNed: Regardless of the situ-ation, don’t allow yourself to get caught up with the thought that you can do anything just because it’s a disaster. Consider your appearance. Com-municate with the patients and local medical pro-viders. People still require communication. Laws still apply. You are still a foreigner. Problem: how do you know when to go home?

It was clear from the first day that the needs of haiti would go on for a long time. But there was a definite time when it seemed that the larger organizations were in place, doing good work, and the immediate crisis was moving into a lon-ger phase. even though we knew that there would be a second wave of medical issues related to in-fection, malnutrition, and other issues, we had to face the fact that the time for our little group of emergency care givers was over. Leaving haiti was like walking out of the eR with the waiting room still full. You just have to trust the next shift.

lessoN leArNed: Coming full circle, you have to remind yourself that the eM portion of a disaster gives way to others with more assets.

DisasTer relief haiti earthquake

© Julie Rémy / MSF


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AhA and other orgnaisations have long established track records. We just need to link in with these groups.

Bodiwala: IFeM’s definition of emergency medicine is on the web. Many countries have adopted that definition broadly. Whilst its purpose is clearly de-fined, I would remind that it does include prehospital care. IFeM does and hopes to continue to collaborate with these organisations too. +In your TravElIng arounD ThE WorlD, havE you bEEn surprIsED abouT an ElEMEnT oF EM ThaT Was sIMIlar across borDErs?Cameron: This is a difficult question to answer as we subconsciously expect things to be the same! I guess it is mostly the en-thusiasm and dedication of people work-ing in emergency medicine, in whatever form, under very different and sometimes difficult circumstances.

Bodiwala: I have found that wherever I went, a bunch of hospital and general practitioners wanting to either establish eMS or eM as a specialty which is pro-foundly encouraging. +WhaT abouT an ElEMEnT oF EM ThaT Was surprIsIngly DIFFEr-EnT FroM counTry To counTry?Cameron: One thing that has taken me a bit by surprise – even within my own country – is the variation in how we process patients on arrival at the hospital. When we look at other businesses with high volumes – banks/supermarkets etc., – there is a standard process for the initial interaction. In high risk areas, such as ours, this is even more important. however, the

The Future of the Federationwfrom page 11

INTERVIEWsecond-by-second process of ambulance arrival, clerical registration, handover, prioritisation, documentation, and movement to eD cubicle is very different everywhere! Why?? +as pEr IFEM bylaWs, only onE naTIonal socIETy can bE a Full MEMbEr oF IFEM. hoW Do you ThInk IFEM shoulD hanDlE counTrIEs ThaT havE MulTIplE, coMpETIng EM socIETIEs?Bodiwala: Usually there is no problem, but should there be a competition we will seek to have clarification from either the government health department or a na-tional medical organisation looking after

all specialties to signify which one is the representative of emergency medicine. +WhaT IF ThE rIval socIETIEs arE ExTrEMEly EnTrEnchED? WhaT Is ThE crITErIa For choos-Ing a DoMInanT playEr?Bodiwala: In my personal opinion (as there is no written bylaw on this specific matter) I would suggest to clarify from the government which of the two or many eM societies is ‘recognised’ by them, which one do they communicate with and other medical admin authorities and which one has the ability to conduct examinations and issue certification. I would also suggest that two or more societies decide among themselves who should represent emergency medicine in the International Federation based on who represents eM on their national scene.

Dr. Peter Cameron poses with students from the first official emergency medi-

cine residency program in Brazil.

of projects that different programs are implementing. For example, gWU recently completed an emergency medicine training program in turkey in association with the emergency Medicine Association of turkey (eMAt). The program used a ‘training of trainers’ methodology to first design an educa-tional curriculum in emergency medicine, then deliver this curriculum to more than 2500 general practitioners over two years. The most critical feature of this program that allowed its success was the strong partnership with eMAt. The physician leaders from this association provided the training programs throughout the country, and in doing so brought an educational benefit to a large number of practitioners. This project specifi-cally targeted those physicians who are not formally trained in emergency medicine, but are practicing in most of the country. As emergency Medicine develops into a specialty, this is a com-mon problem that countries encounter. This educational model of ‘training of trainers’ was an effective method of distribution of important education in emergency medicine.

