EPI Spring 2011 Issue 4

MSF in embattled Ivory Coast Peter Camerons IFEM Rundown Common Laryngoscopy Mistakes
EMERGENCY PHYSICIANS INTERNATIONAL
the south america issue

a r g e n t i n a
An in-depth dossier from the land of contrast
c o l o m b i a
A young EM society gains national recognition
EM Development Reports from
Croatia south africa & japan

Issue 3 Spring 2011 epinternational.ning.com
the 8th Annual NY Symposium on
INterNAtIoNAl emergeNcY medIcINe

an IFEM REgIonal SyMpoSIuM
Global Collaborations in Emergency Medicine
August 17 18, 2011 lenox Hill Hospital New York city

gueSt SpeAkerS:
Joe ONeill, MD Founder of PEPFAR Peter Cameron, MD President of IFEM Lee Wallis, MD President of EMSSA & AFEM Abdel Bellou, MD President of EuSEM Robert Bristow, MD Columbia University Latha Stead, MD University of Florida plus . . . Chairs of IEM Sections for ACEP, SAEM, AAEM, ACOEP, CAEP, ACEM and EuSEM
topIcS:
Lessons Learned from 15 years of IEM collaboration Rebuilding in Haiti, Japan and Africa Building an IEM Fellowship Consortium Public-Private Partnerships for Comprehensive IEM Development
RSVP to: ifemconference2011@gmail.com or call (516) 562-1223 CouRSE DiRECtoRS: Kumar Alagappan, MD Sassan Naderi, MD Terrence Mulligan, DO, MPH John Acerra, MD, MPH
plus . . . Meet the IEM Fellowship Directors
FACu Lt y /At t eN Di Ng S : $ 1 2 5 | R e SiD eNtS: $25 | S tu DeNtS : FRee

2
Spring 2011 // Emergency Physicians International
Editors Desk
Southern Exposure
his issue of Emergency Physicians International (EPI) is focused on emergency medicine in Latin America. It has been both exciting and gratifying to observe the rapidity and intensity of EM development in Latin America the past few years. A number of countries have formed strong, active national EM organizations, and theyve been active participants in the International Federation for Emergency Medicine (IFEM). Several of the national EM organizations have conducted very high quality large international EM conferences (read our report from Colombias 1st international conference on page 28). In fact, for a few years, the attendance at the conferences in Argentina was the largest number of attendees at an EM conference ever. Only in the past couple of years has the American College of Emergency Physicians (ACEP) annual Scientific Assembly exceeded the numbers in South America. Several EM journals have been started in Spanish, and other excellent EM teaching resources (such as the textbook Emergencias) have been produced. Latin American authors are also contributing book chapters to EM reference texts, including EMS: A Practical Global Guidebook. I have been particularly impressed with the leadership development in emergency medicine which has been prominent in Mexico, Argentina, and Colombia. Well-organized EM residency programs are proliferating throughout Latin America, and many of the graduates of these programs are in EM leadership positions early in their careers. I think the two next important developments in Latin American EM on the horizon are research programs and academic department evolution. A number of the EM faculty and recent EM residency graduates have already demonstrated their ability at conducting and presenting clinical research, and as EM further expands and matures in Latin America the potential for international collaboration on projects should increase and be facilitated. Another aspect or opportunity for increased international collaboration in EM will be in providing response to natural disasters, as was demonstrated by Latin American teams last year responding to the earthquakes in Haiti and Chile. So, congratulations to all our emergency medicine colleagues in Latin America, and our best wishes for your further development of the specialty and for increased international cooperation and collaboration!
I think the two next important developments in Latin American EM on the horizon are research programs and academic department evolution. A number of the EM faculty and recent EM residency graduates have already demonstrated their ability at conducting and presenting clinical research, and as EM further expands and matures in Latin America the potential for international collaboration on projects should increase and be facilitated.
C. James Holliman, MD, FACEP, FIFEM editorial director
summer 2010
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With a circulation of 8,000 (quarterly) and an online network of more than 900 members, EPI is the new hub for global emergency care, sparking dialogue and creating a space for new collaborations. Find copies of the print magazine at international EM conferences around the world, or read it online at www.epinternational.ning.com
Join the team

Have an interest in emergency medicine development or in global emergency care? Emergency Physicians International needs your input. To submit or suggest an article, or to simply tell us about emergency medicine in your country, email Logan Plaster at Logan@PlasterPub.com or log on to the EPI Network at www.epinternational.ning.com
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EM DEvElopMEnT rEporTs FroM arounD ThE globE

including
bhutan turkey Colombia hong kong Vietnam South afriCa Panama korea SPain Croatia ghana
an interview with Drs. gautam bodiwala and Peter Cameron Could The Netherlands be a template for EM development in Europe?
The Future of IFEM
www.epinternational.ning.com
Letter from the publisher
Passionate Pioneers
didnt quite know what to expect when I touched down in Bogota, Colombia, for the first international conference hosted by ACEM (Asociacion Colombiana de Especialistas en Mediciona de Urgencias y Emergencias). The vast, fog-filled valley of the Andean plateau stretched out before me, setting a dramatic stage for Colombias newest emergency medicine society to present itself to the national medical establishment, and the world. What I discovered was a fledgling society capable of hosting a world-class educational event (read about it on page 28). I witnessed the energy of a new generation of EM residents who were as friendly as they were passionate. I met physicians who had more reason than most to be jaded (in Medellin there are about nine people killed daily) and yet were passionate, even upbeat, about the future of their specialty. I also witnessed this new organization take historic steps towards national acceptance. And Colombia is not alone. In Croatia, the government has seen fit to bring in international emergency medicine experts to help revamp their EM and EMS systems (story on page 16). In South Africa, a team of emergency physicians have recently formed the African Federation for Emergency Medicine, as well as the first African Journal of Emergency Medicine (story on page 18). Those stories are what Emergency Physicians International is all about. Welcome to this, the third issue of EPI, the South America edition. This issue we take an in-depth look at Colombia and Argentina, while also touching on topics from laryngoscopy to post-Tsunami Japan. We are excited to be printing four issues this year, with distribution at international conferences in South America, Asia, Europe and Africa. Whether youve read EPI before or this is your first issue, welcome to the conversation. And dont forget to sign on to the EPI Network (www.epinternational.ning.com) where the dialogue continues online.
publisher Logan Plaster Logan@Plasterpub.com editorial director C. James Holliman, MD executive editors Peter Cameron, MD Terry Mulligan, do, mph Mark Plaster, MD associate editor LONNIE STOLTZFOOS regional corespondents Conrad buckle, md Marcio Rodrigues, MD Carlos Rissa, md Katrin Hruska, MD editorial advisors ARIF 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 advertising Michelle rucks mrucks@epmonthly.com 5 College Avenue Annapolis, MD 21401 Submissions & Letters c/o logan plaster Emergency Physicians International 210 Columbia Heights Brooklyn, NY 11201 logan@plasterpub.com
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EVENT CALENDAR
06/115/12
12 months of international EM c o n f e r e n c e s
JUNE/2011
5th Dutch North Sea Conference in Emergency Medicine // Egmond aan Zee, The Netherlands
Focusing on EM education, research and collaborations in The Netherlands and EU June 9 10, 2011 www.nvsha.nl English and Dutch spoken
AUGUST
pVisit Cape Town for next Novembers
Emergency Medicine in the Developing World paramedical and nursing staff. October 6 7, 2011 www.emrs.scot.nhs.uk
The IFEM-NYC Symposium on International Emergency Medicine // New York City, USA
Join speakers like Peter Cameron, Lee Wallis and Abdel Bellou for this gathering about global collaborations. Plus, meet the directors of IEM fellowship programs. August 17 18, 2011 www.ifem.cc
The American College of Emergency Physicians (ACEP) Scientific Assembly // San Francisco, USA
The largest emergency medicine meeting in the world, ACEPs scientific assembly will bring together the best EM educators in the United States with a large and active international interest group. October 15 18, 2011 www.ACEP.org
Segundo Congreso Internacional de Reanimacin // Mexico

From basic to advanced CPR, pediatric to adult, in-hospital and pre-hospital care. June 9 11, 2011 http://cuatrof.com/rcp
SEPTEMBER
Sixth Mediterranean Emergency Medicine Congress // Kos, Greece

Come to Greece for this biennial event hosted by EuSEM, AAEM and HeSEM. September 10 14, 2011 www.emcongress.org/2011
Basic Life Support in Obstetrics for Emergency Medicine // San Miguel de Allende, Mexico
Along with track chair Judith Tintinalli, the course will focus on the EM provider, with the intent of establishing the BLSO as a standard for modular training in EM. June 20, 2011 www.eacem.org
NOVEMBER
III Brazilian Congress of Emergency Medicine // So Paulo, Brazil

The Brazilian Association for Emergency Medicine and So Paulo University, School of Medicine will host this congress. September 22 25, 2011 www.abramede.com.br
Symposium on Quality and Safety in Emergency Care // London, England

CEM and IFEM unite to bring together this first-of-its-kind symposium, held at the British Museum November 15 16, 2011 www.ifem.cc
1st 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 www.ifemsymposium2011.com English with Spanish side events
The European Trauma Course // Verona, Italy

The European Trauma Course (ETC) has been developed to teach a system of care for managing trauma patients that is pragmatic, reflecting the reality of emergency medicine throughout Europe. September 22 24, 2011 www.erc.edu
Emergency Medicine in the Developing World // Cape Town, South Africa

All aspects of emergency care will be covered in the scientific and educational plenaries of this biennial, regional African conference. November 15 17, 2011 www.emssa2011.co.za
JULY
Asian Conference for Emergency Medicine (ACEM) 2011 // Bangkok, Thailand

Emergency Medicine in Global Crises: Lean, Safe & Seamless July 4 6, 2011 www.acem2011.org
OCTOBER
January/2012
Retrieval // Glasgow, Scotland

The conference will focus on the full spectrum of prehospital, transfer and retrieval medicine, applicable to medical,
The 1st Middle East Emergency Medicine Conference // Dubai, UAE

For information, contact Aileen Culligan at conference@uae.messefrankfurt.ae January, 17 19, 2012
List your next international event for free on the EPI Network
w w w. e p i n t e r n a t i o n a l . n i n g . c o m www.epinternational.ning.com
3 | Editors Desk 5 | Event Calendar 32 | IEM Fellowship Directory
EMERGENCY PHYSICIANS INTERNATIONAL

29 | Q&A p Dr. Mauricio Garcia Romero talks about how the recent ACEM conference in Bogota exceeded expectations and paved the way for the future. 8 | Clinical Airway guru Rich Levitan explains the top laryngoscopy mistakes that emergency physicians make, and how to avoid them. 10 | Relief Q&A with MSFs Cristina Bertocchi, a trauma surgeon who spent time this spring in the embattled Ivory Coast. 35 | Grand Rounds Dr. Peter Cameron gives a state-of-the specialty address covering the four corners of the globe.
22
Source
14 | Dispatches This month, readers answer the question: What is a case that exemplifies emergency care in your region? 16 | Croatia New certification standards for EM specialists point to hopeful longterm progress. 18 | South Africa Now that the World Cup is history, can South Africa sustain emergency care development and bring regional healthcare to a new level? 20 | Japan u Lessons learned in emergency and disaster medicine in the wake of the Great East Japan Earthquake.
20
Features
22 | EM Development in the Land of Contrast Emergency medicine may be a new specialty in Argentina, but South Americas southernmost nation is showing signs of growth, from new residencies to publications to some of the worlds largest EM conferences. 28 | Colombia Takes Strides ACEMs international conference last November put on display the specialtys clout and unity.
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CLINICAL
How to Avoid Common Laryngoscopy Errors

