Category: Choosing Emergency Medicine

The Importance of the Emergency Medicine Clerkship (2023)

THE IMPORTANCE OF THE EMERGENCY MEDICINE CLERKSHIP
~ iEM Education Project Team ~ Leave a comment

by Linda Katirji and Farhad Aziz

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Introduction

The emergency medicine (EM) clerkship typically takes place during the fourth year of medical school. However, some medical schools may have an optional elective or a core rotation during the third year. Whether or not you plan to specialize in emergency medicine, the rotation is an important part of your medical education that will help you develop unique skills. The emergency room is a unique learning environment which is different than any other setting in the hospital. It provides clinical opportunities that are largely unavailable in other clerkships and rotations, and one of the few places you will encounter a completely undifferentiated patient. During residency, many specialties will also spend a significant amount of time in the Emergency Department (ED). This may be within a structured EM rotation, or while admitting or seeing patients for a certain medical or surgical service. Therefore, it is important to gain an understanding of the flow of the ED as well as the unique thought process that must be employed with emergency department patients. This chapter will discuss some of the unique aspects of the emergency department, some of the skills to acquire during the EM clerkship, as well as how to best be successful and take the most away from your rotation.

Unique Aspects of The Emergency Department Environment

The high volume and acuity of patients in the ED create a time pressure and forces physicians to employ a different style of practice than in most other settings. A steady stream of patients, some of whom may require immediate life-saving measures, means that many times there is little to no time to review history or any medical records prior to evaluating a patient. Most of the time you will need to assess a patient without knowing anything about their background.  Therefore, it is important to gain an understanding of what the most important pieces of information to gather are for each patient.  This can be difficult since most patients will arrive with completely undifferentiated complaints. Some common examples of these undifferentiated complaints are “chest pain” and “abdominal pain”, where the etiology can range from completely benign to immediately life-threatening, or “weakness”, where the differential diagnosis includes essentially the entire spectrum of medical pathology.

This undifferentiated patient is the standard in the ED. However, they can present in any medical setting. It is important to learn the thought process and develop a strategy for thinking through these types of patients whether you plan on a career in EM or not. Emergency physicians (EPs) must employ and master a completely different style of practice than most physicians. EPs must always think worst case scenarios for each chief complaint and must be knowledgeable and comfortable with associated the workup and treatment. A good example of this is chest pain. Even though many times the complaint of “chest pain” is found to be caused by a non-acutely life threatening etiology, EPs must immediately think of six fatal causes of chest pain: acute coronary syndromes, aortic dissection, pulmonary embolism, pericardial tamponade, pneumothorax, esophageal rupture. Additionally, ED doctors must use a different thought process in determining the disposition, or outcome, of the patient. The ED doctor essentially wants to avoid sending a patient home that is not safe to go home, where as a consultant, or admitting service, does not want to admit a patient who does not need be admitted. This may seem trivial, however this difference in thought process can occasionally create tension between the ED and admitting services.

Teaching in the ED is different than most other settings in the hospital as well. There is usually no time set aside for formal rounds, so most teaching is done actively at the bedside or at the time the student or resident presents the patient to the attending physician. Many times, attending physicians will pick out “teaching points” for each patient. Each physician will have a different teaching style. Your learning will generally be more active than passive, and likely more short and frequent rather than one long teaching sessions or lecture on rounds.

Lastly, the ED is a great place for medical students and first-year residents to learn to take responsibility for their patients. Students often time have an increased level of autonomy compared to other rotations. Many times, the student will be the first person to assess the patient, which is a very important role. It is important to learn to distinguish whether a patient is “sick” or “not sick”, and whether or not at first glance you think this patient could go home or needs to be admitted no matter what the diagnosis may be.

Unique Skills To Take Away From EM Clerkships

Emergency medicine is a wonderful rotation that exposes you to not only different patient populations but also a variety of pathology and diseases. This diverse collection of patients and pathology lends emergency medicine residents and students a unique opportunity to gain a mastery of different skills. These skills range from a knowledge of how to approach critically ill patients, gaining procedural skills, reading radiographs and CT scans, performing ultrasounds and much more.

Often you may be busy doing different tasks when you must drop everything to manage a critically ill patient. This is one of the exciting aspects of emergency medicine. These patients offer students a great opportunity to learn the principles of resuscitation, such as managing airways and circulatory collapse, identifying causes for the patient’s decompensation, and instituting the appropriate treatment. Whether you pursue a career in emergency medicine or choose to pursue a different specialty, critically ill patients will likely always be a part of your patient population. Understanding how to approach and stabilize these patients is an important part of being a physician.

Though learning the art of resuscitation is a vital part of the EM rotation, this is also an opportunity to gain competence in a variety of procedures. Whether you intend to pursue a career in pediatrics, internal medicine, orthopedics, general surgery or any other specialty, your rotation through the ED will expose you to a wide array of procedural skills ranging from intubating and placing central lines and arterial lines in the critically ill to performing lumbar punctures and fracture reductions in children. Autonomy is encouraged with procedures, and you will have the opportunity to improve your skills and techniques under the guidance of residents and attendings. EM is a very hands-on specialty. You should take advantage of medical student and resident didactics as an opportunity to learn.  These usually consist of lectures on different subjects but also may include ultrasound practice, procedure labs on mannikins or cadavers and simulation. This will give you an opportunity to practice and provide better patient care during your rotation.

In addition to becoming familiar with a wide array of procedures, your EM clerkship will also allow you to familiarize yourself with a variety of imaging modalities ordered in the ED. There is a tremendous amount of pathology found in the ED which lends itself to a range of imaging. Whether it be learning to perform bedside ultrasonography on a crashing patient or simply learning how to approach reading a chest x-ray or a CT scan of the abdomen on your own, your EM rotation will give you plenty of opportunities to become proficient in a skill you will need later in your career.

Though your EM clerkship gives you exposure to a tremendous amount of skills which will help you become a savvy doctor, no skill is more important than compassion and humility. Every day, you will meet patients on the worst day of their life. Many will have gone through traumatizing experiences, or have a life changing chronic condition, or be in a severe amount of physical or emotional pain. Realizing this and comforting patients and their families is paramount to your success as a physician. You will also encounter a variety of consulting physicians. Speaking with consulting physicians about a patient is an art form in itself that EM physicians must master. While most consultants will be polite and professional, its not uncommon in to meet push-back from a consultant. Occasionally, some may be out right rude. Having a general understanding that they all have knowledge that you can learn from will set you up for a successful career in medicine.

How To Be Successful on Your EM Clerkship

Many of the of the same qualities that allow you to be successful in other rotations will help you to be successful in the ED.  It is important to be hardworking, proactive, and knowledgeable. Keep a close eye on your patients, re-evaluate them frequently, and make sure to follow up on any results, including labs, imaging, and any recommendations by consultants. The unique aspects of the ED and EM clerkship discussed previously mean the first few shifts may be stressful and seem chaotic and hectic. For every student and resident that rotates through the ED there is a significant learning curve – with each shift you spend in the ED, things will feel less and less daunting. It’s important during this time that you know your limitations and what you are comfortable and not comfortable with. Many times you will be the first person to assess the patient. You should have a low threshold for alerting an upper-level resident or attending if the patient appears to be sick, or if they present with a complaint you are uncomfortable with. At the same time, you should be confident in what you do know and take the opportunity to learn how to diagnose, treat, and manage your patient.

The best way to build confidence during your EM rotation is to gain experience and knowledge. Try to be proactive in learning new procedures or treatments with attending or resident assistance. Additionally, it’s very important to keep up with reading and studying. In the emergency room, you may see medical pathology you’ve only read about and will be expected to know how to diagnose and treat these diseases properly. When you have the time, use the resources you have at your disposal and look things up before presenting to your resident or an attending, and have a plan to disposition (ie, admission or discharge) already made for the patient.

Good communication is essential for a physician in any specialty, and in the ED, it is an imperative skill to have.  You will be working with a large team of nurses, technicians, consulting doctors, social workers, and paramedics, just to name a few. When you see a patient, it is a good idea to speak with the nurse before you enter the room to gain a better understanding of the patient’s complaint, as well as gather any information that was relayed by EMS. By communicating the plan of care to the nurse and supporting staff, you will not only improve patient care and reduce mistakes but also forge relationships that will enrich your experience in the ED. In acute settings such as a patient code or rapidly decompensating patient, good communication with the entire team is critical. As a medical student or rotating resident, this is a great time to practice and improve your communication skills in these acute settings under the direction of residents and attendings.