At this point, to my knowledge, there are not any Interna-tional eM Fellowship programs offered in countries other than the United States. emergency medicine programs around the world often will offer various opportunities for ‘visiting fellow-ships’ for physicians to visit their institution and engage in an educational experience. The length and goals of such an experi-ence are variable, and are determined specifically between the visiting faculty member and institution. If you are working to develop emergency medicine in your own country, the Interna-tional emergency Medicine Fellowship programs may represent good resources for potential collaboration.

It is also important to realize that fellowship programs are not exclusively for physicians just finished with residency, or those interested in academic medicine. An IeM Fellowship is a great opportunity to gain a lot of experience in a relatively short time, which leads to a variety of career opportunities. While staying in academics is an option, past international fellows have gone on to careers in ngO’s, various governmental organiza-tions such as the CDC, or careers in community practice with a self-defined element of international eM. Others have gone on to live full time in another country, working to develop the eM system there. Just remember the importance of choosing the right fellowship ‘fit’ in the beginning – your experience will help to define your future career opportunities.

There is a great variety of fantastic work being done across the spectrum of international emergency medicine fellowships. This work is truly bringing better health care and education to many, many people throughout the entire world.

ACADEMICS

Should I Follow the Fellowship Road?wfrom page 12


The Iem Fellowship Directory

CAlIFornIA Harbor-UCLA/IMC Global Health FellowshipRegional Focus: Iraq and possible extension to Haiti

Contact: Ross I. Donaldson, MD, MPHHarbor-UCLA Medical CenterDepartment of Emergency Medicine1000 West Carson Street, Box 21Torrance, CA 90509Length: 1-2 yearsSalary: CompetitiveShifts: 5 per monthDegree: MPH, DTMH availableNumber of Positions: 1Deadline: November 1

( (310) 222-3500 8 [email protected]: www.emedharbor.edu/

Global.html

Keck School of Medicine at the University of Southern California

Contact: Billy Mallon, MDDepartment of Emergency Medicine1200 North State StreetRoom 1011Los Angeles, CA 90033Fax: (323) 226-6454Length: 1-2 yearsSalary: CompetitiveShifts per week: 2Advanced Degree: MPH, DTMHNumber of Positions: 1Deadline: December 1

( (323) 226-66678 [email protected]: www.cbooth.info

UCLA-CIM International Medicine Fellowship

Nicole Durden, Program Manager UCLA Medical Center Dept. of Emergency Medicine924 Westwood Blvd., Ste 500 Los Angeles, CA 90024Length: 1-2 yearsSalary: CompetitiveShifts: 5 per month

Advanced Degree: MPH, PhD Number of Positions: 1Deadline: December 1

( (310) 794-30868 [email protected]: http://cim.ucla.edu

ConnECTICUT Yale University School of MedicineRegional Focus: Africa

Contact: Simon Kotlyar, MDDepartment of Emergency Medicine464 Congress Ave, Suite 260New Haven, CT 06519-1315Fax: 203-785-4580Length: 2 yearsNumber of Positions: 1 Salary: PGY level, MSc tuition, travel stipend, excellent benefitsShifts/hours per week: 0.5 FTEAdvanced Degree: MS, London School of Hygiene and Tropical MedicineDeadline: December 1

( (203) 785-40588 [email protected] : medicine.yale.edu/

emergencymed/fellowships/global/index.aspx

DISTrICT oF ColUMBIA George Washington UniversityRegional Focus: India, Malawi, Egypt, El Salvador, Ethiopia, Peru

Contact: Kate Douglass, MD 2150 Pennsylvania Avenue, NW, 2B-417Washington, DC 20037Fax: (202) 741-2921Length: 2 years with MPH 1 year without MPHSalary: Highly competitive, including MPH tuition and generous CMEAdvanced Degree: MPH Number of Positions: 1-2Deadline: November 15