Intubation has unique educational challenges because of severe time restrictions and patient risk. Repetitive practice cannot be done on the same patient to separate and examine the components of the procedure in real time. As a result, most clinicians improve their skills slowly, through cumulated experience of trial and error. Here are a few common laryngoscopy mistakes, and how to avoid them.
by Rich levitan, MD
look, otherwise the target is not in focus. The Fix: Determine your ocular dominance and examine whether you have the right visual corrective lenses for a distance of 12 to 18 inches. To find out your ocular dominance, hold a laryngoscope with a straight blade attached and look down the barrel of the blade at a small target. Without moving your head, alternatively close one eye and then the other. When you close your dominant eye the image will move and no longer be positioned centrally at the end of the
Error #1: Failing to appreciate the optical components of the procedure. Direct laryngoscopy is visually challenging, with the larynx itself sighted only by the operators dominant pupil, at a distance of 12-18. It is visually analogous to looking down a narrow pipe at a target the size of a quarter. The restrictions affecting direct sighting of the larynx result from the cumulative barriers of the mouth, teeth, tongue, epiglottis, and the dimensions of the laryngoscope blade. The other major variable in sighting the larynx is the operator (i.e. their specific visual acuity and light requirements). Beginning in our early forties, the near accommodation point of persons, even with a history of perfect sight, begins to change. Our near accommodation point moves 2-3 cm outward until our fifties. Reading and driving lenses are not the right distance for sighting the larynx; reading lenses are too close, and driving lenses focus too far. Continuous bifocals, or progressives, make matters even worse. As the distance to the visual target changes looking into the mouth and down to the larynx, the operator has to tilt their head and adjust the specific region of the eyeglass through which they
q Right and left-eyed laryngoscopists: In left-eyed laryngoscopist the head is rotated toward right (right image) aligning the left eye to the target. In right-eyed operator the head is positioned straight relative to patient (right eye aligned with target).
blade. When you close the non-dominant pupil the image does not move. During direct laryngoscopy we subconsciously suppress the non-dominant image because we cannot achieve stereoscopic sight (merge the right and left disparate views). About 85% of operators are right eye dominant; if you wear corrective lenses or are left-handed, there is a higher chance you will be left-eyed. [Levitan RM, et. al. Contrary to popular belief and traditional instruction, the larynx is sighted one eye at a time during direct laryngoscopy. [letter] Acad Emerg Med, 5:844-6, 1998.] [see Figure 1]. The ideal target distance is found between your left arm bent at ninety degrees and full extension. Ideal corrective lenses for laryngoscopy should not be progressives; proper lenses will not only allow you to focus at a closer distance (for those of us older than 40), but also provide slight magnification. A final consideration of laryngoscopy optics involves the illuminance of laryngoscope blades. Especially as we age, brighter laryngoscope lights make an enormous difference. Many EDs stock laryngoscope blade and handle pairs that produce inadequate light [Levitan RM, et. al. Light intensity of curved laryngoscope blades in Philadelphia emergency departments. Ann Emerg Med. 2007; 50:253-7.]. Error #2: Extending the patients head backward (i.e., alanto-occipital extension) Ideal patient positioning for direct laryngoscopy involves having the patients face plane parallel to the ceiling, and elevating the head until the patients ear is horizontally aligned with the sternal pPositioning a patient to achieve ear-to-sternal notch alignment notch. Imagine how patients position themselves In the top image, the head of the bed has been lifted and sheets are placed under in respiratory distress---leaning their head forward the top of the shoulders and occiput. The face plane is parallel to the ceiling. In the relative to the chest. We should recreate this posilower image, a trauma stretcher is tilted to lower the foot of the bed, effectively raistion in a supine orientation for direct laryngoscopy ing the head relative to the stomach, while maintaining cervical spine precautions. [bottom]. In thin patients, a slight lift of the head of the stretcher and a towel or two will be adequate. For the morbidly obese, this may require a massive ramp under the upper back and shoulders. [Collins The Fix: Elevate the head to achieve ear-to-sternal notch positioning relative JS, et. al.. Laryngoscopy and morbid obesity: a comparison of the sniff and to progressively down the tongue and always find the epiglottis. In trauma cases ramped positions. Obes Surg. 2004;14: 1171-5.] In patients in whom cervical with cervical spine precautions, consider tilting the foot of the bed down. Have spine precautions exist, the stretcher can be tilted to lower the foot of the bed, a Yankauer suction tip ready to dab the posterior pharynx, suctioning any acalthough the head cannot be raised relative to the torso [the front of the collar cumulated fluids, and be mindful of epiglottis camouflage. should always be removed and the head stabilized by an assistant]. Proper positioning is critical for finding the epiglottis. Atlanto-occipital exDr. Levitan teaches emergency medicine at Jefferson tension pushes the epiglottis back against the posterior pharyngeal wall, making Medical College and at the Univ. of Maryland and helps run it harder to identify and harder to distract. This is a major factor in what I call a monthly airway management course involving specially epiglottis camouflage, where the epiglottis edge disappears against the pharynprepared cadavers: jeffline.jefferson.edu/jeffcme/Airway geal mucosa. Avoiding over-extension, and having a suction tip catheter available This article originally appeared in the March 2011 edition of to dab the posterior pharynx, where fluids will pool and cover the epiglottis, are Emergency Physicians Monthly. both critical for epiglottoscopy. Also, having the head higher than the stomach is just a prudent thing in patients at risk for aspiration (i.e. full stomach). Finally, there are dramatic benefits in the efficacy of pre-oxygenation and mask ventilation with the head elevated position.
DISASTER RELIEF
Cte dIvoire
Trauma Surgery in Embattled Ivory Coast
u In the Spring of 2011, surgeon Cristiana Bertocchi finished a stint in Cte dIvoireIvory Coastworking with Mdecins Sans Frontires (MSF). She served in the Abobo Sud neighborhood of Abidjan, one of the main flash points in the countrys widespread violence. At the time of her visit, the Ministry of Health hospital in Abobo Sud was the areas only fully-functioning hospital and one of the few in the city. Medical teams there treated hundreds of emergency patients, most of whom had bullet wounds. Interview by MSF Staff
MSF: Can you tell us about Abobo Sud hospital? Dr. Cristiana Bertocchi: The hospital is in the most volatile neighborhood of Abidjan, and for the most part that neighborhood has been abandoned. When you take the road from the house, the base we had in Abidjan, to the hospital [in Abobo] it was winding roads of nothingness: no one on the streets; burned-out car carcasses on sides of road; barricades in different areas. Sometimes armed people would be manning barricades and would come out and question and threaten you. Within the hospital itself, fortunately, there was no violence. But we were close to it, and there was gunfire outside the hospital walls. Gunshots would be heard any time throughout the day, and it could persist for quite some time and be very nearby and sound as if it were actually within the hospital walls. We would all run for cover when that would occur. What sorts of injuries were you treating?
Following the outbreak of violence that occurred on March 17, the teams received 66 wounded by bullets or shrapnel that day. Didier Assal/MSF
What was it like inside the hospital? It was extremely stressful because you had many patients that you were trying to triage and many patients to get in and out of operating room. Youre triaging those people who look likely to survive against the ones that are not. And there are ones that we might have been able to save back home, under calmer conditions, but in a mass casualty situation you probably couldnt because there are so many you have to deal with at the same time. If they had been coming individually instead of mass situation, you would have been able to do something for them, and that was definitely a difficult thing to deal with. At the same time, you have no idea what is outside, security-wise. And you feel you and the hospital grounds are at risk at any moment. It was pretty continuous. With that mass casualty we were running at full capacity 48 hours straight. Otherwise with other incidents we pretty much operated until 11, 12, 1 in the morning. Then wed have a few hours break before starting up again in morning when sun came up and more injuries started coming in. Was it quieter at night? There werent too many that would come in middle of night that required surgery. That goes with situation at night: people are afraid to travel. There wasnt quite as much shooting going on within the vicinity at night. We would hear of some things going on further away. What were some of the other procedures you were doing? We did do a lot laparotomiesI think averaging four or five laparotomies a dayopen abdominal surgery for a variety of injuries inflicted by gunshots. We had several bowel injuries, injuries to bladders, liver injuries. We also did some C-sections, emergency C-sections. We did have a maternity ward with two midwives who assisted. For women unable to deliver vaginally we took them to the OR. We had a lot of fractures, open fractures, open bullet wounds requiring debridement, and then fractures that resulted from bullet wounds that also required debridement and fixation. How were the results? Our success rate as far as patients we took to OR and their survival and
I wasnt at hospital every day of the week but in the first 48 hours, we had between 15 and 20 patients per day with a variety of gunshot wounds. Several were quite severe. Within first 24 hours, I had two patients who were shot multiple times in the head, for which we could do nothing.
Were you getting a few people at a time or large numbers all at once? There was one incident on March 17 which made international news. I guess a missile was fired into a market in Abobo. About 60 or so patients were brought to the hospital. Eight were already dead on arrival and I think another eight died during triage. We had one operating room fully functional and going nonstop. A second operating room we were able to open up; however, we only had only one anesthesiologist, so we were limited in how much we could do. The ones that came with that mass casualty were men, women, some children, mostly with blast wounds. Some were quite severe. We had a woman whose arm was essentially torn. The muscle was torn off. She was left with a big hole in her upper arm. Fortunately, it did not hit any of major vessels or break any bone. We had another guy with mangled hand and several with deep abdomen wounds that required surgery. One died on table from an aortic injury.
10
Following the presidential election of November 2010, Ivory Coast fell prey to armed clashes. In Abidjan, MSF set up emergency support in collaboration with the Ministry of Health in Abobo South Hospital. Chibuzo Okanta/MSF
expected prognosis seemed to be pretty good. But, again, there were a lot of patients. Going back to first 24 hours, I had two with bullet wounds to head. We also had two other patients with gunshot wounds who seemed perfectly stable on arrival, and 15 minutes later, they were dead. We couldnt get them to the OR fast enough because there was already a case going. I can only guess at what their internal injuries were. Based on the bullets wounds one person had, Im guessing a vena caval or hepatic vein injury. Injuries that are difficult to deal with even in a sophisticated trauma center. And with all of the violence we would hear going on outside hospital walls, you can only guess how many more patients out there never made it to hospital. Had you been in an environment like this before? No, Ive not. And from what I could understand, of other international staff I was working with, even for them this was very unusual as far as situations MSF works in. It was extremely stressful and difficult for all of us to work and provide the quality of care we felt we were able to provide under normal circumstances. It sounds like your previous stint in Ivory Coast with MSF was quite different. Well, my first time was essentially the end of the conflict in 2006. And we were passing back the mission hospital to the Ministry of Health. It was totally peaceful. So, completely different climate and different situation this time around. It did not compare in any way at all. Last time, was doing emergency general surgery. This time I was doing emergency trauma surgery.
MSF is a medical humanitarian organization that observes strict neutrality and impartiality in its operations. Its activities in Ivory Coast are funded exclusively by private donors, ensuring its complete independence. MSF is working in Abidjan, providing emergency medical assistance with the collaboration of the Ministry of Health in the Abobo Sud hospital. In the western part of the country, it is providing primary healthcare services and supports hospitals in Dukou, Guiglo, and Bangolo.
11
source
Firsthand reports of specialty development around the globe
dispatches 14 croatia 16 South africa 18 japan 20

Diocletians Palace, in Split, Croatia, was built by the Roman emperor Diocletian at the turn of the fourth century AD. Croatia Report on page 16
13
SOURCE // DISPATCHES
READER-SUBMITTED UPDATES FROM WEST TO EAST
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11
12
Q. Describe a case that exemplifies the setting in which you work