Your EM rotation will be an exciting, unique experience during medical school and residency. Whether you plan to specialize in EM or not, you will learn many procedural skills, improve your own method of diagnosing and treating patients and be able to practice a different method of medical decision making.

Authors

Linda KATIRJI

Linda KATIRJI

University of Kentucky, Department of Emergency Medicine

Farhad AZIZ

Farhad AZIZ

The Ohio State University, Department of Emergency Medicine

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Cite This Article

Please replace “iEM Education Project Team” below with the author(s) surname and initials.

Cite this article as: iEM Education Project Team, "The Importance of the Emergency Medicine Clerkship (2023)," in International Emergency Medicine Education Project, April 17, 2023, https://iem-student.org/2023/04/17/the-importance-of-the-emergency-medicine-clerkship-2023/, date accessed: October 1, 2023

2018 version of this topic – https://iem-student.org/the-importance-of-the-emergency-medicine-clerkship/

References

  1. EMRA and CORD Student Advising Guide (https://www.emra.org/books/msadvisingguide/msag/)
  2. EMRA Medical Student Page (https://www.emra.org/students/)
  3. The Emergency Medicine Clerkship Primer (https://www.saem.org/docs/default-source/saem-documents/students/em-clerkship-primer_0_0.pdf)

Reviewed By

Arif Alper Cevik, MD, FEMAT, FIFEM

Arif Alper Cevik, MD, FEMAT, FIFEM

Prof Cevik is an Emergency Medicine academician at United Arab Emirates University, interested in international emergency medicine, emergency medicine education, medical education, point of care ultrasound and trauma. He is the founder and director of the International Emergency Medicine Education Project – iem-student.org, vice-chair of the International Federation for Emergency Medicine (IFEM) core curriculum and education committee and board member of the Asian Society for Emergency Medicine and Emirati Board of Emergency Medicine.

Journal Club 10/17/22: Global Burden of Disease

~ Global EM Student Leadership Program ~ Leave a comment

The Economic Impact of Ebolavirus in West Africa: A Burden the Size of Iceland by Andrew L. Mariotti

Between 2014 and 2016, West Africa experienced an Ebola virus epidemic that resulted in 28,000 cases, 11,000 deaths, and a loss of up to $32.6 billion in gross domestic product. To put this in perspective, America’s 2021-2022 flu season culminated in 9 million cases, 5,000 deaths, and a loss of up to $8 billion in GDP. In other words, a single Ebola infection represents a nearly 1200 times greater economic cost, emphasizing the intense strain this disease places on West African nations. 

Factors precipitating these costs are multi-faceted and stem not only from the increased morbidity of Ebola but also from structural constraints. The 16 countries of West Africa represent a GDP of $726 million and struggle with a human capital index (see figure below) of 0.40, nearly 0.17 points under the global average. Given this set of conditions, it’s no wonder a disease as serious as Ebola can lead to losses greater than the size of Iceland’s economy ($24.4 billion GDP).

While many strategies to ameliorate these issues emphasize the importance of developing new infrastructure and creating jobs, it’s worth considering how treating Ebola – and reducing the associated disease burden – could palliate a gargantuan economic burden holding this region back from development. How to accomplish this aim would require an entirely new blog post. However, the thought of what a $32.6 billion investment could return for the future growth and development of these underserved populations is worth consideration.

Further Reading:

Discussion Questions:

  • What barriers to effective Ebola treatment and containment would provide the greatest benefit to individuals in endemic regions were it to be realistically mitigated?
  • How does the way we think about the importance of treating epidemics change when considering the economic impact it has on a country and could decreasing disease burden be an effective strategy for helping developing nations become more industrialized?

Chapter 4: Global Health and the Global Burden of Disease by Kelsey Yenney

In this chapter, a focus was placed on common terms used to describe the health of a population as well as discuss two ongoing projects that guide policymakers when setting priorities. Throughout this post I will refer to the ‘global burden of disease’; authors in this book have provided the definition as “quantity of diseases/conditions AND their impact on the population”. 

Describing the health of populations is done in terms of descriptive statistics and there are many reasons to quantify the burden of disease. The health of a population must be measured and understood for the healthcare system to adequately respond. Quantifying the burden of disease allows for planning, policy making, executing delivery and program evaluation. For example (as used by the author of this chapter), the Minister of Health of Malawi may learn that there were 260 new cases of tuberculosis per 100,000 people in one year. Given that the population at the time was 15.5 million, she can plan that 40,300 people will be diagnosed and treated in her country in the coming year to achieve universal coverage of TB. Descriptive statistics allow policy makers, practitioners, and other healthcare providers to attempt to stay “one step ahead” of the ebbs and flows of epidemiology. 

Understanding the burden of disease requires disease surveillance. In 1992, the World Bank commissioned WHO to quantify the global burden of disease; until that time, there was historically insufficient data with which to estimate the burden of disease in many countries, thus leading to an insufficient understanding of the global burden of diseases. In those studies, it was determined that less than 30% of the data on disease and death came from medically certified documents. A new project in 1994 (“Global Burden of Disease”) looked at 107 conditions and over 400 sequelae or secondary outcomes from disease. Diseases were grouped into different categories and countries were grouped based on their “established market economies”. Later in 1994, the term “DALY” (Disability-Adjusted Life Year) was created which describes the number of years of life that is lost or affected by disease. 

When thinking about the transitions of epidemiology, Abdel Omran named four significant concepts that describe observed shifts in the types of diseases that affect a population as economic conditions improve. For example, malnutrition becomes less frequent as a country gains food security, water sanitation, etc. However, as infrastructure and economy grow, diseases caused by cigarette smoke, processed foods, etc. can increase. The four stages of population health described by Omran were as follows:

  1. Age of Pestilence and Famine: high mortality due to infectious disease and starvation
  2. Age of Receding Pandemics: life expectancy increases as food security; access to housing and clean water improves
  3. Age of Degenerative and Manmade Diseases: fertility rate decreases, infant mortality continues to fall; major causes of death are non-communicable diseases
  4. Age of Delayed Chronic Disease: primary prevention of disease

The above stages were used by policymakers to create a prioritized stepwise process to promote the cheapest and easiest approach to targeting a country’s biggest threat based on where they “fell within the stages”. However, diseases do not occur in a stepwise approach and each country has a diverse range of disease burden. All nations, no matter the GDP, must prevent and plan for infectious disease, mental health, non-communicable disease, etc. 

In 1977, Milton Weinsten and William Stason proposed a formula that became known as cost-effectiveness to make choices between different medical interventions. They proposed that a health intervention was only cost-effective if it was to be under 3x the per capita health costs. This meant that in the US, for example, at the time, a health intervention would be cost-effective if it was less than several thousand dollars because the per capita health expenditure of the US healthcare system is high. However, in impoverished countries, a health intervention would need to fall within $5-15 to be deemed cost-effective. This does not fall anywhere close to the ideals of equity. Using cost-effectiveness as a sole model to reduce global burden of disease severely limits the right to health as it does not consider the many aspects of disease. 

Discussion Questions:

  • What are some conditions/public health concerns that may not be prevalent at the time but can be planned for?
  • For example, no matter what stage of population health a country may be in, infrastructure for flooding may be put in place. What are some major limitations you can see with the proposed cost-effectiveness model?
  • What are some ways that countries are or could be dealing with increasing chronic disease in settings still with large burdens of transmissible disease?

Wrap up!

As you can imagine, our mentees had a wonderful discussion surrounding these two topics! We are thrilled to be able to present a brief summary of their work here. Please stay tuned for details about our upcoming meetings.  Connect with us through one of our contact options listed below if you are interested in attending!

Thank you to our authors and presenters!