( (202) 741-2954 8 [email protected]: www.gwemediem.com

GEorGIA Emory University

Contact: Scott Sasser, MD Department of Emergency Medicine 531 Asbury Circle - Annex Suite N - 340 Atlanta, GA 30322 Fax: 404-778-2630 Length: 2 years Number of Positions: 1 Salary: Instructor Shift / hours per week: Advanced Degree: Deadline: check with department

( (404) 778-59758 [email protected]

Medical College of GeorgiaRegional Focus: Peru, Bangkok

Contact: Hartmut Gross, MD 1120 15th StreetAugusta, Georgia 30912Fax (706) 721-7718Length: 1 yearSalary: Competitive salary, benefits, CME, international travel fundsShifts per month: half-time EM clinical faculty positionAdvanced Degree: NoneNumber of Positions: 1

( Phone: (706) 721-4412 8 [email protected]: www.mcg.edu/

ems/residency/internationalMedFellow.htm

IllInoIS Cook County Hospital

Contact: Jamil Bayram, MD & Robert Simon, MDCook County Hospital, Rush University Medical Center,and Int’tl Medical CorpsDept. of EM1653 W. Congress Parkway, 177 MurdockChicago, IL 60612Fax: (312) 942-4021 Length: 2 years (with MPH)Salary: Very competitive; benefits; tuition fees for the MPH; travel expenses and

stipends are providedNumber of Positions: 1- 2Deadline: Open


University of Illinois at ChicagoContact: Janet Lin, MD, MPHDepartment of Emergency MedicineCollege of Medicine East Suite 469A808 South Wood StreetChicago, IL 60612Length: 2 yearsSalary: N/ANumber of Positions: 1-2Deadline: Open

( (312) 413-7393 8 [email protected]

MArYlAnD The Johns Hopkins University

Contact: Alexander Vu, DO Center for International Emergency, Disaster & Refugee Studies1830 E. Monument Street, Suite 6-100Baltimore, MD 21205Fax: (410) 502-8881Length: 2 yearsSalary: Competitive Number of Positions: 1-2Advanced Degree: MPHDeadline: December

((410) 614-5665 8 [email protected]

University of MarylandRegional Focus: China, Egypt, South Africa and Botswana

Contact: Bob Corder, MDSchool of MedicineDivision of EM110 S. Paca Street, 6th Floor, Suite 200Baltimore, MD 21201Length: 2 yearsSalary: Competitive Number of Positions: 1Advanced Degree: MPHDeadline: Open

( Phone: (410)328-8025 8 [email protected]


MASSAChUSETTS Harvard University / Beth Israel Deaconess Medical Center

Contact: Philip D. Anderson, MDDepartment of EMOne Deaconess RoadW/CC -2Boston, MA 02215Length: 2 yearsSalary: Competitive, benefits, CME benefits and MPH tuitionPositions: OneAdvanced Degree: MPH Deadline: December 1

( (617) 754-23248 [email protected] Harvard University / Brigham and Women’s HospitalRegional Focus: Various

Contact: Stephanie Rosborough, MDDepartment of EM75 Francis StreetBoston, MA 02115Length: 2 yearsPositions: OneSalary: Competitive with excellent benefitsShifts/Week: 1-2Advanced Degree: MPHDeadline: November 20

( (617) 732-58138 [email protected]: www.brighamandwomens.org/dihhp/iem

nEw York Bellevue Hospital Center/New York University School of Medicine

Contact: Michael Mojica, MDEmergency Care Institute Room 345ABellevue Hospital Center27th Street and First AvenueNew York, NY 10016Length: 1 - 2 yearsSalary: CompetitiveNo. of Positions: 1

( (212) 562-8147 8 [email protected]

New York - Presbyterian: The University Hospitals of Columbia and CornellRegional Focus: Southern Asia, Kenya, Dominician Republic