_______________________
1
UNITED STATES Young pregnant female with vaginal bleeding; elderly male or female short of breath or with chest pain; patient of any age with abdominal pain; patient of any age with low or medium speed motor vehicle collision. _______________________
2
COSTA RICA Lots of patients (about 140,000 per year), <5 emergency medicine
physicians per hospital working with other specialty doctors, and much resistance to changing our medical practices to more efficient models than what we currently practice. We have three main alternating functions in the department. The first is doctor in charge, who is responsible for inflow and out-flow of patients coming through the ED. We regulate the flow of patients coming to be hospitalized, supervise interns from various other specialties making rounds in the ED, and make a rapid assessment of some patients. The second role is triage doctor, ensuring an effective bedside triage with the triage nurse. We even-
tually see and treat triage patients, if possible, and assist the doctor in charge. In the third role, doctor of minors, we coordinate care of less severe injuries (such as orthopedic injuries), supervision of interns, and making a see-and-treat/fast-track, if necessary, depending of the flow of patients. _______________________
critical care beds, almost 30 beds for observation, and 500 beds for hospitalization. There are 24-hour cath lab, intermediate care, ICU, and renal transplantation services. There are days in which the service is overcrowded (70% of the time). _______________________
4
BRAZIL I work in two different places: a university hospital emergency department, which is full of patients, but where we have access to all kinds of exams and therapies; the second is a
3
COLOMBIA This is a Level III Public Hospital (Level I trauma), belonging to the University of Antioquia, with four
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A 34-year old manual worker who has been abusing NSAIDs presents with acute abdomen from perforated gastric ulcer in shock from distributive shock. GHANA
13
14
_______________________
6
UNITED KINGDOM We recently became a trauma center in London, receiving at least 10 traumas per day. We recently had a 5-year-old girl who was shot in the chest. We performed a thoracotomy in ED, then went to the emergency theatre. The patient survived. _______________________
cal patients or patients who are in need of thoracic surgery. All other patients are present on a typical day, varying from small surgical problems to patients in cardiac arrest or septic shock. _______________________
_______________________
12
TURKEY Cases here are not especially unique, although there are fewer drug abuse cases. There can be overcrowding (over 500 patients per day, excluding pediatric patients) here at our Level I trauma ED at a government-owned teaching hospital.
10
YEMEN A man has a motorcycle accident resulting in severe head trauma. Because of the lack of ambulance services, he is brought to the ED of the largest government hospital in a taxi by bystanders. They leave him in the hospital. He is placed in a room with no equipment except an oxygen tank, an old suction machine, and wound care materials. He cannot pay (he is unconscious and has no one accompanying him), so he is given some treatment free. Unfortunately the only treatment available is IV fluids and antibiotics. There is no portable X-ray machine, and no CT scanner in the hospital. His wounds are sutured and dressings applied, and he is placed in an empty room with the hope that a relative may find him to purchase lab tests, X-rays, and medications for him. If his condition worsens, incorrect attempts at CPR may be tried before he dies. _______________________
7
GHANA A 34-year old manual worker who has been abusing NSAIDs presents with acute abdomen from perforated gastric ulcer in shock from distributive shock. It takes 24 hours to get electrolyte report. Radiography takes 46 hour to be done. It takes the surgeon house officer several hours to see, and report to the resident to come and see. It is just as difficult to get the anesthesiologist to see the patient and agree to surgery. _______________________
_______________________
13
THAILAND A call on the police radio for a FR to attend an accident. Two rival volunteer groups attend the accident and arrive at the same time, a fight ensues, the group with the most weapons wins and hastily takes the patient to a government hospital far away because the patient does not have insurance to go to a hospital nearby. Vitals are not checked at the scene or en route, and even if they are, when they arrive at the hospital the doctors or nurses are not interested in what a rescue worker has to say, anyway, and are often told to leave, turned away or abused. No other information is ever received about the patient by EMS workers. _______________________
small ED financed by the main administration of my city, which is also full of patients, but we do not have a good structure. _______________________
8
SPAIN Male patient, 55-years-old, without personal or family diseases, who comes to the ED with discomfort. _______________________
5
SWEDEN If a patient case would exemplify the settings in which I work, it would be an elderly patient, probably a female >80 years old, previously quite healthy, brought to the ED because of a falling accident in her home, resulting in a fracture.
11
BAHRAIN On average we treat 300,000 patients/year including pediatrics which overall includes 60% of emergency cases. We work in three shifts with an average of eight physicians working in each shift duty.
14
GUAM Two men come in to the emergency department intoxicated, each with stab wounds in chest from an altercation. Requires multiple tube thoracostomies.
9
NETHERLANDS I work in the largest peripheral hospital in the Netherlands. We see approximately 120 patients a day in two locations. As a Level II trauma hospital we dont see neurosurgi-
15
source
The resuscitation room in Rebro Hospital in Zagreb, the capital and largest city in the Republic of Croatia. Since the end of the war in the 1990s, this city of 1 million has attracted close to a million visitors annually.
croatia & the EU: A brief timeline

Croatia submits formal application for EU membership.
2003
New certification standards for EM specialists point to hopeful long-term progress

by C. James Holliman, MD
croatia
EU agrees to start accession talks with Croatia.
2004
mergency Medicine (EM) in Croatia is looking ahead to significant positive developments. The Croatian government has recently passed new legislation to reorganize emergency health care delivery in Croatia. Currently, Croatia mainly uses the Franco-German model of EMS with physicians staffing most of its ambulances, and hospital based emergency care is provided by specialists and sub-specialists in multiple other medical disciplines. Most of the hospital emergency facilities have multiple single rooms for each different specialty. Emergency Medical Services (EMS) units often take patients to their EMS Centers, which are independent facilities not connected with hospitals. Some of these EMS Centers are fairly well equipped, with clinical laboratory and radiology services available. Many of the patients seen at the EMS Centers only have primary care issues, but if a patient seen at an EMS Center needs to be admitted to the hospital after initial or resuscitative treat-
ment, the patient has to be placed back in the ambulance and then transported to the hospital. Although there is a designated trauma hospital in the capital city of Zagreb, it is in a building by itself and is not connected to a full service hospital or emergency department. A formal trauma referral or facility classification system does not yet exist in Croatia. EMS in Croatia is administered largely at the county level. There are multiple small dispatch centers that are not linked, and many of the EMS Centers have their own dispatchers. The training for EMS physicians is not specified, and many have no additional training after graduating from medical school; there are no operational EM residency training programs. Also, there are no defined standardized clinical protocols for prehospital clinical care. Reform The Croatian government has noted these inefficiencies and inadequacies of emergency
In June, the EU cancels the next round of EU membership talks with Croatia, citing a lack of progress in resolving a longstanding border row with Slovenia.
2009
In November, Slovenia lifts block on Croatias EU membership talks after the two countries sign deal allowing international mediators to resolve their border dispute. Croatian EU membership talks resume.
2009
source: BBC.co.uk
care delivery and has passed new legislation to correct some of these problems. EM has been officially recognized as a medical specialty even though there is little structure to support it as of yet. The designation of EM Specialist has also been created, and about 70 healthcare workers will be given the designation by July, 2011. According to the new regulations, the title of emergency medicine specialist can be given to a medical doctor who has more than 15 years of practice in outpatient emergency care and is a specialist in internal medicine, general surgery, anaesthesiology, reanimatology, and intensive care or family/general medicine. They must have more than 10 years of emergency care practice, they must practice in an emergency medicine institution, and they must pass the specialist board examination in emergency medicine. These criteria are subject to a recommendation of the Expert Council of the health institution where the applicant works, as well as an opinion of the Croatian Medical Chamber about the applicants performance in the field of emergency care. While these regulations are promising, there is still much work to be done. There is no certification exam for these EM Specialists, for instance. A 5-year curriculum for residency training has been proposed, which includes 11 months of EMS experience and multiple short clinical rotations to other specialties. The new legislation has also established The Croatian Institute of EM as the umbrella organization at the national level to build a better more integrated system of emergency healthcare delivery. The Croatian government has contracted the Zagreb-based consulting firm Karol Consulting to analyze the national situation of EM and EMS, compare its standards to those of other national systems, and to make recommendations for improving EM and EMS in Croatia. (Table) These proposals and recommendations are, of course, very ambitious, and the process of bringing them about fully is estimated to take 1520 years, according to Karol Consulting. This comprehensive EM and EMS development plan for Croatia can serve as a model plan for many other countries that face the same challenges and wish to improve the delivery of emergency health care services to their populations.
16
The EMS Center in Karlovac (L) and the Karlovac ambulance. Croatian EMS crews have special 4-wheel drive vehicles for reaching roadless areas.
The main recommendations of Karol Consulting for the EM and EMS systems in Croatia
Transition the focus of emergency care delivery from the prehospital environment to the hospital-based emergency department.
personnel at the paramedic and Emergency Medical Technician (EMT) equivalent level, and gradually transition to having all ambulances staffed by paramedics and EMTs.
Equip and staff full service hospitalbased emergency departments.
vational experience in other countries, direct instruction by faculty from other countries, and by having some physicians undertake full residency training in existing residencies in other countries.
trauma referral system.
for EM and EMS.
10 11
Define training for nurses who will work in emergency departments. Define Continuing Medical Education requirements for physicians, nurses, and other emergency health care personnel.
14
Gradually transition the EMS doctors to full-time work in hospital based Emergency departments.
4 5
Close the EMS Centers and transfer their equipment to hospitals. Standardize training and certification of prehospital
Define training for an advanced level paramedic equivalent (IC paramedic or intensive care paramedic) who would respond to assist other EMS units with severe or multiple casualty situations, and conduct interhospital transfers of patients with complex illnesses.
Develop a quality of care improvement system to include quality of care indicators and linkage of governmental funding to these quality indicators.
Develop EM residency training programs at several of the larger hospitals in Croatia, and have the residency curriculum meet the requirements of the already approved European Society for EM and International Federation for EM curricula.
15
12
Regionalize the administration of EM and EMS to have all EMS dispatching conducted by 4 regional dispatch centers.
Develop training in emergency care for the rural General Practice doctors, and coordinate their primary care services with EM and EMS services.
Develop core faculty for EM residencies, utilizing short term courses, obser-
Develop designated trauma centers at 4 of the largest hospitals and develop a
13
Develop standardized equipment and medication lists and standardized clinical care protocols
16
Develop national level certification exams for EM physician specialists and for nurses and EMS personnel.
17
Source
Thanks to funding during the FIFA World Cup, South African EM coordinators gained an arsenal of modern equipment. Now that the party is over, will the RSA be able to keep up the momentum?
Guidelines, Journals for EM in a Developing Africa The Emergency Medicine Society of South Africa (EMSSA) and the African Federation for Emergency Medicine (AFEM) have published a handbook of disaster medicine for Southern Africa, drawing from combined years of experience in the field and speaking specifically to the challenges faced in the developing world. EMSSA has published their new national guidelines on both procedural sedation and Rapid Sequence Intubation. The society is also hard at work preparing for their third Emergency Medicine in the Developing World Conference, to be held in Cape Town November 15th17th, 2011. EMSSA was recently awarded the privilege of hosting the International Conference on Emergency Medicine (ICEM) in 2016, hot on the heels of Dublin (2012) and Hong Kong (2014). AFEM is helping to drive a number of collaborative and supportive projects in Botswana, Tanzania, Ghana, and Rwanda. This new regional society is tentatively planning its first conference for November 2012 in Ghana. AFEM has gathered members together on a virtual network at africanemergcare.ning.com. This site has reached 200 members and features blogs and conference links. The first edition of the African Journal of Emergency Medicine will be published in May 2011. This is exciting news for burgeoning emergency care researchers on the continent and will hopefully lead to an active collaborative research network throughout Africa. The future looks bright for emergency care in South Africa, and there are no signs that the rapid growth of the speciality will slow down. We continue to acknowledge the contributions of individuals and organizations, both at home and abroad, who have helped us achieve all of this. EM in South Africa cannot develop in isolation, and we thank you, the international EM community, for your ongoing support, and we welcome your input. For further details on the African Journal of Emergency Medicine contact enquiries@ afjem.com
facts & figures

Number of official languages. Three most common are Zulu, Xhosa, and Afrikaans
11
Now that the World Cup is history, can South Africa sustain emergency care development and bring regional healthcare to a new level?
by Lee Wallis, MD
South Africa
The HIV infection rate. It is estimated that 5.6 million people were living with HIV and Aids in 2009, 300,000 children under 15 years old
20%
Total expenditure on health as percentage of GDP
8.6%
he 2010 FIFA Soccer World Cup, hosted in 9 cities across South Africa, was a real adventurean exciting, exhausting showcase for a country working hard to grow up. For the emergency medicine (EM) fraternity, the World Cup was an opportunity to further develop effective prehospital and in-hospital emergency and disaster preparedness systems and resources. As described in the Fall 2010 issue of EPI, the World Cup was invaluable in building an Emergency Care legacy for South Africa. The post-World Cup blues having now set in, it is time to take stock of the current state of emergency care in South Africa. New Options for EM Training Eight years after the speciality was first recognized, there are now 61 emergency physicians on the specialist register; we have
5 EM registrar training programs nationally (Cape Town, Johannesburg, Pretoria, Limpopo, and Pietermaritzburg) with 60 trainees on a 4-year program (42 of these are in Cape Town). Subspeciality training in critical care has been approved, and pediatric emergency medicine has been applied for. The opportunities for non-specialist EM training have also increased. The College of Emergency Medicine, the national examination body, has added a Higher Diploma in Emergency Care, in addition to the existing Diploma in Primary Emergency Care (a popular credential acquired by junior doctors with an interest in emergency medicine). There is also a Master of Science degree offered at the University of the Witwatersrand and a Master of Philosophy degree at the University of Cape Town, both of which are offered to doctors, registered nurses, and paramedics.
healthcare spending breakdown

40% Public 60% Private
18
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Japan
Many medical records were lost in this disaster, an issue made all the more critical by the advanced age of the population and the prevalence of chronic illness.
sendai: Ground Zero population