Andrew L. Mariotti, MS3

Andrew L. Mariotti, MS3

University of Colorado School of Medicine

Kelsey Yenney, MS3

Kelsey Yenney, MS3

Washington State University
Elson S. Floyd College of Medicine

Blog Editorial Team

Halley Alberts, MD

Halley Alberts, MD

PGY-2 University of South Carolina Prisma Health Midlands
Co-Director & Blog Editor

Jeff Downen, PGY2

Jeff Downen, PGY2

Blog Editor
University of Florida - Jacksonville

Mohamed Hussein, MBBCh

Mohamed Hussein, MBBCh

Trauma Research Fellow
Blog Editor

Resources

  • Drame, M.L., P. Ferrinho, and M.R.O. Martins, Impact of the recent Ebola epidemic with pandemic potential on the economies of Guinea, Liberia and Sierra Leone and other West African countries. Pan Afr Med J, 2021. 40: p. 228.
  • de Courville, C., et al., The economic burden of influenza among adults aged 18 to 64: A systematic literature review. Influenza Other Respir Viruses, 2022. 16(3): p. 376-385.
  • Joia Mukherjee. An Introduction to Global Health Delivery : Practice, Equity, Human Rights. Oxford University Press; 2018. Chapter 4: Global Health and the Global Burden of Disease 

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Cite this article as: Global EM Student Leadership Program, "Journal Club 10/17/22: Global Burden of Disease," in International Emergency Medicine Education Project, April 3, 2023, https://iem-student.org/2023/04/03/journal-club-10-17-22-global-burden-of-disease/, date accessed: October 1, 2023

Journal Club 9/19/22: Medical Tourism

~ Global EM Student Leadership Program ~ Leave a comment

Telemedicine in Low-Resource Settings by Rachel Patel

Telemedicine is defined as the delivery of health care and the exchange of health-care information across distances.

The types of telemedicine are as follows:

  • Live, two-way (or real-time) synchronous audio and video allows specialists, local physicians, and patients to see and hear each other in real-time to discuss conditions 
  • Store-and-forward sends medical imaging such as X-rays, photos or ultrasound recordings to remote specialists for analysis and future consultation
  • Remote patient monitoring collects personal health and medical data from a patient in one location and electronically transmits the data to a physician in a different location 

The advantages of telemedicine in low-resource settings include:

  • Increasing health access across geographical barriers
  • Cost-effectively providing services, from radiology to dermatology to at least some of the millions of patients who lack adequate healthcare
  • Contact precautions (e.g. COVID-19 pandemic)
  • Surveillance and monitoring of medical emergencies, generating health data to inform international aid programs and policies
  • Interconnected network of data sharing as well as funding for international crises

Limitations include:

  • Patients who have emergent health conditions, or need a physical exam or laboratory testing for medical decision making
  • If sensitive topics need to be addressed, especially if there is patient discomfort or concern for privacy
  • Limited access to technological devices (e.g., phones, tablets, computers) or connectivity

Discussion Questions:

  • What are some of the ethical implications of telemedicine?
  • How do you see telemedicine factoring into medical care as we move forward in a post-COVID world?
  • Is there a place for telemedicine in emergency medicine?

The Roots of Global Health Inequity by Grace Bunemann

** A short blog post & presentation are far too brief of formats to discuss this extensive topic adequately. The following is an overview of Chapter 1 from Dr. Joia S. Mukherjee’s book entitled An Introduction to Global Health Delivery. **

To simply explain LMIC (lower middle-income country) Health Systems today, it is important to review the history of slavery and colonialism which led to years of resource extraction ultimately resulting in weak health systems seen in LMIC countries today.

Prior to World War II, the conduct of a government against its own people was considered a matter of national sovereignty, however global opinion changed following the liberation of the Nazi concentration camps. After WWII, it was believed that all people, regardless of their country of origin, have an inalienable set of human rights. These principles were upheld in the Universal Declaration of Human Rights in 1948.

“Everyone has the right to a standard of living adequate for the health and well-being of himself and of his family, including food, clothing, housing and medical care and necessary social services, and the right to security in the event of unemployment, sickness, disability, widowhood, old age or other lack of livelihood in circumstances beyond his control.”

The same European countries that were championing human rights had little issue with the continuation of colonialism and denying those who were colonized their human rights. Importantly, only four independent African countries were able to vote for the Declaration (South Africa, Egypt, Ethiopia, and Liberia). 

In 1978, the International Conference on Primary Health Care was held in Alma Ata (currently Almary, Kazakhstan). The conference hosted 600 representatives from the 150 WHO member states and aimed to discuss models for care delivery and develop solutions for people living without access to health care.  

In parallel to the Cold War, socialist republics advocated for government funds to deliver on the promise of health as a human right by building public health systems with doctors, nurses, and hospitals while capitalist states argued that health systems could not be built until economic growth occurred and reasoned that volunteers could be used to deliver basic health services in impoverished countries. 

It is important to note a majority of delegates advocated for the public provision of health as a human right and the Alma Ata Declaration is the result. It advocated for health as a human right and included the need to address the social factors related to ill health, such as lack of food, water, and sanitation. The declaration set modest yet concrete goals like 90 percent of children should have weight for an age that corresponds to reference values, every family should be within a 15-minute walk of potable water, and women should have access to medically trained attendants for childbirth.

The concept that health demanded more resources than those available within an impoverished country’s budget and that health should be financed through international collaboration were radical notions. Several factors impacted the Alma Ata Declaration including physician opposition, Cold War geopolitics, and neoliberal reforms. 

In 1979, a proposed alternative to the Alma Ata Declaration was published in the New England Journal of Medicine entitled ‘Selective Primary Health Care — An Interim Strategy for Disease Control in Developing Countries.’ It praised the goals of Alma Ata as laudable, but ascertained the objective was unrealistic given the impoverishment of those countries with the highest disease burden. This publication countered that it is more realistic to target scarce resources to prevent and control the spread of diseases that account for the highest mortality and morbidity. Selective Primary Health Care became the new standard for global health efforts for years to come. 

“It is impossible to understand global health delivery without understanding the destructive history of slavery, colonialism, and neoliberalism that left governments impoverished and unable to fulfill the right to health.”

Wrap up!

As you can imagine, our mentees had a wonderful discussion surrounding these two topics! We are thrilled to be able to present a brief summary of their work here. Please stay tuned for details about our upcoming meetings.  Connect with us through one of our contact options listed below if you are interested in attending!

Thank you to our authors and presenters!

Rachel Patel, MS4

Rachel Patel, MS4

Rutgers Robert Wood Johnson Medical School

Grace Bunemann, MS4

Grace Bunemann, MS4

Campbell University School of Osteopathic Medicine

Blog Editorial Team

Halley Alberts, MD

Halley Alberts, MD

PGY-2 University of South Carolina Prisma Health Midlands
GEMS LP Co-Director & Blog Editor