Contact: Rachel T. Moresky, MDColumbia University Medical Center - Center for EM622 West 168th Street PH 1-137New York, NY 10032Length: 2 yearsSalary: CompetitiveNo. of Positions: 2Advanced Degree: MPHDeadline: December 1

( (212) 305-29958 [email protected]: www.nypemergency.org/fellowships

North Shore - Long Island Jewish Health System

Contact: Sassan Naderi, MDDept. of EM270-05 76th AveNew Hyde Park, NY 11040Length: 1 yearNo. of Positions: 1 - 2Salary: $90,000Hours per week: 18Advanced Degree: N/A

Deadline: Rolling ( (718) 470-75018 [email protected] St. Luke’s Roosevelt Hospital Center - Global Health Fellowship

Contact: John D. Cahill, MDDept. of EM1111 Amsterdam AvenueNew York, NY 10025Length: 2 yearsNo. of Positions: 2Salary: $87,000Hours per week: 20Advanced Degree: MPH optionalDeadline: Rolling

( (212) 523-33308 [email protected]: www.slredglobalhealth.com University of Rochester Medical Center

Contact: David H. Adler, MDDept. of EM601 Elmwood AvenueBox 655Rochester, NY 14642Length: 2 yearsSalary: $80,000 - $100,000/year depending on clinical

time; CME, benefits, 5k/year travelNo. of Positions: 1Advanced Degree: MPH, clinical investigation, or medical managementDeadline: April 15

( (585) 463-2945 8 david_adler@ urmc.rochester.edu

norTh CArolInA

Duke International Emergency Medicine Fellowship/Global Health Residency ProgramRegional Focus: East Africa

Contact: Charles J. Gerardo, MDDuke University, DUMC 3096Durham, NC, 27710Length: 2 yearsNumber of Positions: 1Salary: Competitive, including tuition for advanced degreeAdvanced Degree: MS in Global Health (MSc-GH)Deadline: November 1

( 919-681-44588 [email protected]


A dynamite victim gets emergency care in a Brazilian emergency department. Programs like Vanderbilt University’s International Emergency Medicine Fellowship focus on IEM work in South America.

photo by márcio rodrigues



orEGon

Oregon Health & Science University - Global Health Fellowship

Contact: Mohamud Daya, MDOregon Health & Science UniversityDept. of EM3181 SW Sam Jackson Park Road, CDW-EMPortland, OR, 97068Length: 2 yearsNo. of Positions: 1-2Salary: PGY level, CME allowance, benefitsShifts per week: 1Advanced Degree: Master’s or certificate options (tuition support provided)Deadline: Rolling

( (503) 494-8220: www.emergencyresidency.com

PEnnSYlvAnIA

University of PittsburghContact: Allan B. Wolfson, MDDept. of EM230 McKee Place, Ste. 500Pittsburgh, PA 15213Length: 2 yearsSalary: Negotiable

Shifts per week: NegotiableAdvanced Degree: MPH offered from the University of Pittsburgh Graduate School of Public Health

( (412) 647-82658 [email protected]: affiliatedresidency. health.pitt.edu

TEnnESSEE Vanderbilt University International Emergency Medicine FellowshipRegional Focus: South America

Contact: Seth Wright, MDVanderbilt University703 Oxford HouseNashville, TN, 37232Length: 1-2 yearsNo. of Positions: 2Salary: $88,000 + excellent benefits, tuition, travel expensesHours per week: 14.75Advanced Degree: MPH, DTMHDeadline: Rolling

( (615) 936-00758 [email protected]: emergencymedicine.mc.vanderbilt.edu

TExAS

Baylor College of Medicine / Texas Children’s Hospital Regional Focus: Various

Contact: Charles G. Macias, MD, MPH Texas Children’s Hospital 6621 Fannin, MC 1-1481 Houston, TX, 77030 Length: 4 years (pediatrics trained); 3 years (EM trained) with Board eligibility in PEM at completion Salary: PGY level Number of Positions: 1 Clinical Hours per week: 32-40 Conferences/week: 4 hours, except PICU rotationAdvanced Degrees: MPH, MEd, MS, MBA Deadline: August 31 through ERAS (apply for PEM Fellowship)