Just over one million
City of Trees
nickname
Lessons learned in emergency and disaster medicine in the wake of the Great East Japan Earthquake
by Seikei Hibino, MD
The coast facing the Pacific is full of oyster and Hotate clam farms
coastline
n March 11, 2011, a massive earthquake rocked Japan 129 km (80 miles) northeast of Sendai, the largest city on the Northeast of Japan. The quake led to a massive Tsunami which devastated the Japanese coastline and caused thousands of deaths. As a Japanese emergency physician currently practicing in the United States, I followed the news through Japanese-language media, which gave me a unique insight into the response of medical community. The inciting earthquake, terrible though it was, could have caused many more injuries. Because Japan is no stranger to earthquakes, the country has developed strict codes for new construction. As a result, most of the buildings had minimal damage. This was a big contrast from the last major earthquake, near Kobe, in 1995, Hanshin-Daishinnsai, when many buildings collapsed causing rampant blunt trauma and crush injuries. There was a thirty-minute lag between the megathrust earthquake and the resulting
tsunami which would cause the most serious damage. Thanks to Japans strong emergency warning system, a significant number of people escaped inland during this brief period. Even so, the death toll was catastrophic, and there was little that medical teams could domost patients were triaged as either black or green with very few in between. The causes of death were more than 90% drowning, several from burning, and disaster death. Reported casualties have kept increasing to well over 23,000. One JMAT ( Japan Medical Association Team) volunteer estimated well over 100,000 in his report. Medical teams also contended with the potential radiation dangers presented by the reactor failure Fukushima. A hydrogen explosion at the nuclear plant caused minor trauma for roughly 20 people, and, on March 24, three workers were exposed to radiation significant enough to inflict minor burns. They were decontaminated and transferred to the National Institute of Radiological Sciences, a tertiary radiological emergency
The day after the tsunami, 282 people had died from postearthquake-related factors, such as exposure to cold and wet weather, communicable disease and infection, unsanitary conditions, or inability to receive adequate medical care for pre-existing conditions. Source: Yomiuri Shimbun
after the shock
facility, and discharged in stable condition several days later. Japans DMAT was established shortly after the Kobe Earthquake in Japan. It is headquartered under the Ministry of Health, Labor and Welfare in Tokyo. Every prefecture has a branch in its capital city. Relief efforts were organized locally at those branches and reported to the headquarter with its needs. Food, water, medical supplies are delivered accordingly. As for medical evacuation, local airports were prepared with what they call Staging Care Unit where they triage and stabilize patients before the transfer. Communication was very problematic. Land lines and cell phones were not operational, leaving rescuers to rely on a combination of satellite phones and walkie-talkies. Cell phone-based internet was operational, however, even when the phone was jammed. There was very little trauma. Mainly rescuers dealt with chronic illnesses and other issues related to the elderly population. Loss of essential utilities meant loss of ventilators, dialysis machines, and other high tech medical devices. This appears to be the reason behind most of the medical evacuations that took place. Running out of routine medications such as insulin, blood pressure medicines and antiepileptics had serious consequences. Refugee camps were congested and lacked adequate food or heating. Very old and very young are particularly vulnerable to respiratory and GI infections. Every disaster teaches many lessons. DMAT in Japan worked, but better communication and coordination with other volunteer organizationsparticularly via the internetcould have optimized relief efforts. Another essential area to address is the use of electronic medical records. Many, many medical records were lost in this disaster, an issue made all the more critical by the advanced age of the population and the prevalence of chronic illness. Protection of private information is very important, but universal access to medical records would have helped tremendously in this situation. Tragic though the events in March were, they also have the ability to be Japans greatest teacher, preparing medical rescuers and others for the next disaster.
20
Medical Care in an Evacuation Shelter

A nurse from Okinawa recounts the challenges of caring for survivors in a shelter in Iwate, Japan.
by Naoko Kurauchi
he photo below left is of an evacuation shelter housed in a local school gymnasium. There was little ventilating in the gym because the air was freezing cold outside. it may look like people have space for themselves in the gym but this was a sunny day when most people were out to go clean up the remains of their houses. The medical relief teams went around the evacuation shelters during the day so we werent able to reach the working age men. Doing night rounds may solve this problem in the future. With so many people huddled together, the local health officials and public health nurses were deeply concerned about flu outbreaks and we (the medical relief teams) were asked to evaluate the hygiene situations. The toilets were amazingly clean, but we recommended to increase the number of alcohol handwash gel and place them more within peoples reach rather than just by the entrance. Japanese people are used to using masks all the time, especially in the winter when the flu is going around, so people willingly wore masks which were handed out everywhere. The public health nurses became concerned when we spotted several pet dogs. But there was nothing they could do about it they were family members. The city council was starting to count how many cages were necessary, but that would take ages. While people slept, their dogs roamed freely. Some people didnt mind,
but some werent happy about it but couldnt complain because they were all neighbors and didnt want to cause trouble. The biggest issue may be that in Japan, even when hit by disasters, local municipalities are still held responsible for organizing relief. I felt this strongly when entering Iwate we were to go through the prefectural office and there were given briefings about where to go and what to do. They also asked us to guide all physicians/groups acting on their own. This has been Japans disaster response style until now but it may be time to change. In times of disasters, the national government should take lead in the response rather than disaster hit areas having to organise for themselves when they too have lost houses, family and possessions, and are tired out physically and psychologically. This time, many offers by international NGOs and groups were not taken by the Japanese government. It may be that Japan was well prepared and did not need the external aid. However, in the early post-disaster periods we lacked blankets and doctors simply because there was no way to transport supplies and personnel with the roads damaged severely and a shortage of petrol. The frustration among Japanese relief workers not able to reach the disaster areas was immense. Whether it be foreign or domestic help in organizing relief, I think Japan may need to rethink its ways of accepting external support.
International Emergency Department Leadership Institute 24-28 October, 2011 Boston, Massachusetts, USA
As the number of interdisciplinary emergency departments grows internationally, where can ED leaders acquire the administrative skills they need to build and sustain successful emergency departments? The International Emergency Department Leadership Institute (IEDLI) was created by Harvard Medical School faculty and other international experts in order to provide ED leaders with the skills and knowledge they need to successfully operate emergency departments in any part of the world. In this one-week course of over 35 hours of interactive lectures and workshops, leaders will explore strategies to: Establish the EDs role within the hospital Improve efficiency and control costs Decrease overcrowding Develop quality improvement programs Educate and motivate ED doctors and nurses Develop an emergency medicine training program Form a strong administrative structure This program is designed for doctors, nurses and administrators. LOGO
Early registration discounts end July 1! www.IEDLI.org Advanced Program for IEDLI alumni 26-28 October, 2011
The International Emergency Department Leadership Institute is a collaboration between Harvard Medical Faculty Physicians at BIDMC and Brigham and Womens Hospital.
21
The Third biennial
Emergency Medicine In the Developing World

Conference
Cape Town, South Africa

15 to 17 November 2011
Isixeko Sasekapa, uMzantsi Afrika
Greetings Emergency Medicine Workers