Mohamed Hussein, MBBCh

Mohamed Hussein, MBBCh

Trauma Research Fellow
Blog Editor

Jeff Downen, MD, MS

Jeff Downen, MD, MS

PGY-2 University of Florida, Jacksonville
Blog Editor

Resources

  • Hollander JE, Carr BG. Virtually perfect? Telemedicine for Covid-19. New England Journal of Medicine 2020; 328; 1679–1681 
  • Calton B, Abedini N, Fratkin M. Telemedicine in the time of coronavirus. Journal of Pain and Symptom Management 2020; https://doi.org/10.1016/j.jpainsymman.2020.03.019external icon 
  • Ohannessian R, Duong Ta, Odone A. Global Telemedicine Implementation and Integration Within Health Systems to Fight the COVID-19 Pandemic: A Call to Action. JMIR Public Health Surveill 2020;6(2):e18810 doi: 10.2196/18810. 
  • Smith AC, Thomas E, Snoswell CL, Haydon H, Mehrotra A, Clemensen J, Caffery LJ. Telehealth for global emergencies: Implications for coronavirus disease 2019 (COVID-19). Journal of Telemedicine and Telecare 2020; DOI: 10.1177/1357633X20916567 
  • Tuckson, R., Edmunds, M., Hodgkins, M. Telehealth. New England Journal of Medicine 2017; 377:1585–1592. Retrieved from https://www.nejm.org/doi/full/10.1056/NEJMsr1503323 
  • Tolone S, et al. Telephonic triage before surgical ward admission and telemedicine during COVID-19 outbreak in Italy. Effective and easy procedures to reduce in-hospital positivity. International Journal of Surgery 2020; 78 : 123–125. 
  • Perez Sust P, et al. Turning the Crisis Into an Opportunity: Digital Health Strategies Deployed During the COVID-19 Outbreak. JMIR Public Health Surveill 2020;6(2):e19106) doi: 10.2196/19106 
  • Project ECHO: Provides resources to connect frontline healthcare professionals with experts for distance learning and consultation
  • Joia Mukherjee. An Introduction to Global Health Delivery : Practice, Equity, Human Rights. Oxford University Press; 2018. Chapter 1: The Roots of Global Health Inequity.
  • Boston 677 HA, Ma 02115 +1495‑1000. ALMA-ATA at 40: A Milestone in the Evolution of the Right to Health and an Enduring Legacy for Human Rights in Global Health. Health and Human Rights Journal. Published September 6, 2018. https://www.hhrjournal.org/2018/09/alma-ata-at-40-a-milestone-in-the-evolution-of-the-right-to-health-and-an-enduring-legacy-for-human-rights-in-global-health/
  • Alma-Ata 40 years on | Health Poverty Action. http://www.healthpovertyaction.org. Accessed February 22, 2023. https://www.healthpovertyaction.org/news-events/alma-ata-40-years-on/

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Cite this article as: Global EM Student Leadership Program, "Journal Club 9/19/22: Medical Tourism," in International Emergency Medicine Education Project, March 27, 2023, https://iem-student.org/2023/03/27/journal-club-9-19-22-medical-tourism/, date accessed: October 1, 2023

Project Proposal 12/20: Developing a Community Education Program to Combat Envenomation in India

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Problem Statement

The WHO classified snakebite envenomations as an NTD in 2017 for causing enormous suffering, disability, and premature death worldwide. Bites by venomous snakes can cause paralysis, fatal hemorrhages, irreversible kidney failure, tissue damage and more, leading to permanent disability and limb amputation. Over half the world’s envenomation events and deaths occur in India; this epidemic has been termed “the neglected famer’s tragedy” due to a disproportionate increase in agricultural areas, and a “therapeutic black hole” due to ineffective or unavailable interventions within the region. With 5.8 billion people at risk of encounters, and 2.7 million reported cases of envenomings, it is estimated that there are between 81,000 to 138,000 deaths and countless more debilitating injuries each year in the country. 

The WHO developed the Snakebite Envenoming Strategic Plan which calls for a 50% reduction in mortality and disability caused by snakebite envenoming by 2030 through 4 goals: 

  1. Empower and engage communities.
  2. Ensure safe, effective treatment.
  3. Strengthen systems.
  4. Increase partnerships, coordination, and resources through strong collaboration.

Project Proposal

Our project focuses on the first WHO goal; Empower and engage communities.  However, it includes aspects of all the 2030 goals by creating an education system that will help prevent envenomations and arm the community with a safe plan to approach such events to reduce morbidity and mortality. The project will focus on educating and engaging community leaders, to promote sustainability and community engagement.  These community leaders will be trained to teach and discuss topics including characteristics of venomous and non-venomous snakes, dispelling, and discussing common misconceptions surrounding proper envenomation management, first-aid, initial management, and stabilization.  Community leaders and community members will also be connected with national partners like the National Snake Bite initiative (NSI) as well as international partners like WHO through The Platform, an interactive Application that allows the public to participate in reporting events and venomous snake sightings, slowly creating a regionalized database. 

Qualitative surveys before and after educational campaigns on community knowledge, perceptions, sociocultural and spiritual understanding and depiction of snakes and snakebite envenoming can help to measure how receptive communities have been to the program. Since envenomation events are underreported, it is difficult to assess any qualitative differences (hospital admission events), however, since we plan to implement this program on a community-by-community basis it may be possible to investigate numbers through local health ministries, clinics, and hospitals to assess different trends before and after program implementation.

Based on the WHO Snakebite Working group budget we estimate this project would not cost more than $15,000 USD, with much of the funds allocated to program creation, program coordinators and educators, community leaders, and program creation.  The WHO allocated over $140 million USD over 10 years worldwide to this problem and $650,000 USD to community education in 10 countries.  Using this logic, we estimated that more than $65,000 would be allocated to a country like India.  If this project were to pilot its educational campaign in a specific region, we estimate no needing more than $15,000 USD. 

By partnering with national partners on the ground like the NSI and community leaders who will continue to train and educate, this program will become sustainable through working with those that are inherently invested in more positive outcomes through education in their own communities. Additionally, the WHO’s Platform application will be promoted during educational programming to further engage and empower the community to take an active role in their own education and safety by sharing photos of potentially venomous snake sightings along with their location data. By promoting effective interventions involving education surrounding proper venomous snake identification, snake education, medical interventions, and effective reporting this program will reduce snake bite deaths and long-term disability and empower at risk communities in India to take their safety into their own hands.  

Discussion

After presenting the proposal to the group, we engaged in discussion on this proposal. One of the questions that sparked deep and insightful conversation was “Why is the focus of this project education, and not ensuring that are adequate and strategically placed life saving anti-venom available?”

Below is a summary of the most pertinent ideas posed:

1. Many companies producing have stopped/gone out of business and even if there was plentiful supply it would still not help with preventing or addressing the problem when most cases of snakebite envenomation that occur are not reported.

2. With an educational campaign the people are able to take power into their own hands.

3. The cost benefit ratio of this method is extremely low. Many people reside far away from any form of health care and in India, the cost of initial treatment has been reported to be as high as USD$ 5,150, which makes investments in anti-venom unsustainable. 

References

  1. https://www.who.int/health-topics/snakebite#tab=tab_1

  2. https://www.who.int/activities/preventing-and-controlling-snakebite-envenoming

  3. https://www.who.int/publications/i/item/9789241515641

  4. https://www.who.int/india/health-topics/snakebite

  5. https://www.nature.com/articles/d41586-020-03327-9#ref-CR

  6. Kasturiratne A, Wickremasinghe AR, de Silva N, et al. The global burden of snakebite: a literature analysis and modelling based on regional estimates of envenoming and deaths. PLoS Med. 2008;5(11):e218. doi:10.1371/journal.pmed.0050218

  7. Yanamandra U, Yanamandra S. Traditional first aid in a case of snake bite: more harm than good. BMJ Case Rep. 2014;2014:bcr2013202891. Published 2014 Feb 13. doi:10.1136/bcr-2013-202891

  8. Chauhan V, Thakur S. The North-South divide in snake bite envenomation in India. J Emerg Trauma Shock. 2016;9(4):151-154. doi:10.4103/0974-2700.193350

  9. International Journal of Mental Health Systems, vol. 9, no. 1, 12 Mar. 2015, 10.1186/s13033-015-0007-9. Accessed 13 June 2020.

About GEMS LP project proposals

These project proposals are completed by our mentees, who are medical students, to encourage independent thinking from a global perspective.

Thank you to our authors and presenters!

Nikkole Turgeon, MS4

University of Vermont Larner College of Medicine

Racheal Kantor, MS4

Racheal Kantor, MS4

Medical School of International Health, Ben-Gurion University

Nicholas Imperato, MS4

Philadelphia College of Osteopathic Medicine

Blog Editorial Team

Halley Alberts, MD

Halley Alberts, MD

PGY-2 University of South Carolina Prisma Health Midlands
Co-Director & Blog Editor

Jeff Downen, MD, MS

Jeff Downen, MD, MS

PGY-2 University of Florida, Jacksonville
Blog Editor

Mohamed Hussein, MBBCh

Mohamed Hussein, MBBCh

Trauma Research Fellow
Blog Editor

Keep in Touch:

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Cite this article as: Global EM Student Leadership Program, "Project Proposal 12/20: Developing a Community Education Program to Combat Envenomation in India," in International Emergency Medicine Education Project, March 9, 2023, https://iem-student.org/2023/03/09/developing-a-community-education-program-to-combat-envenomation-in-india/, date accessed: October 1, 2023

Project Proposal 12/20: Establishing an Objective Risk Assessment for Road Traffic Accidents in Ghana

~ Global EM Student Leadership Program ~ Leave a comment

Background

Worldwide, road traffic accidents (RTAs) account for about 1.3 million fatalities and, on average, 3% of a given country’s GDP. Over half of these deaths occur among vulnerable road users, such as pedestrians, cyclists, and motor cyclists. Approximately 93% of all of the world’s RTA-associated mortalities occur in middle- to low-income countries, even though they have only 60% of the world’s vehicles. Road traffic injuries cause considerable economic losses to individuals, their families, and to countries as a whole that take a considerable toll even years or decades after the incident occurred. These losses arise from the cost of treatment as well as lost productivity for those killed or disabled by their injuries, and for family members who need to take time off work or school to care for the injured.