University of Texas Southwestern (Dallas-Parkland)Regional Focus: Mexico/Latin America

Contact: Robert E. Suter, DO, MHADiv. Emergency MedicineUT Southwestern Medical

Center at Dallas5323 Harry Hines Boulevard CS2.122Dallas, TX, 75390-8579Length: 2 years Salary: CompetitiveNumber of Positions: 4 Hours: 56 clinical hours/monthAdvanced Degrees: MPH Deadline: December 1

( (214) 648-39168 robert.suter @utsouthwestern.edu

UTAh

University of Utah Regional Focus: Ghana, Thailand, India, Peru

Contact: Eric Barton, MD Associate ProfessorDiv. of Emergency Medicine201 Presidents Circle Room 201 SLC, UT 84112Length: 1 to 2 yearsSalary: competitiveNumber of positions: 1 or 2Shifts: 7 per month/54 hoursAdvanced degrees: MPHDeadline: Rolling


oRDER NoWOfficial EPI Article Reprints Available

CONtACt: GREG RuCkER PARs Int’l

253 W. 35th street, 7th FloorNew york, Ny 10001

p: 212.221.9595, ext. 10514 Summer 2010 // Emergency Physicians International

www.epinternational.ning.com 15


www.epinternational.ning.com 15

Bhutan 18

turkey 21

vietnam 24

colomBia 26

hong kong 28

dispatches 16

This past spring, Vietnam took a strong step towards greater EM development through a historic international collaborationDetails on page 26

sourceFirsthand reports oF specialty development around the globe

a new magazine by

+

The Future of IFEMan interview with

Drs. gautam bodiwala

and Peter Cameron

Could The Netherlands

be a template for EM

development in Europe?

EMERGENCY PHYSICIANS

INTERNATIONAL

21EM DEvElopMEnT rEporTs FroM arounD ThE globE including

bhutan

turkey

Colombia

hong kong

Vietnam

South afriCa

Panama

koreaSPainCroatia

ghana

Issue 1 // Summer 2010 // epinternational.ning.com


Join ACEM’s World-Renowned FacultyJudith tintinalli on the “Career of a Lifetime”Jim holliman on “Trauma Team”RobeRt SuteR discusses “Cardiac Markers”edbeRt hSu on the “Human Stampedes” JoSeph lex on the “History of EM in Europe” CaRloS GaRCia on “H1N1: The Real Story”peteR CameRon on “The Golden Hour”and much, much more!

Please contact Dr. Mauricio Garcia at [email protected] 54D # 135-34 Int 1 Apto 403Tel (+57 + 1) 8104964cel (+57) 3108303338

Colombia: The only risk is wanting to stay!

Join the Colombian assoCiation of speCialist in emergenCy mediCine (aCem) for

“New Horizons in Emergency Medicine”

discover the beauty of Colombia at aCem’s first international Conference

November 11-13, 2010 Camara de Comercio

Sede calle 26., Bogota D.C. Colombia, South America

Registration opens August 1, 2010

English and Spanish tracks available

CASE STUDY

Dx: liver Abscesswfrom page 14

continued from page 5

1. Liver Abscesses: Abscesses may be single or

multiple. They are characterized by a hypoechoic fluid collection with a hyperechoic shaggy wall. Early on the abscess contents may be close in echogenicity to the liver parenchyma, but as the contents liquefy further, the fluid becomes hypoechoic or even anechoic.

2.Hemangiomas: Hemangiomas are the most

common primary tumor of the liver and are usually solitary. The are quite hyperechoic, often appearing bright white, and are also homogenous and well circumscribed.

3.Metastases: Metastases may be single or multiple.

They may be of similar echogenicity to the liver, but in a more heterogeneous pattern. Often liver metastases or primary liver masses are more echoic that the liver due to increased vascularity.