Scientific content Paediatrics to Psychiatry, Toxicology to Trauma
Molweni basebenzi becandelo lenkonzo ezingxamisekileyo
Join us in the Mother City for a truly African conference experience
Pre-conference workshops: 14 November 2011 Cardiology, Ultrasound, Airway, Nursing, Disaster and Paediatrics Venue Cape Town International Convention Centre Call for Abstracts Abstracts may now be submitted through the website www.emssa2011.co.za. Abstract submission will close on 1 September 2011.
Visit us on www.emssa2011.co.za for more details
ID In-Depth
ARGENTINA
em development in the
Emergency medicine may be a new specialty in Argentina, but South Americas southernmost nation is showing signs of growth, from new residencies to publications to some of the worlds largest EM conferences.
by Silvio Aguilera, MD, MBA & Daniel Gonzalez, MD
land of contrast
he Republic of Argentina is found in the extreme south of South America. It has an area of 2.78 million km2 (1) and a population of 38 million inhabitants. Most of the population lives in urban areas. The country is divided into 24 provinces each with an autonomous government (governor). In turn, each province is divided into departments or municipalities with a local government (mayor). A third of the countrys inhabitants live in the city of Buenos Aires and its surroundings. The language spoken is Spanish. 17.7% of the population falls within the group of people with unsatisfactory basic needs (poor housing, houses with three or more people per room, children between the ages of 6 and 12 who do not attend school or four or more people per person in employment). (2) The causes of death per 100,000 people are: Cardiovascular Diseases (222), malignant tumors (141),
Cerebrovascular disease (81), and External injuries (28). Health spending accounts for 10.2% of gross domestic product (14th in the world rankings). Health indicators reveal a life expectancy of 77.4 years, infant mortality rates of 16.7% ranging from 10% to 29% depending on the region and a maternal mortality rate of 8,2 for every 100,000 births. The illiteracy rate is 3.7%. The Health System The health system in Argentina is divided into public (55%) and private (45%) operating in parallel. Accordingly, Argentina has both private and public medical schools, hospitals and pre-hospital emergency services. The private health system has two components. One is the Social Services (covering 17.3 million people) characterized by the compulsory nature of the membership (direct reduction from the salary), a solid financial base and is regulated by the state (Su-
perintendent of Health Services). The other is the prepaid medical system (covering 3 million people) characterized by the voluntary nature of the membership, the availability of a grace period, the lack of coverage for pre-existing conditions and they are not regulated by the state although they must meet a minimal medical cover established in the Mandatory Minimum Program (PMO). The state system takes care of the population that does not have mandatory coverage or voluntary care (covering 17.7 million people). The nation, through the Ministry of Health and Environment, provides coordination, regulation and technical and financial assistance while the individual provinces and municipalities provide direct services to assist the population. The financing of the public health system comes from taxes. Argentina has 153,065 hospital beds available. These beds are spread throughout 3,311 hospitals, of which 38% are for the public sector or state financed treatment. Each hospital (public or private) has emergency services. In some of the large hospiwww.epinternational.ning.com
23
ID ARGENTINA
tals (mainly public ones) the emergency services are divided into sections: medical, surgical, pediatric and orthopedic. In general the emergency service departments at the private hospitals have smaller waiting times, are more technologically advanced and have more comfortable facilities. (6) (7) (8) (9) Medical Education Argentina has 26 medical schools, 10 public and 16 private, with 60,000 students enrolled. Some of these schools are public and free and others are private and paid for. Together, approximately 4,000 students graduate each year. To enter university you must have a high school diploma. Most universities require an entrance exam. The study programs vary from one university to the next but inn general they take six years. The first three years focus on basic and clinical sciences and the remaining three years are spent in hospitals and specialist clinics. Some of the programs include a compulsory rotating internship in the sixth year in the four basic specialties general medicine, pediatrics, surgery and gynecology. There are no rotations to emergency services and only some of the universities teach matters relating to emergency medicine. Recent graduates are allowed to practice their profession as there is no national exam. Many of these graduates start as general practitioners working in hospital emergency rooms or in low or medium complexity units in the area of pre-hospital emergency services. Graduate training is carried out through residence programs in the different specialties. The programs vary in duration according to the specialty, ranging from 3 to 5 years. Unfortunately, the vacancies available in the different specialties are scarce. Currently there are 116,000 practicing physicians in Argentina, which represents 1 doctor per 310 inhabitants. Some of the features are: the shortage of general practitioners and the large number of medical specialists and their poor geographical distribution. There is a major deficit in the number of nurses with one nurse per 1,250 inhabitants, which means there is one nurse for every four doctors. Emergency Medicine in Argentina Emergency traumatology (Emergentologia) is a specialty that has been recently recognized by the Argentine Ministry of Health. According to Jeffrey Arnolds classification, the emergency medical system in Argentina is between developed and mature as it has national organizations (Argentine
Emergency Society, Argentine Society of Emergency Pathology and Trauma), training in emergency residences, the directors of emergency departments or directors of pre-hospital emergency services are emergency doctors, there are doctors in the ambulances and there is official recognition of the specialty but there is no board to certify to that. (10). Figure 1 shows the current status of emergency medicine in Argentina according to the scheme proposed by Dr. Arnold. In 2002, the Argentine Emergency Society (SAE) was founded as a national organization for physicians who performed their work primarily in emergency medicine. Since then there have been five international conferences, several of them held jointly with the American Academy of Emergency medicine (AAEM) and the American College of Emergency medicine (ACEP) from the USA. The Society also forms part of the Latin American Cooperation for Emergencies and Disasters Association (ALACED) which brings together the principal Scientific Societies of Latin America. In 2008 the SAE published the first Emergency medicine book in Latin America containing work from more than 100 authors from Latin America, the USA and Europe.(11) Pre-hospital Emergency Medical Services Classically, there are two different models for organizing the emergency systems. In the AngloAmerican model the patients are transported to the hospital to receive a high level of care. In this model, non-medical personnel, such as emergency medical technicians (EMT) or paramedics (EMT-P) man the ambulances and provide care at the scene and then transport the injured or critical patients to the emergency rooms of hospitals where emergency physicians (ME) provide the definitive treatment. In accordance with this, emergency medicine is an independent medical specialty controlled by emergency physicians. In contrast, the Franco-German model of emergency care brings the hospital to the patient, bringing emergency physicians and medical technology to the scene with the hope of providing a higher level of medical care in a shorter amount of time. In this model the emergency physicians (anesthesiologists in most European countries) provide emergency medical care on a pre-hospital level. The patients are later transferred to the inpatient hospital services. In this model, in general, emergency medicine is not a unique specialty.
In Argentina, the model that has been developed is mixed; the emergency services at the hospital level have been developed largely through their doctors becoming professionals in the specialty of emergency medicine and the development of true emergency departments. The chief is dedicated to emergency medicine and the staff, often exclusively or semi exclusively, works in emergency medicine. While this is the current trend, there are still a lot of hospitals with the traditional emergency services with different medical specialties where the chief is not an emergency medicine specialist. The reference to the mixed model also encompasses the development of pre-hospital emergency medicine all of the ambulances have a doctor as part of their crew. Most of these physicians come from different specialties such as internal medicine, cardiology and intensive care. Many of them have formal training through a full medical residency. Others come from formal practices in hospitals (they are called attendees and their assistance is voluntary and without payment) while still others through training in different courses. The pre-hospital emergency system is mixed and in the same cities private companies can coexist with public companies. The private companies serve the calls of their patients directly or indirectly through contracts with various social services or pre-paid health systems. They do not take calls from people who do not fall into these groups. In contrast, the public systems serve all calls that they receive. The country has more than 400 private emergency companies and some of them are much larger than the public ones. In the city of Buenos Aires and the surrounding areas for example, there are four private companies serving between 500.000 and 900.000 patients each year. The coexistence of these private companies together with the public enterprises leads to an overlap resulting in the loss of efficiency of the system as a whole. There is no single telephone number for emergencies. Public services depend on the municipality and have a three digit number that is not the same throughout the country. Currently most of these services incorporate the number 107 as a reference system. The private companies have a number that corresponds to a land line that could be 5 or 6 numbers long. The fire and police services have different numbers and there is nowhere that gathers the three services (emergency, fire and police) under the same number. Most of the emergency systems with a large number of calls per day have a computerized dispatch
Argentine Medicine by Number // 26 medical schools (10 public, 16 private); 4,000 med school graduates every year; 116,000 practicing physicia
24
Underdeveloped Specialty development National Organization Residency Certification by the Board Official specialty Specialty magazines Investigation Database Subspecialty Training Care System Emergency Doctors Medical Director Prehospital emergency Transport system Trauma system Quality Assurance Peer review Non-specialist staff Nonspecialist Auto-Taxi No No No No No No No No
Developed Yes Yes Yes Yes
Mature Yes Yes Yes Yes
Argentina Yes Yes No Yes
Academic development No No No No Yes Yes No No Yes Yes Yes Yes Yes Clinical No Yes
While there is no uniformity in criteria and each system uses its own protocols the categorization is the same and emergencies fall into the following categories: Code red or Code 1 or Emergency Code yellow or Code 2 or Urgent Code green or Code 3 or Non-urgent visit Code blue or Transferred (which may be of high or medium complexity) A characteristic of the pre-hospital emergency systems in Argentina is that they answer all calls made by direct or indirect partners. This includes Code green, code 3 or non-urgent visits. In these cases a doctor is sent by car to the address of the person who called. Usually public emergency services do not offer this service Legislation In 1997 (12) a law passed that regulates the activities of outpatient emergency services throughout the Republic of Argentina. These services include: a) Emergency Medical Systems: Defined as the organization of physical and human resources to implement coordinated patient care in critical situations, with threat to life (emergencies) or potential threat to life (urgent) or where the threat is found circumstantially. b) Scheduled Ground Transportation Systems: defined as the organization of physical and human resources to implement coordinated patient transport from one point to another with different levels of complexity, in secure conditions according to the clinical state of the patient. The transfer of patients is classified as either high or low risk. c) Domiciliary Medical Consultation Systems: is the organization of physical and human resources to carry out medical consultations in the patients home, a priori, when there is no risk to life or evidence of the need to visit a health center. This law establishes the guidelines for setting up services relating to human resources, the office infrastructure, communications, facilities and the characteristics of the ambulances. The ultimate responsibility for these services falls on the Medical Director, a compulsory figure for all pre-hospital emergency services. The law does not establish response times for the care of outpatients in the different categories (emergency, urgent, non-urgent). Training In accordance with what has been mentioned above, all care is provided by a doctor, so there are no mobile units without a doctor. The law states that in highly complex units there must be, apart from a t
Doctors trained in residencies Emergency doctor BLS, EMT ambulance No No No No
Doctors trained in residencied Emergency doctor Paramedic or Doctor Yes Yes Yes Yes
Few doctors trained in residencies Emergency doctor Doctor Yes Yes No No
Management System
TABLE 1: Measuring Up: The current status of emergency medicine in
Argentina according to the scheme proposed by Dr. Jeffrey Arnold.
system based on protocols that consist of a series of questions for the caller. The type of response sent is based on the responses that are received. These systems also provide instructions to the caller to assist the victim until the emergency unit arrives. The level of telephone support can range from simple advice (nasal compression in case of a nosebleed) to complete instructions for CPR. The people who
receive the calls and perform the categorization are not doctors but are often medical students that receive adequate training before and during their work. The presence of a doctor in the office is adopted by some systems while others do not deem this necessary. Depending on the dimensions of the system receiving the call, the office may be in the same area or may be in a completely separate area.
ans (1 docter per 310 inhabitants); 1 nurse per 1,250 citizens; <25%: The transfer-to-hospital rate when mobile units respond to emergencies
25
ID ARGENTINA
doctor, a nurse and a driver. The doctor must have completed a minimum of four years in the practice of the profession and also must have no less than two years experience in the fields of either: intensive care, coronary care, cardiology, anesthesiology, hospital emergency services, general surgery or in a medical clinic. They should also be trained in advance in cardiopulmonary resuscitation, emergency medicine management, the advanced management of adult and pediatric trauma and baby deliveries. The presence of a physician allows the patient to receive excellent care on site without being taken to a hospital. Because of this the transfer to hospital rates are lower than in systems where the pre-hospital care is not carried out by a doctor. These transfer rates are less than 25% in cases of emergency and urgency (13) and these percentages are consistent with the international literature from those countries with physician manned ambulances. (14)(15)(16) The training of the pre-hospital emergency doctors can be formalized through residency programs. Currently there are approximately thirteen residency programs in emergency medicine. Some of them are in the city of Buenos Aires and others in the provinces of Buenos Aires, Cordoba and Mendoza. Some of these programs are for first grade emergency medicine residents and others for second grade, where to go further it is necessary to have a prior residency in internal medicine. The duration of these programs is 3 to 5 years and they are held in public or private hospitals. Most of these physicians, when they complete their residency program, work in hospital emergency departments (public or private) as working in the pre-hospital services is considered a low priority. Informal training is accomplished through attendance systems to public hospital emergency services and supplemented by different courses. There is also on the job training to gain experience through working in the emergency departments. There are also a number of widely available international courses such as Advance Cardiac Life Support (ACLS), Advance Trauma Life Support (ATLS), Pre-hospital Trauma Life Support (PHTLS) and Pediatric Advance Life Support (PALS). Other less widely available courses include Advance Medical Life Support (AMLS), Advance Burn Life Support (ABLS) and Advanced Disaster Life Support (ADLS). The ATLS program was initiated in 1989 and quickly gained a growing demand throughout the country. Currently it has 66 national instructors teaching an annual average of 22 ATLS courses across the country and is carried forward by the Argentine chapter of the American College of Surgeons.
The University of Buenos Aires School of Medicine graduates many of the countrys 3,000 medical graduates every year.
our country we have given 340 courses to 8,306 physicians and 17 courses to 134 instructors. Currently there are 69 PHTLS instructors in Argentina. We have conducted 12 PHTLS conferences with an audience of 6,821 attendees, In 2002 we began teaching a PHTLS Officer course to the armed forces of our country.(17) Like other medical specialists, emergency physicians are usually compensated based on a duty payment (fixed rate per hour) and less often through a salary. In some cases payment is made per duty performed (fee for services). At times the payment is mixed: one part is fixed (per hour) plus an amount for the care provided. In Argentina, helicopters are rarely used for the transportation of patients, even in disaster situations. In the Buenos Aires metropolitan area the only organizations that have helicopters are the Federal Police and the Public Service (SAME) who use them for the transfer of patients to the relevant hospital. The Province of Buenos Aires has a patient transfer system where the state helicopters are used for inter-hospital transport. Disaster Preparation In the past 15 years, Argentina has gone through many historical, political and social situations which were accompanied by complex scenarios in which it was necessary to design health care plans to meet the demand generated by each of these events. The first terrorist attack took place on March 17, 1992 when a bomb exploded at the Israeli Embassy in Buenos Aires, killing 29 people and wounding 246. On August 18, 1994 a car bomb destroyed the Argentine Israelite Mutual Association (AMIA) in Buenos Aires, killing 86 people and wounding more than 300. (18)(19) The latter was the trigger event for advancing disaster management in Argentina. Although a local disaster response had been initiated in Buenos Aires in 1984, the AMIA bomb highlighted the lack of a coordinated system for handling emergencies in the country and in 1999 the national government formed the Federal Emergency System (SIFEM) under the direction of the Argentine president. SIFEM is the organizational scheme for the national government that communicates with the relevant national government agencies and coordinates their actions with the provinces, the autonomous government of Buenos Aires and the municipalities to prevent and effectively manage emergency care, natural disasters or anthropics. SIFEM is comprised of representatives from the federal police, fire service, the military, the Ministry of Health and the National Civil Defense. SIFEM plans for different stages (mitigation, response and recovery) and plans for events
ACLS courses are conducted through the Authorized Training Center of the American Heart association (AHA). There are currently 7 AHA centers that train more than 1.000 doctors annually. Some of these centers belong to scientific societies (Argentine Society of Intensive Care, Cardiology Society of Argentina and the Anesthesiology Association) or by non-profit foundations whose objective is to train health personnel (Vittal Foundation, EMME, Resucicor and Cardiovascular). With respect to PALS there are three AHA authorized training centers belonging to the Intensive Care Society, the Pediatric Society and the University of Maimnides. They train more than 1,000 doctors annually. The PHTLS course represents the pre-hospital management of trauma patients and is delivered according to the rules of the National Association of Emergency Technicians (NAEMT) of the American College of Surgeons responsible for the EMME Foundation which was designated in 1995 by NAEMT as being solely responsible for the PHTLS courses in Argentina. Currently the foundation has helped EMME open in Chile, Uruguay, Paraguay, Colombia, Venezuela, Peru and Costa Rica. This foundation coordinates the territories throughout Latin America and up to 2007 had carried out 1061 courses in Argentina, Bolivia, Brazil, Colombia, Mexico, Peru and Venezuela providing training for 460 teachers and 29,783 students. In
26
Mixed system, mixed results: In the same cities private and public emergency medicine companies co-exist. The country has more that 400 private emergency companies and some of them are much larger than the public ones. The coexistence of these private companies together with the public enterprises leads to overlap, resulting in a less efficient system.
(floods, landslides, earthquakes, droughts, fires, anthropogenics, volcanoes etc). The process of forming SIFEM also stimulated the development of systems at provincial, municipal and local levels.(20) There is also the Directorate of National Health Emergencies (DINESA) whose mission is to provide health care for emergency situations, mitigate the negative effects of natural and man-made disasters and to direct and implement sanitary response to the areas affected by the disasters. DINESAs objective is to provide assistance in times of disaster, through technical and human resources that, alongside the Provincial Emergency response teams, ensure proper health care. Among its many programs there is a Humanitarian Supply System (the SUMA program) that was born from a collective effort of the countries in Latin America and the Caribbean and is sponsored by the Pan American Health Organization (regional Americas office for the World Health Organization WHO), financial support from the Dutch government and the support of the United Kingdom, United States, Canada, Germany and the Humanitarian Aid department of the European Union. The main objective of the program is to improve the administration of humanitarian aid, strengthen the local capacity for effective supply management and ensure this assistance reaches the affected areas in a timely and appropriate manner. Conclusions Although emergency medicine has only recently been recognized as a specialty by the Ministry of
Health it is well developed in our country. The prehospital system is based on ambulances always having doctors amongst their crew and the ambulances being well deployed. The system is mixed with the private system being more important with more than 20 years of development in our country. There are residency programs and national organizations and a large number of doctors work as much in the prehospital services as in the hospitals.
Silvio Aguilera, MD, MBA Medical Director Vittal, Buenos Aires, Argentina. Vice-President of the Vittal Foundation. Founding member and ExPresident of the Argentine Emergency Society. Daniel Gonzalez, MD Head of the Emergency department, Policlnico Bancario, Buenos Aires, Argentina. President of the Argentine Emergency Society
Bibliography
Argentina. Atlas y su geografa. Editorial Oriente S.A. 1994. Instituto Nacional de Estadsticas y Censos Anuario Estadstico de la Repblica Argentina, 2002-2003 INDEC 2003 Buenos Aires. Argentina. World development indicators database, April 2009. World Bank http://go.worldbank.org/1SF48T40L0 World Health Organization Statistical Information System http:// www.who.int/whosis/ Alexander Preker, Richard Schefflerand and Mark Bassett. Private voluntary health insurance in development. Friend or foe?. The World Bank. Year 2007 Abramzn, M. (2000). Recursos humanos en salud. Argentina. Indicadores bsicos. 2001. Ministerio de Salud y Accin Social de la Nacin/Organizacin Panamericana de la Salud/Organizacin Mundial de la Salud. Gins Gonzlez Garca, Federico Tobar. Salud para los argentinos. Ediciones ISALUD. 2004. Argentina. Indicadores bsicos 2004. Ministerio de Salud y Ambiente de la Nacin/Organizacin Panamericana de la Salud/Organizacin Mundial de la Salud. http://www.msal.gov.ar http://www. ops.org.ar Arnold JL: International emergency medicine and the recent devel-
opment of emergency medicine worldwide. Ann Emerg Med January 1999;33:97-103. Machado A., Aguilera S. Emergencias. Edimed. 2008. Ley de Emergencias Aguilera S. Prehospital Emergency Medicine in Argentina. Fifth Mediterranean Emergency Medicine Congress. 14-17 September 2009. Valencia, Spain. Seth W. Wrightems. Emergency Medicine in Ukraine: Challenges in the Post-Soviet Era en Ucrania. Am J Emerg Med 2000;18:828-832. 36. Grange J, Baumann G, Vaezazizi M. On-site physicians reduce ambulance transports at mass gatherings. Prehosp Emerg Care 2003; 7,3: 322-326. 37. Pozner CN, Levine M. Listwa T, Zane R, Does the presence of physicians at professional football games reduce the number of patient transports? Ann Emerg Med 2006;48:S55. Rois Osvaldo. Coordinador Territorial PHTLS (NAEMT EEUU) para la Argentina. Personal comunication. Biancolini C, Del Bosco C, Jorge M. Argentine Jewish community institution bomb explosion. J Trauma 1999;47:728732. Muro M: Looking back on the AMIA outrage. IX WCDEM Jerusalem. 1995 Muro M, Cohen R, Maffei D, Ballesteros M, Espinosa L: Terrorism in Argentina. Prehosp Disast Med 2003;18(2): April June 2003.
27
R Report
Colombia Takes Strides