 The country of Ghana experiences, on average, 2,000 RTA-associated deaths and 14,000 RTA associated injuries annually. At the Korle-Bu teaching hospital in Accra, Ghana, the largest health facility and teaching hospital in Ghana and the main referral site for all of southern Ghana, between 2016 and 2017, 62% of deaths in the hospital’s accident center were related to RTAs. These RTA-associated deaths and injuries cost the country around 1.6% of its GDP, which amounts to over $1.3 million per year.

In the early 2000s, the Ghanaian government began to recognize the serious socio-economic impact of RTAs on its country. To address the issue, the National Road Safety Commission (NRSC) was established to collect data on RTAs and propose solutions and policies in response. Various data was collected, such as the number of annual deaths and injuries and road user classes associated with these fatalities. Data collected demonstrated that, in Ghana, the road user class with the highest share of fatalities was consistently  pedestrians (824; 39.5%) followed by motorcycle users (437; 21%) and bus occupants (364; 17.5%). Considering RTAs in the context of emergency care, studies showed that, again at the Korle-Bu Teaching Hospital, almost 40% of emergency care visits were from RTAs, followed distantly by falls and interpersonal violence. Of the victims that died upon or after arrival to the hospital, 50% were pedestrians, 31% were passengers, and 18.7% were motorists.

From the numbers provided, it’s readily apparent that deaths caused by injuries, and, specifically, RTA-associated injuries, rank among the top ten causes of death in Ghana. It was concluded that underlying drivers of this issue were broadly two-fold: there was a high proportion of RTA-associated injuries due to poor road conditions and unregulated driving practices, and emergency care providers were lacking in proper, formal trauma-based care, both prehospital and when they arrived to an emergency care facility.

To address these shortcomings, various sizable mitigation measures were adopted by Ghana’s government in an attempt to decrease the number of RTAs and their associated costs. In 2004, Ghana established a National Ambulance Service (NAS), providing over 200 ambulances staffed with formally trained, BLS-certified EMTs for pre-hospital care. Ghana’s first EM residency program was established in 2009, followed one year later by its first 2-year Emergency Nursing degree program. More recently, in 2019, the NRSC passed the National Road Safety Authority Acts that were designed to promote and mandate best road safety practices, both in road users and road developers. However, despite these resolutions, RTAs and their associated injuries and deaths continue to remain consistently high in the country.

A literature review of available research on Ghanian RTAs revealed several limitations in the studies. While the NRSC has been instrumental in collecting RTA data and devising protocols to mitigate RTAs, there is still a lack of detailed, objective research on RTAs in Ghana. Additionally, there are significant inconsistencies in the source of the data and whether it is a registry-based report or a population-based study. The causes of accidents are not well-documented, and there is limited data available detailing where the majority of RTAs occur aside from the regions most heavily affected. According to data from 2016, over 75% of RTAs occur in 5 regions (Ashanti, Greater Accra, Eastern, Central and Brong Ahafo), of which four of the five regions correspond to the four most populous regions (with the exception of Ahafo, which is the least populated). Interestingly enough, however, about 60% of RTA fatalities were in non-urban sections of the road networks. Despite this information, we were unable to find details regarding where the specific accidents occur within each region.

Research collected by the University of Ghana’s School of Public Health identified the following risk factors that were highly associated with RTAs: stop-light violations, improper signaling, speeding. However, we believe that the study used to determine these risk factors relied too heavily on subjective analysis, leading to potentially erroneous and biased data. Therefore, we propose utilizing traffic cameras for gathering objective data in areas with a high burden of RTAs. This analysis will allow local authorities to identify risk factors that lead to RTAs, resulting in the utilization of emergency medicine services.

In short, an objective method of identifying common risks, causes, and associations of RTAs is crucial in order to decrease morbidity and mortality as well as the need for emergency care. This is especially important, as Ghana spends over $130 million USD each year on RTA-related injuries alone.

Project Proposal

We believe one way to do this is to utilize traffic cameras that are already in place in these high traffic areas to analyze accidents. As the infrastructure is already in place for surveillance – all we need to do is collect and analyze the footage, which has limited costs associated with it. We would need to pay salary to 1-2 data analysts in order to analyze the information. If more cameras were needed, this would cost anywhere from $65-80,000 USD per camera installation. After installation and retrieval of the camera data, what information will we collect? First, we would like to identify what specific intersections and roadways are involved in RTAs. We also would collect temporal statistics such as day of the week, month and time of day as well as weather conditions. The type and number of vehicles involved in the accident as well as identifying whether the drivers are local versus nonlocal are also important characteristics. Lastly, we would look at whether drivers violated traffic laws such as running a redlight or were speeding as well as being in the incorrect driving lane.

The data collected from this proposal can be used to promote infrastructure changes to lessen the risk of future RTAs. In particular, the installation of crosswalks have been proven to mitigate incidences of motor accidents. According to a 2017 study, 68% of pedestrian fatalities from RTAs in Ghana are related to “pedestrian crossing behaviors.” However, the study was limited in its ability to deduce further information from these incidents, such as the causality of the accident. The review of the stop light camera footage from the event would allow the local government to determine if more facilities such as crosswalks may be beneficial to install in populated intersections.

Conclusion

The high prevalence of RTAs in Ghana is a public health concern that dramatically burdens the emergency medical community. We believe that the data collected from traffic cameras can be used to more concretely understand the risk factors that lead to motor accidents in Ghana. Ultimately, this information can be used to improve infrastructure features to mitigate risk of future accidents.

References

  1. https://www.cdc.gov/injury/features/global-road-safety/index.html
  2. Blankson PK, Lartey M. Road traffic accidents in Ghana: contributing factors and economic consequences. Ghana Med J. 2020 Sep;54(3):131. doi: 10.4314/gmj.v54i3.1. PMID: 33883755; PMCID: PMC8042801.
  3. Blankson PK, Nonvignon J, Aryeetey G, Aikins M. Injuries and their related household costs in a tertiary hospital in Ghana. Afr J Emerg Med. 2020;10(Suppl 1):S44-S49. doi: 10.1016/j.afjem.2020.04.004. Epub 2020 May 26. PMID: 33318901; PMCID: PMC7723915.
  4. Zakariah A, Stewart BT, Boateng E, Achena C, Tansley G, Mock C. The Birth and Growth of the National Ambulance Service in Ghana. Prehosp Disaster Med. 2017 Feb;32(1):83-93. doi: 10.1017/S1049023X16001151. Epub 2016 Dec 12. PMID: 27938469; PMCID: PMC5558015.
  5. https://ugspace.ug.edu.gh/bitstream/handle/123456789/36413/Injury%20Patterns%20and%20Emergency%20Care%20in%20Road%20Traffic%20Accidents%20in%20Accra.pdf?sequence=1&isAllowed=y

About GEMSLP project proposals

These project proposals are completed by our mentees, who are medical students, to encourage independent thinking from a global perspective.

Thank you to our authors and presenters!