4.Cysts: Liver cysts may be single or multiple. They are

usually benign when they have thin walls and an anechoic fluid center. Posterior enhancement may be noted.

5.Gallbladder Stones & Polyps: For a good case

example see the November 2009

issue of Soundings or check it out at www.erpocketbooks.com

6. During a focused bedside ultrasound, you may

happen to come across a liver mass during the scan. The liver is an excellent acoustic window, so many bedside ultrasound applications will provide you with a great view of the liver parenchyma. Although EM physicians are not typically trained to make “formal” interpretations of liver sonograms, it is useful to understand some hepatic ultrasound basics so that the appropriate management decisions can be made. When a

liver mass is discovered during a focused, bedside scan, explain to the patient the limitations of your scan, and ensure that appropriate, comprehensive imaging is arranged for a definitive diagnosis.

7.Practice Makes Perfect: With bedside

ultrasound there is no substitute for experience. The more ultrasounds you do, the better you will be able to differentiate abnormal from normal, even when you may not be sure exactly what the abnormality is.

pearls & pitfalls for Imaging liver masses

This image demonstrates a view of the right upper quadrant using the 2.5 Mhz curvilinear probe just below the costal margin. The liver is moderately echoic and takes up most of the image. The abscess has an anechoic/hypoechoic center with a slightly hyperechoic surrounding rim. The diaphragm is very hyperechoic and sepa-rates the liver in the near field (top of im-age) from the lung in the far field (bottom left of image). The right kidney cannot be seen in this image, but is nearby.

Liver abscesses may be caused by a va-riety of organisms. Pyogenic abscesses cause about 80% of cases and are often polymicrobial with e. coli or klebsiella pneumonia being the primary pathogen. entamoeba histolytica causes about 10% of cases and Candida albicans or another fungal organism is the usual cause in the remaining 10%. treatment usually entails antimicrobials targeted at the suspected organism or organisms and drainage, of-ten performed percutaneously.

Your patient is admitted to the hospital overnight for antibiotics and antiparasit-ics. In the morning he is improved and is

liVer

abscess

**

*

*

***

*

Diaphragm

discharged so that he can get himself to the closest urban hospital where they perform a

Ct guided drainage of the abscess. The cul-tures grow out klebsiella pneumoniae.

AbouT THe AuTHors

braDy Pregerson manages a free online em

ultrasound image library and is the editor of the emergency

medicine Pocketbook series. for more information visit ERPocketBooks.com

Teresa wu is the em ultrasound Director and Co-Director for

simulation based Training for the maricopa emergency medicine

Program in Phoenix, arizona.


Join ACEM’s World-Renowned FacultyJudith tintinalli on the “Career of a Lifetime”Jim holliman on “Trauma Team”RobeRt SuteR discusses “Cardiac Markers”edbeRt hSu on the “Human Stampedes” JoSeph lex on the “History of EM in Europe” CaRloS GaRCia on “H1N1: The Real Story”peteR CameRon on “The Golden Hour”and much, much more!

Please contact Dr. Mauricio Garcia at [email protected] 54D # 135-34 Int 1 Apto 403Tel (+57 + 1) 8104964cel (+57) 3108303338

Colombia: The only risk is wanting to stay!

Join the Colombian assoCiation of speCialist in emergenCy mediCine (aCem) for

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November 11-13, 2010 Camara de Comercio

Sede calle 26., Bogota D.C. Colombia, South America

Registration opens August 1, 2010

English and Spanish tracks available

52 Summer 2010 // Emergency Physicians International www.epinternational.ning.com 52

GE Healthcare

GE imagination at work© 2010 GE Healthcare, a division of General Electric Company.

Introducing Vscan™ pocket-sized ultrasound.

Learn more about this bedside visualization tool for your Emergency Department. Go to vscan.gehealthcare.com.

GE Healthcare supports the promotion of approved, on-label uses and applications of Vscan only in those countries in which Vscan has been cleared for use by the applicable regulatory authorities. For more information on Vscan, please go to vscan.gehealthcare.com.

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