Watershed conference shows new societys clout, unity
by Logan Plaster
n Colombia, a country known more than most for its fierce turf wars, emergency medicine (EM) has ridden into the medical establishment on a surprising wave of collaboration. While the development of EM has been contentious the world over, Colombian emergency care specialists seem to have found a way to unite factions and begin to create one of the strongest emergency care systems in South America. A significant marker on Colombias road towards a fully-developed emergency medicine system was a conference held in the Fall of 2010 in Bogota, the sprawling capital city of 7 million. This was the first conference hosted by the Asociacion Colombiana de Especialistas en Mediciona de Urgencias y Emergencias (ACEM). Headed by ACEM president Mauricio Garcia and a host of hardworking conference coordinators, the conference set out to put the new society on the map and put emergency medicine squarely on its way towards advanced development. By all accounts, they succeeded beyond expectations and, perhaps, proved that Colombia will become a regional leader in EM development. *************** To back up, in 2005, there were two emergency medicine societies in Colombia, ASCOME (Asociacion Colombiana de Medicina de Emergencia) and ACAPH (Asociacion Colombiana de Atencion Prehospitalaria). Each was comprised of both emergency medicine specialists and general practitioners who happened to work in emergency medicine. In Colombia, after you graduate from medical school, only two percent of people will go into a specialty because that additional training has to be paid for by the student, said Dr. Gladys Lopez, a Colombian emergency physician practicing in the United States who helped coordinate the ACEM conference. It is extremely expensive, so you become a general practitioner. Even without specialty training you are a general practitioner. According to Lopez, this payto-play residency model has created a lack of specialty training in Colombia that has been detrimental to the health of the country in general, and to the workings of the emergency departments in particular, where many of these medicos generales end up working. There are a lot of medical errors due to a lack of training, said Lopez. So far, this story is nothing new. All over the world, as emergency care has developed, emergency departments have initially been staffed by non-specialized general practitioners. But here is where Colombia is unique. In 2005, rather than fight for their turf, the two existing EM societies supported the formation of a third societyACEMwhich would represent emergency medicine specialization within Colombia and to the world. That year, ACEM was born and emergency medicine was recognized by Colombias ministry of health as a unique specialty. The following year, with the support of both original organizations, ACEM became Colombias official representative to the International Federation for Emergency Medicine (IFEM). This is different from so many other countries in Latin America which have had to fight for recognition, said Lopez. In Colombia, they seemed to understand early on that this was the way to support the growth of the specialty. This kind of collaborationbetween traditional general practitioners and younger specialists, between a new medical society and the ministries of health is rare in any country. On every continent, differences in EM training, priorities and perspectives have formed hard divisions that last for years. Colombia has done an amazing job, said Dr. Bob Suter, invited speaker and
ACEM leaders and invited guests raise a glass to celebrate their evening at Colombias historic National Academy of Medicine, where the fledgling society received an important nod of recognition.
past president of the American College of Emergency Physicians (ACEP). The people who practice emergency medicine but dont have training have immediately recognized the trained physicians as the true specialists. I think that speaks very well of the older Colombian physicians who have not focused on themselves, but rather have focused on the future of emergency medicine, which is residencytrained physicians. Colombia has arguably done a better job of negotiating that transition and that immediate recognition of the trained specialists than any other country in the world. Not that it has been easy. Even strong supporters of Colombias development like Dr. Alberto Machado, the Argentine president of the regional EM society ALACED, are sensitive to this changing-of-the-guard. I will be happy if some day my emergency department will be completely staffed by trained emergency physicians, but believe me, when we developed emergency medicine [in Argentina], there was no one with EM residency training. It is the same everywhere. Sometimes you find consensus and sometimes you fight. I think it will be a middle road. In all the countries, this is a problem. There are people who work in emergency, and love emergency, but they dont have the emergency training. *************** As a result of this remarkably smooth transition in Colombia, ACEM was able to host a conference in November that was a huge success by all accounts, and represented a watershed event for a fledging society. With 850 participants, ACEM doubled their registration projections and ended up hosting one of the largest international EM meetings in South America to date. Not bad, said Lopez, for a medical society boasting only 35 official members and 70 full EM specialists in all of Colombia.
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Colombia has arguably done a better job of negotiating that transition and that immediate recognition of the trained specialists than any other country in the world.
-Dr. Bob Suter, DO Past President of the American College of Emergency Physicians (ACEP)
Interview with
Dr. Mauricio Garcia Romero

President of ACEM
What are the challenges that you see facing emergency medicine in Colombia right now? There are many challenges. You have to put them in two separate groups, the work itself and the specialty development, your vision for the future. Day by day, I have to manage the other specialists who think they are going to do my job. The idea is to make them feel that we are helping them, being a support as emergency physicians, rather than a competition. The idea isnt to simply work hard day by day and that is all, going home and coming to work again and again. The idea is to think about the future, getting together and making an organization that works together. We need to keep getting together in order to look forward. We have to learn from each other. We have so much to learn from the U.S.A and from Europe, all of the challenges they have already faced and now we have to try to do the same thing, but in our context, in our country. What is the next step for development in Colombia? The first and most important step is simply to make our presence known. The idea with this congress was to show Colombia, the medical associations, all the doctors, and the international community that emergency medicine in Colombia is here, and it is developing. Not that fast, but it is developing. And it is doing so with strong, solid steps forward. The second step is to take advantage of this meeting, meeting people and making contacts with the international community and with international sponsors so that we can show them that were doing the right things to develop emergency medicine. Did the conference succeed at this goal? I think that the congress has shown that we are a strong specialty. We are here, and we are accomplishing real things. But it has not been easy. More than half thought that this would not be good enough and that it was not going to be possible. Maybe they were a little afraid of exposing themselves to criticism. If you expose yourself,
continued on page 30
This is a wonderful conference and the Colombians are to be commended for their excellent progress in emergency medicine in such a short period of time, said Dr. Suter, who came to Colombia in 2005 and was the plenary speaker at the pivotal conference where ACEM was created. In the ensuing five years, ACEM has really, truly developed the specialty of emergency medicine in a way that is having an impact throughout the entire country. As any country early in the development of the EM, they have work to do in terms of getting adequate numbers of emergency physicians out, particularly to the smaller communities. But it appears that they have excellent leadership, a comprehensive plan, the support of the medical establishment and government, and so I am very optimistic that well see nothing but continued success for Colombian emergency medicine, and that that will provide leadership and inspiration to other countries in Latin America and throughout the world. According to Dr. Lopez, the biggest thing to come out of ACEMs conference last fall was the conference itself, which proved that ACEM, small and young though they were, could successfully execute a sophisticated medical meeting. No one thought that this conference could succeed and excel at the level it was presented, said Lopez. Keynote speaker and textbook author Judith Tintinalli agreed, noting that Everything [in Colombia was] really pretty perfect. Its as professional as anything Ive seen. For Tintinalli, that included the level of training being provided, which was more advanced than she had expected. Theyre not basic. Theyre definitely intermediate and advanced level. That means that the level of emergency care here is advanced. The cardiology sections included material that was absolutely up-to-date throughout the world, said Tintinalli. If you were looking to address people at a more basic level, you wouldnt have started with lectures on biomarkers. They talked about current biomarkers for heart attacks. They talked about thrombolysis. Even beyond their general education, Tintinalli was impressed at Colombias ability to gather crucial trauma statistics, a hurtle faced by every developing system. They have all the trauma data, they know all the land mine injury data how many children have been injured, etc I know Chile has no data system. I know Argentina has no data system. So the fact that Colombia is presenting national data is great, said Dr. Tintinalli. ACEM has caught the interest of more than the international EM lecture circuit. During the week of lectures, the young society received an important nod of approval: a show of support from Colombias National Academy of Medicine. On the second night of the conference, the ACEM leadership, along with many young residents, were invited to the historic Academy of Medicine headquarters for an evening of wine and special recognition. This very high entity represents many societies in Colombia, said Lopez.
continued on page 30
29
R COLOMBIA
<< from page 29
you are subject to criticism. But now, everything is going just fine. Are there lessons youve learned this year that will help you with the next congress? At least a hundred. First, the logistics. Making the arrangements, the logistics, was really hard. On the surface everyone thinks that it is just fine, but we know that there were a lot of mistakes that had to be worked through. Now the work that we have to do is to show the residents that there is more to emergency medicine than simply showing up for work. How is that accomplished? Changing culture is very hard because it has to start early, all the way back at medical school. You have to think beyond studying. If we work together, even if we think different things, we will ultimately have the same goal: working towards what is best for the patient. What makes the Colombian medical culture unique? I think that Colombian doctors have many strengths, the greatest perhaps being that they are always thinking about the patient. We want to. We care about the patient. Which is not always good because the doctor actually neglects themselves in the process. A Colombian doctors will stay at work late just because the patient needs them, but they might not claim the extra hours. The idea in the future is that we have enough benefits and opportunities provided through the professional organizations that Colombians can be even better doctors. It is just the culture. We might even get paid, but we still do the things that need to get done. That is how we are raised. We just care about the patient; we dont care about anything else. It must be 50/50 between patient care and physician treatment, but we dont do that. Here is like 90/10 in favor of patient rights. If we work together we can change that. That is the change of culture that we need. Dr. Romero has been ACEM president for two year. He will be considered for a new term this June.
A skills lab held at the Fundacion Santa Fe in Bogota, Colombia, in 2008 in conjunction with a trauma course led by Dr. C. James Holliman.
<< from page 29
It was another milestone, one which was orchestrated by Dr. Jorge Otero. Otero, a Colombian emergency physician currently practicing at Yale University in the United States, was named as a delegate to the Academy of Medicine in 2010. We were not expecting this [support] to happen, said Lopez, but we basically think that this will set a precedent for the academy. It will set us apart as the only specialty of specialists. Despite this recognition, Colombia struggles to gain the broader attention of the international EM community. We need more representation [in IFEM], said Lopez. Being a total member and going to the meetings is not giving us enough information and possibilities to do things in Latin America. So the idea for ACEM and other Latin American societies that are full members of IFEM is probably to start thinking about naming fellows to IFEM that will be represented in higher levels. There are also local challenges that persist, said Camilo Rendon Jimenez, past president of ACEM, such as the fact that people still turn to other specialties out of habit, even in areas of emergency medicine. Another problem is education. Currently there are five EM specialty programs in Colombia, two in Medellin, two in Bogota and one in Cali. But
there arent enough emergency physician teachers, said Jimenez. Many emergency departments are still being run by other specialties. Now, at this moment, its changing. At the biggest hospital, emergency physicians are being brought on to run the emergency department. Whats next? According to Lopez, ACEM will try to obtain representatives in Colombias ministry of health and education. In addition, said Tintinalli, research needs to be a strong focus moving forward. In my talk, I talked about the need to really move forward with research, even if you have to do it by your own bootstraps, said Tintinalli. I havent seen any research here. Dr. Jimenez agreed, emphasizing that a key to stepping out into greater collaborative research is simply sitting down face to face, something that this conference finally executed. ACEM as a group has not published anything as of this moment, said Dr. Jimenez. Everyone is doing his own work. This is the first meeting and its important to see the physicians from Medellin and Cali. I think that from here is the first step to work as a group. This is the beginning.
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The IEM Fellowship Directory