Holly Farkosh, MS4

Holly Farkosh, MS4

Marshall University Joan C. Edwards School of Medicine

Andrew McAward, MS2

Andrew McAward, MS2

Marshall University Joan C. Edwards School of Medicine

Tram Lee, MS3

University of Oklahoma Health Sciences Center

Blog Editorial Team

Halley Alberts, MD

Halley Alberts, MD

PGY-2 University of South Carolina Prisma Health Midlands
GEMS LP Co-Director & Blog Editor

Jeff Downen, MD, MS

Jeff Downen, MD, MS

PGY-2 University of Florida, Jacksonville
Blog Editor

Mohamed Hussein, MBBCh

Mohamed Hussein, MBBCh

Trauma Research Fellow
Blog Editor

Keep in Touch:

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Cite this article as: Global EM Student Leadership Program, "Project Proposal 12/20: Establishing an Objective Risk Assessment for Road Traffic Accidents in Ghana," in International Emergency Medicine Education Project, March 1, 2023, https://iem-student.org/2023/03/01/project-proposal-12-20-establishing-an-objective-risk-assessment-for-road-traffic-accidents-in-ghana/, date accessed: October 1, 2023

Project Proposal 12/20 :Creating Culturally Appropriate Mental Health Care Programs After Disasters

~ Global EM Student Leadership Program ~ Leave a comment

Mental health conditions are the leading cause of disability worldwide, accounting for an estimated 175.3 million years lost to disability (Figure 1). Inequalities in access to or quality of mental health care globally are directly related to social, structural, and economic determinants. Increasingly, research suggests that these socioeconomic inequalities lead to health issues not just for disadvantaged populations but for all those involved in unjust or unequal societies. In addition, most of our information on global access to mental health care is limited to formal psychiatric care, which discounts other forms of local or indigenous healing practices.

Disasters have countless impacts on communities and can cause stress due to feelings of powerlessness, loss of community life and culture, and destruction and physical displacement. An estimated 1 in 3 highly exposed trauma survivors may experience post-traumatic stress disorder (PTSD), and 1 in 4 may experience major depression. Psychological distress, which does not meet the criteria for another formal psychiatric diagnosis, is nearly universal after exposure to a disaster and deserves significant attention as well.

It is also crucial to ensure that mental health responses after disasters are conscious of unique local contexts. Previously, priorities in disaster responses have primarily been defined by mental health professionals mostly by nations of the Global North, which gives insufficient attention to locally-defined priorities. These established programs focus mainly on major neuropsychiatric disorders as defined by Western professionals and assume that the features, courses, and outcomes will mirror those seen in the cultures where they were initially developed. Existing programs and literature also tend to focus on PTSD, with other forms and manifestations of psychological distress falling through the cracks. This focus on applying formal diagnosis and treatment assumes that they are generalizable across cultures and may marginalize indigenous forms of healing that could be vital to the community.

Key Priorities

With these concerns in mind, we want to highlight some key priorities in creating a culturally sensitive mental health care program in the post-disaster setting. First, we need to remember that systemic factors such as structural violence and poverty are important determinants of mental health outcomes (Figure 2). Thus it is imperative to first support efforts addressing basic socioeconomic needs and promote physical safety of the population. In addition, mental health programming may be carried out in tandem with medical colleagues addressing other problems to increase coverage and decrease the need for additional infrastructure.  

Figure 2: Proximal and distal factors of the social determinants of mental health with sustainable development goals mapped onto the different domains. 

In assessing the community’s mental health needs, there should be an effort to learn and adapt to the local context, as an individual’s response to suffering is likely influenced by the religious, spiritual, and moral context of the local community. In addition, classification systems used in mental health evaluation (i.e., DSM-5) should be modified to integrate the knowledge of culturally specific idioms of stress, taking into account also differences related to class, gender, age, sexuality, minority/majority position. Lastly, special attention must be given to those with existing psychopathology as these individuals are at risk of having worse outcomes in response to disasters. 

Proposed Solution

Guided by these principles, we proposed examples of programming components that partner with the local community and integrate an understanding of local resources and traditions of healing. 

  1. Work with psychologists, community health workers, and local religious leaders to facilitate memorial services in response to possible losses in the community.
  2. Promote education on when and where to seek service, especially in social settings that communities frequently gather. 
  3. Develop programs that go beyond the toolkit of professionals and mobilize indigenous resources and family-specific social activities to encourage people to also rely on support from immediate social networks. 
  4. Partner with specialists to support task-shifting to local non-specialist providers.
  5. Establish screening protocols for aid workers and staff working in disaster settings as these individuals are also at risk for mental health issues.

We want to have a continuous evaluation of the program in four outcomes areas, each with different indicators:

  • Relevance (indicated by population need and cultural and contextual fit)
  • Effectiveness (indicated by mental health outcome)
  • Quality (indicated by adherence, competence, and attendance)
  • Feasibility (indicated by coverage and cost)

While some of the indicators, such as coverage, helps to define operational characteristics of the program, other factors, such as cultural and contextual need, support the program by engaging with local stakeholders. Information regarding these indicators can be obtained using various methods, including community surveys, national health system records, cohort studies, and observational studies.

Though the world’s mental health burden is experienced heavily in low and middle-income countries (LMICs), often only a tiny portion of the annual operating health budgets in these countries will go toward addressing mental health issues. For example, the Emerald (Emerging mental health systems in LMICs) study, which was a multinational study conducted to assess the infrastructural and policy needs for expanding mental health services in Ethiopia, India, Nepal, Nigeria, South Africa, and Uganda, revealed that in some LMICs, there is less than $0.25 per person per year available for mental health budgeting. In addition to limited resources and finances, mental health programs face other challenges related to sustainability, such as poorly trained staff and a lack of understanding about service delivery processes and quality improvement. High turnover of senior-level policymakers can prevent longitudinal advocacy and agenda-setting, and low community participation can also be a barrier.    

While the exact cost for our program is difficult to predict given system collapse and displacement of populations in the post-disaster setting, here we provide an estimation of a possible budget using the operating budget of the NGO Médecins Sans Frontières (MSF) in 2020 as a starting point. 

  • MSF Operating Budget 2020 = €550,000,000 Euros, with 80% spent on programming spending (€440,000,000)
    • €440,000,000 spent across 10 countries = €44,000,000/country in 2020
    • *Presuming 2% for mental health budget allocation = €880,000 for mental health budget/country/year
  • ~350,000 Mental Health Consultations across 10 countries
    • ~35,000 Mental Health consultations annually per nation engaged 
  • €880,000 / 35,000 consultations = €25/consultation (used for medications, counseling, etc) 

Even assuming just 2% of the operations budget is allocated to mental health programming, it can be estimated that major NGOs may be able to make a more significant fiscal investment in mental health than what public services can currently offer in LMICs. In the emergent setting, the surge of financial resources from these agencies towards affected groups presents new opportunities and motivation for development. Additionally, the destruction or collapse of health systems amidst destabilization may provide opportunities to build more equitable and person-centered care systems. Furthermore, media attention can stir public interest and political willpower to dedicate more resources to mental health treatment systems. 

Historically, international health actors have not prioritized the transition of care from transient emergent systems to nascent local infrastructure. Thus two types of investment are needed to ensure a smooth transition and subsequent strengthening of the local health system. Initially, startup investment from aid organizations is needed to maintain operating budgets amidst transitions. Then continuous funding for long-term service delivery from health departments or public agencies is required to promote infrastructure longevity and tackle some of the previously mentioned system-level challenges impeding sustainability of programming. 

Summary

  In summary, our current understanding of and approach to global mental health focus on priorities does not pay sufficient attention to local priorities and marginalizes indigenous healing techniques. Guided by an understanding of the social determinants of mental health, at-risk populations in disaster settings, and the crucial importance of adapting to local contexts, we proposed several priorities in infrastructure support, assessment, and intervention when establishing culturally sensitive mental health care programs. Outcomes of the program will then be evaluated in its relevance, effectiveness, quality, and feasibility and used to modify the program in response to changing needs in the post-disaster setting. While the increase in support from NGOs during times of disaster will likely result in increased resources available for mental health programming, transition, and down-scale of post-disaster services to local health systems will never be sufficient nor sustainable without addressing systems-level problems. 