15 16 23 21 11 29 12 24 26 25
7
22
6
19 20 18 17
9
28
10
27
13 14
California
1. Harbor-UCLA/IMC Global Health Fellowship Regional Focus: Iraq, Haiti and possibly others Contact: Ross I. Donaldson, MD, MPH, Harbor-UCLA Medical Center Department of EM 1000 West Carson Street, Box 21 Torrance, CA 90509 Length: 1-2 years Salary: Very Competitive Shifts: 5 per month Degree: MPH, DTMH available Positions: 1-2 Deadline: November 1 ( (310) 222-3500 8ross@rossdonaldson.com :www.emedharbor.edu/ Global.html :www.internationalmedicalcorps .org 2. Keck School of Medicine at USC Regional Focus: Chile, Ghana, Mumbai, Thai-Myanmar border, British Guyana Contact: Billy Mallon, MD Department of EM
1200 North State Street Room 1011 Los Angeles, CA 90033 Fax: (323) 226-6454 Length: 1-2 years Salary: Competitive Shifts per week: 2 Degree: MPH, DTMH Positions: 1 Deadline: December 1 ( (323) 226-6667 8 wkmallon@yahoo.com : www.cbooth.info 3. Loma Linda University Regional Focus: Vietnam, China, and Kenya Contact: Debbie Washke, MD Department of EM 11234 Anderson St,. RM A108 Loma Linda, CA 92354 Fax: (909) 558-0121 Length: 1-2 years Salary: About $80,000 Degree: MPH with 2-year program Positions: 1 Deadline: March 1 ( (909) 824-4344 8 dwashke@llu.edu
4. Stanford International Emergency Medicine Fellowship Contact: S.V. Mahadevan and Matthew Strehlow Stanford University 701 Welch Rd. Bldg C Palo Alto, CA 94304 Fax: 650 723-0121 Length: 1-2 years Positions: 1-2 Salary: Please contact Hours per week: approx. 15 Degree: MPH possible for 2 yr candidate Deadline: ACEP Scientific Assembly ( (650) 723-0063 8 jgalfin1@stanford.edu : emed.stanford.edu/fellowships/ international.html 5. UCLA-CIM International Medicine Fellowship Contact: Nicole Durden, UCLA Medical Center Dept. of EM 924 Westwood Blvd., Ste 300 Los Angeles, CA 90024 Length: 1-2 years Salary: Competitive Shifts: 5 per month Degree: MPH, PhD Positions: 1
Deadline: October 15 ( (310) 794-3086 8ndurden@mednet.ucla.edu :http://cim.ucla.edu
Connecticut
6. Yale University School of Medicine Regional Focus: Africa Contact: Simon Kotlyar, MD Department of EM 464 Congress Ave, Suite 260 New Haven, CT 06519-1315 Fax: 203-785-4580 Length:2 years Positions: 1 Salary:PGY level, MSc tuition, travel stipend, excellent benefits Shifts/hours per week: 0.5 FTE Degree: MS, London School of Hygiene and Tropical Medicine Deadline: December 1 ((203) 785-4058 8simon.kotlyar@yale.edu :medicine.yale.edu/ emergencymed/fellowships/ global/index.aspx
32

Delaware
7. Christiana Care Health System Regional Focus: Africa Contact: Susan E. Thompson, DO Christiana Care Health Systems Dept. of EM Administration 4755 Ogletown-Stanton Road Newark, DE 19718 Length:1 2 years Shifts: Between two and three 8or 9-hour shifts/week Degree: MPH with 2-year program Deadline: November 15 ((302) 733-3904 8susthompson@christianacare. org Salary: Competitive salary, benefits, CME, intl travel funds Shifts per month: half-time EM clinical faculty position Degree: None Positions: 1 ((706) 721-4412 8hgross@mail.mcg.edu :www.mcg.edu/ ems/residency/ internationalMedFellow.htm 14. University of Maryland Regional Focus: China, Egypt, South Africa, Botswana, The Netherlands Contact: Veronica Pei, MD, MPH University of Maryland Department of Emergency Medicine 110 S. Paca Street, 6th Floor, Suite 200 Baltimore, MD 21201 Length: 2 years Salary: Competitive Positions: 1 Degree: MPH Deadline: Open (Phone: (410)328-8025 8veronica.pei@gmail.com massachusetts 15. Harvard University / Beth Israel Deaconess Medical Center Contact: Philip D. Anderson, MD Department of EM One Deaconess Road W/CC -2 Boston, MA 02215 Length: 2 years Salary: Competitive, benefits, CME benefits and MPH tuition Positions: One Degree: MPH Deadline: December 1 ( (617) 754-2324 8 pdanders@bidmc.harvard.edu 16. Harvard University / Brigham and Womens Hospital Regional Focus: Various Contact: Stephanie Rosborough, MD, Department of EM 75 Francis Street Boston, MA 02115 Length: 2 years Positions: One Salary: Competitive with excellent benefits Shifts/Week: 1-2 Degree: MPH Deadline: November 20 ( (617) 732-5813 8 iem@partners.org : www.brighamandwomens.org/ dihhp/iem New York, NY 10016 Length: 1 - 2 years Salary: Competitive Positions: 1 ((212) 562-8147 8peg.aao@att.net 18. New York - Presbyterian: The University Hospitals of Columbia and Cornell Regional Focus: Africa (Uganda, Tanzania, Kenya, Sudan, Ghana, Malawi, Sierra Leone); India, Sri Lanka, Montenegro, Dominican Republic, Burma; WHO in Geneva Contact: Rachel T. Moresky, MD, MPH Columbia University Medical Center - Center for EM 622 West 168th Street PH 1-137 New York, NY 10032 Length: 2 years Salary: Competitive Positions: 2 Degree: MPH Deadline: November 1 ( (212) 304 5745 8rtm2102@columbia.edu : www.nypemergency.org/ fellowships 19. North Shore - Long Island JewishHealth System Contact: Sassan Naderi, MD Dept. of EM 270-05 76th Ave New Hyde Park, NY 11040 Length: 1year Positions: 1 - 2 Salary: $90,000 Hours per week: 18 Deadline: Rolling ( (718) 470-7501 8 snaderi@nshs.edu 20. St. Lukes Roosevelt Hospital Center - Global Health Fellowship Focus: HIV/TB/Tropical Contact: John D. Cahill, MD Dept. of EM 1111 Amsterdam Avenue New York, NY 10025 Length: 2 years Positions: 2 Salary: $87,000 Hours per week:20 Degree: MPH optional Deadline: Rolling ( (212) 523-3330 8applications@slredglobalhealth. com : www.slredglobalhealth.com
Illinois
District of Columbia
8. George Washington University Regional Focus: India, Malawi, Egypt, El Salvador, Ethiopia, Peru Contact: Kate Douglass, MD, MPH 2150 Pennsylvania Avenue, NW, 2B-417, Washington, DC 20037 Fax: (202) 741-2921 Length: 2 years (1 year possible under special circumstances) Salary: Highly competitive, MPH tuition and generous CME Degree: MPH Positions: 1-2 Deadline: November 15 ((202) 741-2954 8kdouglass@mfa.gwu.edu :www.gwemediem.com
11. Cook County Hospital Contact: Jamil Bayram, MD & Robert Simon, MD Cook County Hospital, Rush University Medical Center Dept. of EM 1653 W. Congress Parkway, 177 Murdock Chicago, IL 60612 Fax: (312) 942-4021 Length: 2 years (with MPH) Salary: Very competitive, benefits, tuition fees for the MPH, travel expenses and stipends Positions: 1- 2 Deadline: Open ( (312) 942-4978 8 jamil_bayram@rush.edu 12. Univ. of Illinois at Chicago Contact: Janet Lin, MD, MPH Department of EM, College of Medicine East Suite 469A 808 South Wood Street Chicago, IL 60612 Length: 2 years Salary: N/A Positions: 1-2 Deadline: Open ((312) 413-7393 8jlin7@uic.edu
Georgia
9. Emory University Contact: Scott Sasser, MD Department of EM 531 Asbury Circle - Annex Suite N - 340 Atlanta, GA 30322 Fax: 404-778-2630 Length: 2 years Positions: 1 Salary: Instructor Deadline:Check withdepartment ((404) 778-5975 8ssasser@emory.edu 10. Medical College of Georgia Regional Focus: Peru, Bangkok Contact: Hartmut Gross, MD 1120 15th Street Augusta, Georgia 30912 Fax: (706) 721-7718 Length: 1 year
Maryland
13. The Johns Hopkins University Contact: Alexander Vu, DO, MPH International Emergency Medicine Center for Public Health and Human Rights 5801 Smith Avenue, Suite 3220 Baltimore, MD 21212 Fax: (410) 502-8881 Length: 2 years Salary: Competitive Positions: 1-2 Degree: MPH Deadline: September 15 ((410) 735-6436 8avu3@jhmi.edu
New York
17. Bellevue Hospital Center/ New York University School of Medicine Contact: Peter Gordon, MD Emergency Care Institute Room 345A, Bellevue Hospital Center 27th Street and First Avenue
33

21. University of Rochester Medical Center Contact: David H. Adler, MD Dept. of EM 601 Elmwood Avenue, Box 655 Rochester, NY 14642 Length: 2 years Salary: $80,000 - $100,000/year depending on clinical time; CME, benefits, 5k/year travel Positions: 1 Degree: MPH, clinical investigation, or medical management Deadline: April 15 ((585)463-2945 8david_adler@ :www.urmc.rochester.edu/ emergency-medicine/education/ international.cfm North carolina 22. Duke International EM Fellowship/Global Health Residency Program Focuses: East Africa, Casualty department epidemiology, trauma epidemiology research, validation of trauma scoring in resource limited settings Contact: Charles J. Gerardo, MD Duke University, DUMC 3096 Durham, NC, 27710 Length: 2 years Positions: 1 Salary: Competitive, including tuition for advanced degree Degree: MS in Global Health (MSc-GH) Deadline: September 24 ( 919-681-4458 8 gerar001@mc.duke.edu : www.dukeglobalhealth.org :globalhealth.duke.edu Oregon 23. Oregon Health & Science University -Global HealthFellowship Contact: Amy Marr, MD OHSU Dept. of EM 3181 SW Sam Jackson Park Road, CDW-EM Portland, OR, 97068 Length: 2 years Positions: 1-2 Salary: PGY level, CME allowance, benefits Shifts per week: 1 Degree: Masters or certificate options (tuition support provided) Deadline: Rolling ( (503) 494-8220 8 marra@ohsu.edu : www.emergencyresidency. com Pennsylvania 24. University of Pittsburgh Contact: Allan B. Wolfson, MD Dept. of EM 230 McKee Place, Ste. 500 Pittsburgh, PA 15213 Length: 2 years Salary: Negotiable Shifts per week: Negotiable Degree: MPH offered from the University of Pittsburgh Graduate School of Public Health ( (412) 647-8265 8wolfsonab@upmc.edu : affiliatedresidency. health.pitt.edu
texas
27. Baylor College of Medicine / Texas Childrens Hospital Regional Focus: Various Contact: Charles G. Macias, MD, MPH Texas Childrens 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 Positions: 1 Hours per week: 32-40 Conferences/week: 4 hours, except PICU rotation Degrees: MPH, MEd, MS, MBA Deadline: August 31 through ERAS (apply for PEM Fellowship) ( (832) 824-5468 8pwomack@ :texaschildrenshospital.org 28. University of Texas Southwestern (Dallas-Parkland) Regional Focus: Mexico/Latin America. Others negotiable. Contact: Robert E. Suter, DO, MHA Div. Emergency Medicine UT Southwestern Medical Center at Dallas 5323 Harry Hines Boulevard CS2.122 Dallas, TX, 75390-8579 Length: 2 years Salary: Competitive Positions: 4 Hours: 56 clinical hours/month Degrees: MPH Deadline: December 1 ( (214) 648-3916 8robert.suter @utsouthwestern.edu
8erik.barton@hsc.utah.edu -----------------------------------
the netherlands
The NVSHA (Dutch Society for Emergency Medicine) Contact Dr. Pieter van Driel 8vandrielpieter@hotmail.com Terry Mulligan, DO, MPH 8terrymulligan@yahoo.com Length: 1 to 2 years Number of positions: 1 or 2 Degrees: Subspecialty/ Fellowship Status in Dutch EM System Deadline: Rolling. Currently open only to Dutch EPs ( +31 624 11 3566 : nvsha.nl
canada
University of Toronto / Canadian Association of Emergency Physicians (CAEP) Regional Focus: Global, Africa Contact: Valerie Krym 8v.krym@utoronto.ca
Rhode Island
25. Rhode Island Hospital Regional Focus: Liberia, Rwanda, Uganda, Kenya, and Haiti Contact: Lawrence Proano, MD University EM Foundation 593 Eddy Street, Providence, RI 02903 Length: 2 years Salary: $87,500 Positions: 1-2 Hours per Week: 16 Degree: MPH from Brown University ( (401) 444-5826 8lproano@lifespan.org
australia / New Zealand

Australasian College of Emergency Medicine (ACEM) Regional Focus: Global, Australia, NZ & South Pacific Contact: Peter Cameron, MD 8peter.cameron@med.monash. edu.au and Gerard Oreilly 8oreillygerard@hotmail.com
tennessee
26. Vanderbilt University International EM Fellowship Regional Focus: South America Contact: Seth Wright, MD Vanderbilt University 703 Oxford House Nashville, TN,37232 Length: 1-2 years Positions:2 Salary:$92,000 + excellent benefits, tuition, travel expenses Hours per week: 14.75 Degree: MPH, DTMH Deadline: Rolling ( (615) 936-0075 8seth.wright@vanderbilt.edu : emergencymedicine. mc.vanderbilt.edu
south africa
South Africa: Univ. Cape Town / Stellenbosch Univ. / EM Society of South Africa (EMSSA) Regional Focus: Africa, South Africa Contact: Lee Wallis, MD 8leewallis@bvr.co.za
utah
29. University of Utah Regional Focus: Ghana, Thailand, India, Peru Contact: Erik Barton, MD, MS, MBA University of Utah Health Care 30 North 1900 East, Rm 1C26 Salt Lake City, UT 84132 Length: 1 to 2 years Salary: competitive Positions: 1 or 2 Shifts: 7 per month/54 hours Degrees: MPH Deadline: Rolling ( (801) 581-2417
Forthcoming Programs
IFEM Fellowship Regional Focus: Global Contact: Peter Cameron, MD 8peter.cameron@med.monash. edu.au
34
with peter cameron, MD
Grand Rounds
The State of the Specialty
From Argentina to Vietnam, EM takes steps forward in development, always under the scrutiny of outside interests. Global change will come when we come together and speak as one voice.
cine. There is a lack of knowledge regarding the emergency team required to manage complex emergencies highly trained nurses, allied health, technicians, IT and so forth. International comparisons and benchmarking of resources and outcomes are essential in lobbying governments for improved emergency care. The International Federation for Emergency Medicine (IFEM) is the only global voice for improvements in emergency care. Working with national and regional societies, it can act as a credible authority to lobby governments and the medical establishment. A major IFEM achievement has been agreement on what is required to train a medical specialist in emergency care, and publication of international curricula on undergraduate and postgraduate emergency medicine training. We are now looking at innovative methods for making curriculum content available to emergency medicine training programs through an international collaboration with the UK College of Emergency Medicine. If this proves feasible, it will be a major advance, especially for low resource countries or countries commencing specialist programs. A further development, still under negotiation, is the possibility of partnering with the Guidelines International Network to develop emergency specific guidelines that will be useful for emergency clinicians internationally. Utilising their extensive resources, we could adapt existing guidelines to fit an international framework. One of the roles of IFEM has been to provide a collegiate structure where colleagues from around the world can meet and discuss common issues and hopefully find solutions to their problems. A biannual conference is now being complemented by symposia which will be coordinated to address specific issues. This year, IFEM is running three symposia, each in conjunction with a regional organization. The first is on resuscitation and will take place in Mexico this June in cooperation with the local Mexican society. This meeting will review the implications of the changes to the resuscitation guidelines in 2010. Second, there will be a symposium on international residency programs, to assess common objectives, curricula and outcomes, in New York, in August. It is hoped that some consensus on the structure and function of these programs might result. Finally, IFEM and CEM (UK) will sponsor a symposium on improving patient safety and quality of care in emergency medicine in London, in November. A potential outcome of this conference could be an international consensus on the framework for targeting and measuring improvements in the quality of emergency care. As these symposia are developed and the organisation and structure improves over time, we believe that they could become forums for major issues that face emergency medicine, and the consensus statements that emerge could become powerful documents to drive change internationally. There is so much happening on the international scene, I urge you to become involved, either through your local or regional organisations or through the committees, symposia and other forums within IFEM. It is amazing how much influence a small group of like-minded individuals can have on developments internationally.
Dr. Cameron is the President of the International Federation for Emergency Medicine. www.ifem.cc
As emergency medicine grows internationally, the amount of activity in the four corners of the world is expanding exponentially. Continuing developments in Europe, Asia, Africa, the Middle East, the Americas and Oceania, are driving improvements in emergency care. However, in spite of this rapid development, there are many threats to emergency medicine. In Europe, the specialty is only recognised as a full specialty in a handful of countries, and there are potential threats from traditional specialties to halt further developments.
In Asia, EM development runs the gamut, from very advanced regions such as Singapore and Hong Kong to countries like Vietnam, where the specialty is recognised but infrastructure is not in place to train clinicians appropriately. In Africa, most of the continent has no organised emergency medical system, despite the obvious need and the potential to significantly improve patient outcomes. Latin America is now recognising the importance of emergency medicine, with official recognition in countries as diverse as Argentina and Colombia. And yet, the ability to coordinate and collaborate in Latin America seems hampered by finance, politics and tradition. The Pacific Islands face particular difficulties as the small Island states do not have the infrastructure or critical mass to initiate training programs of their own, and will need to form regional collaborations to ensure sustainability. The Middle East has had some great leaders in emergency medicine, in countries such as Israel and Bahrain. Unfortunately, tumultuous political events are undermining the orderly development of emergency systems in many countries and even threatening doctors who work in the hospitals of those countries. Our colleagues working in these conflict zones deserve our support. Even in advanced economies with sophisticated emergency medical systems, such as the United States, Australia and Canada, there are significant threats facing the practice of emergency medicine. The most obvious is overcrowding or access block in emergency departments. There have been many strategies employed to mitigate this threat to quality emergency care, but few have been successful in managing the problem in a sustainable way. Probably the most successful intervention has been the 4-hour standard introduced in the UK. This protocol emptied the emergency departments, yet it is unclear the extent to which this improved the quality of care for emergency patients overall. Another threat to emergency medicine is a by-product of the rationing of healthcare services taking place around the globe. During this process, there have been continual attempts to devalue the importance of having qualified emergency medical staff at the front end of the emergency medical system. There is an under-appreciation of the need for senior qualified people, 24/7 on site in emergency departments. There is also a lack of understanding as to why these clinicians need to be better trained than their highly-trained subspecialist colleagues who only need to know about a very small specialised part of medi-
35
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EPI Spring 2011 Issue 4

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MSF in embattled Ivory Coast Peter Camerons IFEM Rundown Common Laryngoscopy Mistakes

EMERGENCY PHYSICIANS INTERNATIONAL

the south america issue

EM Development Reports from

Croatia south africa & japan

the 8th Annual NY Symposium on

INterNAtIoNAl emergeNcY medIcINe

Global Collaborations in Emergency Medicine

August 17 18, 2011 lenox Hill Hospital New York city

plus . . . Meet the IEM Fellowship Directors

FACu Lt y /At t eN Di Ng S : $ 1 2 5 | R e SiD eNtS: $25 | S tu DeNtS : FRee

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

Join the team

EM DEvElopMEnT rEporTs FroM arounD ThE globE

The Future of IFEM

Letter from the publisher

Logan Plaster Publisher

connect with international colleagues on emergency medicines largest professional network

EP International is a product of M. L. Plaster Publishing Co., LLC 2010 Founder / CEO

Executive Vice President

Spring 2011 // Emergency Physicians International

pVisit Cape Town for next Novembers

Segundo Congreso Internacional de Reanimacin // Mexico

Sixth Mediterranean Emergency Medicine Congress // Kos, Greece

III Brazilian Congress of Emergency Medicine // So Paulo, Brazil

Symposium on Quality and Safety in Emergency Care // London, England

1st IFEM Symposium on Resuscitation // San Miguel de Allende, Mexico

The European Trauma Course // Verona, Italy

Emergency Medicine in the Developing World // Cape Town, South Africa

Asian Conference for Emergency Medicine (ACEM) 2011 // Bangkok, Thailand

Retrieval // Glasgow, Scotland

The 1st Middle East Emergency Medicine Conference // Dubai, UAE

3 | Editors Desk 5 | Event Calendar 32 | IEM Fellowship Directory

EMERGENCY PHYSICIANS INTERNATIONAL

Spring 2011 // Emergency Physicians International

Save 50 -100 USD !

Deadline: May 31, 2011

How to Avoid Common Laryngoscopy Errors

Spring 2011 // Emergency Physicians International

Trauma Surgery in Embattled Ivory Coast

Spring 2011 // Emergency Physicians International

dispatches 14 croatia 16 South africa 18 japan 20

Q. Describe a case that exemplifies the setting in which you work

Spring 2011 // Emergency Physicians International

croatia & the EU: A brief timeline

New certification standards for EM specialists point to hopeful long-term progress

EU agrees to start accession talks with Croatia.

Spring 2011 // Emergency Physicians International

Equip and staff full service hospitalbased emergency departments.

trauma referral system.

for EM and EMS.

Develop designated trauma centers at 4 of the largest hospitals and develop a

facts & figures

Total expenditure on health as percentage of GDP

healthcare spending breakdown

Spring 2011 // Emergency Physicians International

ONE SIZE...ALL DIGITS SIMPLE AND SAFE EVERY TIME!

YOUR PATIENTS ARE ON THE CUTTING EDGE...ARE YOU?

Emergency Department Sedation Practices:

A Cape Town Survey

Most Common Procedural Sedation Agents

The T-Ring is also available in a disposable laceration tray