References

  1. Bischoff, R.J., Springer, P.R., Taylor, N. (2017). Global Mental Health in Action: Reducing Disparities One Community at a Time. Journal of Marital and Family Therapy, 43, 276-290. doi: 10.1111/jmft.12202
  2. Kirmayer, L.J., Pedersen, D. Toward a new architecture for global mental health. Transcultural Psychiatry. 2014;51(6):759-776. doi: 10.1177/1363461514557202
  3. North, C.S. Pfefferbaum, B. Mental Health: Response to Community Disasters: A Systematic Review. JAMA. 2013;310(5):507-518. doi: 10.1001/jama.2013.107799 
  4. Jordans, M., & Kohrt, B. (2020). Scaling up mental health care and psychosocial support in low-resource settings: A roadmap to impact. Epidemiology and Psychiatric Sciences, 29, E189. doi:10.1017/S2045796020001018
  5. Lund C, Brooke-Sumner C, Baingana F, Baron EC, Breuer E, Chandra P, Haushofer J, Herrman H, Jordans M, Kieling C, Medina-Mora ME, Morgan E, Omigbodun O, Tol W, Patel V, Saxena S. Social determinants of mental disorders and the Sustainable Development Goals: a systematic review of reviews. Lancet Psychiatry. 2018 Apr;5(4):357-369. doi: 10.1016/S2215-0366(18)30060-9. 
  6. Bredström, A. Culture and Context in Mental Health Diagnosing: Scrutinizing the DSM-5 Revision. J Med Humanit 40, 347–363 (2019). 
  7. Raviola G, Eustache E, Oswald C, Belkin GS. Mental health response in Haiti in the aftermath of the 2010 earthquake: a case study for building long-term solutions. Harv Rev Psychiatry. 2012;20(1):68-77. doi:10.3109/10673229.2012.652877
  8. Semrau, Maya, et al. “Strengthening Mental Health Systems in Low- and Middle-Income Countries: The Emerald Programme.” BMC Medicine, vol. 13, no. 1, 10 Apr. 2015, 10.1186/s12916-015-0309-4. Accessed 7 May 2019.
  9. Epping-Jordan, JoAnne E, et al. “Beyond the Crisis: Building Back Better Mental Health Care in 10 Emergency-Affected Areas Using a Longer-Term Perspective.” International Journal of Mental Health Systems, vol. 9, no. 1, 12 Mar. 2015, 10.1186/s13033-015-0007-9. Accessed 13 June 2020.

About GEMSLP project proposals

These project proposals are completed by our mentees, who are medical students, to encourage independent thinking from a global perspective.

Thank you to our authors and presenters!

Alison Neely, MS4

Alison Neely, MS4

Albert Einstein College of Medicine

Luxi Qiao, MS4

Luxi Qiao, MS4

Washington University School of Medicine

Jacob Reshetar, MS4

University of Minnesota School of Medicine

Blog Editorial Team

Halley Alberts, MD

Halley Alberts, MD

PGY-2 University of South Carolina Prisma Health Midlands
Co-Director & Blog Editor

Jeff Downen, MD, MS

Jeff Downen, MD, MS

PGY-2 University of Florida, Jacksonville
Blog Editor

Mohamed Hussein, MBBCh

Mohamed Hussein, MBBCh

Trauma Research Fellow
Blog Editor

Keep in Touch:

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Cite this article as: Global EM Student Leadership Program, "Project Proposal 12/20 :Creating Culturally Appropriate Mental Health Care Programs After Disasters," in International Emergency Medicine Education Project, February 22, 2023, https://iem-student.org/2023/02/22/creating-culturally-appropriate-mental-health-care-programs-after-disasters/, date accessed: October 1, 2023

Two Roads, One Path: Academic vs. Non-Academic EM – Part 1

academic emergency medicine vs non-academic emergency medicine
~ Anthony Rodigin, USA ~ Leave a comment

Are academic and non-academic emergency medicine (EM) really two completely different worlds?

With this post I want to start a short series on this topic, hopefully with a little twist in the approach.

Why even question?

How and why do you question a distinction that is on the one hand very apparent and real, and on the other is very customary and traditional and may be true for all medical specialties?

Part of the answer is that in order to plan a fulfilling life in EM (not everyone believes in a “career”), it is best to understand the entire landscape – not only regionally and nationally, but also globally. To this end, perhaps more innovation, ingenuity and out-of-the-box thinking is needed to benefit future EM trainees than what habitual teachings on the subject offer.

Are we really committed for life to whatever we pick out of residency?  Is the decision regarding a fellowship for a senior registrar a now-or-never decision? Is there such an age as “too late” for academics and vice versa? Is the connection between academic and non-academic EM a one-way street? Is it true that once in EM you cannot do anything else because “you don’t know how to do anything else”, according to some?

Today we will begin by looking at a few labels and presuppositions that may be cemented in the collective EM subconscious. It is my intuitive suspicion that only by uncorking, uncovering or by altogether removing some of these, will we be able to get to the real deal underneath.

As they say, the devil is in the details.

Discussion One:  Smoke and Mirrors

Where will you work at and who will you work for?

First, academic vs. non-academic EM identity can to a large extent be affected by how your nation’s overall healthcare system is set up.

In countries with predominantly socialized medicine, “community practice” – very possibly a US-driven term – may simply indicate not being employed at one of the largest tertiary urban centers available, which carry all the prestige and concentrate all of research efforts. In such nations a classically proposed counterpart to academic medicine, a business-driven private EM enterprise, may be lacking completely.

If everyone works for the government, be it local or federal, then becoming “academic”, equally or more so than due to one’s personal talents and inclinations, may be the outcome of having urbanization, luck, connections or some other ability to find a bigger place to work. At one point or another one simply wins the lucky lottery ticket to move and “move up”. In essence, the EM physician is a large capital city’s teaching hospital worker first, and an academician largely by default. Such career aiming of course succumbs to the philosophy that urban and central is always better than rural and peripheral.

Second, let’s consider “community practice” as a kind of a weird term: if you are in academic EM, who else are you serving if not some community or communities? These may be communities of colleagues, trainees, organizations and researchers in addition to patients, but they are communities nonetheless.

Equally, if an EM physician is truly and solely in non-academic practice, does she really envision and lead her professional life without any engagement in research, publications, teaching, administration, local and international networking? What would the website “Life in non-academic EM” look like – a steady picture of a work mule without links or content?

Both terms academic and non-academic EM may be infused and muddied with other meanings like institutional- or government-affiliated practice, private practice, non-teaching, and so on.

In real life, both type of endeavors (if the distinction between academic and non-academic is genuine) can be conducted in very urban or in rather rural environments; and either practice type may be institutionally affiliated or tied to NGOs, governments or businesses. In the United States some recent criticism has sprung related to the so-called inbred residencies – EM training programs created and operated by large corporate entities.

More importantly for a future trainee: both types of EM practices may or may not involve exclusive night shifts, overtime, faraway travel, being underpaid, unfair seniority, feeling unappreciated and cogwheelish (new word for you), without a clear sense of direction or belonging.

Don’t get ridiculous with cliches.

Now to some cliches, most of which are from the trainees themselves.

One: the sigh “I love teaching, but I hate research” from those choosing non-academics.

Let me ask a provocative question: are all of the globally famous EM research superstars you and I know necessarily brilliant teachers? It appears that “I love research, but I hate teaching” never stopped anyone from an academic road. This, of course, is poor logic either way.

Teaching is a hard thing to do well, and there is a distinction between bedside and classroom teaching, but so is research! Just like the so-called charisma of say a journalist, perhaps some abilities one can be born with (in the words of Professor Snape, “possess the predisposition”). Yet, vast majority of skills can be and have to be acquired.

So instead of anguishing over your inborn leanings and phobias, think rather of what you would prefer to be doing, once you learn it, during any typical week of the next five or more years after residency. Now, how can you realistically translate that into life, given the types of attainable EM jobs out there in your current or anticipated environment?

Two: “get in, get out (of the ED), and enjoy the rest of your life!”

Often the EM backpack mentality, as bumper-stickered above, is sold as the prime appeal of non-academic work.

All true – academicians, when not at work, do not enjoy their lives to any significant extent. They spend most of their free time in dusky library dungeons and at other EM-bound noble activities, while those outside of academics enjoy hundreds of free hours sailing the high seas or YouTube.

As a very weak truism, non-academic EM may sometimes open up more free time for non-EM related activities of one’s life. But is wastage of time laying on a couch an activity, and are you susceptible?

On the contrary, it may be plausible that academicians may enjoy fewer and shorter shifts, more diverse practices, more immediate access to cutting edge innovations and articles, fuller specialist call panels and fewer unfinished charts to review and sign at home.

Three: “One should only do a fellowship if planning an academic career…in which case, you better get into one!”

No, you should probably do a fellowship primarily because you are very interested in what the fellowship is about. Everything else is an extra, albeit a welcome one – like perhaps natural entry into an academic institution or a network of contacts for expanded career options.

It is also completely legitimate to consider the burden and the years of your medical training so far. In some countries just getting to a recognized EM residency (which may be abroad!) has already cost you several years post medical graduation. In such cases, ambivalent feelings towards adding even more years via a fellowship to the perpetual student status are fully valid.

On the other hand, it may very well be that in the near future (if not already), all EM docs without a fellowship, whether entrepreneurial or in public service, academic or not, will become non-competitive for best jobs.

Is doing a fellowship straight off the bat after residency the only option? What if you are not interested in any during training, but become interested later?

To be fair, right after residency makes not only intuitive sense, but typically the system is set up that way, especially fellowship funding. Still, one has to be careful, as not all of fellowships are funded, nor are all fellowships accredited. Viewed in a constructive light, this creates not only constraints but also degrees of freedom for making choices.

True, if years pass, an entire family’s lifestyle dependent on attending level salary may not be very compatible with the salary of a fellow even with all the moonlighting in the world. But is the latter income difference profound in your country, or are the main barriers to a delayed fellowship of a different sort – e.g., government rules written in stone, the mass competition from the youngsters or some unspoken negative culture towards old-timers in their forties among fellowship directors?

Overall, nothing is insurmountable if given enough will, persistence and preparation. Otherwise, there would have been no people in their forties in my medical school class or residency.

Which professional currency would you rather deal in?

All mentioned above is not to be construed to say that some harsh realities do not exist.  One problem with cliches is that they are very zonal, while proclaiming to be universals.

The simple overhanging truth is that every field has its own currency, and both academic and non-academic EM are no exceptions.

For future EM trainees this is pertinent and applicable not only because of the obvious choices you will have to make after formal training, but also because of the need to gear and adjust your preferences while still in training.

Grant funding and publications are absolutely the ubiquitous currency in academics. Productivity, billing and people management (aka “leadership”) skills are the hardcore coinage in business-driven EM. Advancement and promotion within socialized medicine systems may call for yet another set of valuables altogether.

Still, thinking in terms of such hard constraints will tend to corner you in at least two ways.

First, it is not to be implied that ability to generate grants or publications never helps or is not useful in non-academics, or that no academician has to keep track of her billing and productivity metrics.

Second, if cornered, you will be liable to forget the correct reasons for choosing a certain path – the ones that spring from your deep interests and curiosities. These reasons miraculously happen to be the same ones to keep you out of burnout and disappointment years later, no matter what type of practice.

I am proposing a much simpler approach to the above dilemma. Choose currencies that will create the least disdain and subconscious resistance (manifested by nausea and wanting to do what your dog does after it gets wet), and then ones for which you think you already have more inborn propensity if not talent.

Finally, are you really ego-, career- and promotion-driven?  How would you define your own future success in EM?

Enough from me for now.

In future discussions and interviews we will try to elicit opinions of other EM physicians to shine different shades of light on the intriguing sub-topics this topic uncovers.

Stay tuned!

 

Journal Club 3/21/22: Mental Health in the International Community

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Prevalence of burnout among university students in low- and middle- income countries: a systematic review and meta analysis - presented by Jonathan Kajjimu

Burnout is a form of distress that manifests with features of emotional exhaustion, depersonalization, and reduced personal/professional accomplishment. Emotional exhaustion or unsuccessful coping with stressors, is the fatigued feeling that develops as one’s emotional energies are drained. Depersonalization refers to a student’s indifference, negative or cynical attitude. Reduced personal accomplishment is a negative self-evaluation of one’s abilities which manifests itself with feelings of failure. University education is an intrinsically demanding time which puts university students at risk for burnout, coupled with other burnout risk factors such as individual/personal factors and extracurricular factors. Burnout causes significant physical, emotional, psychological, and spiritual damage to students.  

However, from this article there had been paucity of and discrepancies in data on the overall prevalence of burnout in university students from low- and middle-income countries (LMICs). Students pursuing health-related programs in mostly high-income countries (HICs) had been mostly studied previously.

In this review, 55 articles were included, with a total of 27,940 (female: 16,215, 58.0%) university students from 24 LMICs. The Maslach Burnout Inventory (MBI) was found to be the most widely used tool for measuring burnout in 43 studies (78.2%). The pooled prevalence of burnout was 12.1% (95% CI: 11.9–12.3; p = < 0.001). Pooled significant prevalence of emotional exhaustion, cynicism, and reduced personal/professional efficacy were 27.8% (95% CI 27.4–28.3), 32.6% (95% CI: 32.0– 33.1), & 29.9% (95% CI: 28.8–30.9) respectively. Burnout pooled prevalence was highest among the African region at 35.4%, followed by the Asian region at 30.2%, and the European region at 20.7%. 


Figure 1: Forest plot for the prevalence of burnout in LMICs

In this review, burnout rates found in LMICS were lower than those in HICs, which the author believed to be due to publication bias. Authors further recommended low cost interventions that were needed more in low income countries than in middle income countries for managing burnout. These included mindfulness practices, yoga exercises, and group discussions. The current COVID-19 pandemic was also highlighted as having been found to put university students at a higher risk of burnout. Consequences of burnout in students include absenteeism, drop out, reduced academic performance, depression, alcohol and drug abuse, suicide, professional impairment and dissatisfaction, increased incidence of errors and near-misses.

Discussion Questions:

  • How can medical schools focus more on mental health of medical students?
  • How can we ensure that medical students always have their wellbeing in check? 
  • Do you think medical students actually get burnt out or are they just morally injured?

Some of the great recommendations received were having wellness days, “Opt out sessions”, and free counselling sessions in medical school for openly bringing out mental health issue discussions. However, one student confidently believed it would be difficult for schools to focus on mental health of students despite other discussants’ optimism.

Med students can: Focus on reducing energy drain. Identify what you can change – and what you can’t.  Align your goals, values and beliefs. Set limits and delegate. Create new challenges that are aligned with your values. Give yourself frequent breaks. Seek support. Monitor your energy level and emotional state. Eat energy and brain foods. Pace yourself. Build problem-solving skills. Lighten the situation with humor. Having regular physical exercise. 

Medical schools can: Advocate for student autonomy i.e. ability to influence student environment and schedule control. Provide adequate support services such as counselling, secretarial, administrative, social work, and financial. Encourage collegial work environments, healthy relationships and sharing of common goals. Minimize school-home interference. Promote proper work-life balance. Ensure vacation time and limit overtime. Establish mentoring. Consider periodic sabbaticals.

Kaggwa MM, Kajjimu J, Sserunkuma J, Najjuka SM, Atim LM, Olum R, et al. (2021) Prevalence of burnout among university students in low- and middle-income countries: A systematic review and meta-analysis. PLoS ONE 16(8): e0256402. https://doi.org/10.1371/journal. pone.0256402

Mental Health in the International Community - Presented by Alexander Gallaer

Mental illness is a topic that is still gaining awareness, acceptance, and understanding in many parts of the world. While western medicine, most notably the DSM-V, has sought to carefully categorize and define mental disease, the definition of what constitutes mental illness is still very much disputed globally. Unfortunately, many global populations may suffer from unaddressed mental health struggles as a result of these varying attitudes. Notably, post-traumatic stress disorder (PTSD), as defined by the DSM-V, is a disease that has an enormous global burden. As emergency physicians increasingly become the sole health care providers, especially in marginalized populations, it is important to have awareness of what groups may need special attention or follow up to diagnose or address underlying PTSD. Some of these groups include male military veterans (lifetime prevalence of 30.9% (1)), emergency healthcare providers (up to 15.8% (2)), and, most notably here, refugee populations (up to 62% in some Cambodian cohorts (3)). Early recognition of symptoms and swift referral of patients to mental health services as soon as symptoms are identified could alleviate long term disease burden and lead to improved outcomes (4). Because refugee populations are high risk, providers can consider routinely screening for symptoms.

Discussion Questions:

  • How would you approach treating a mental health crisis in an individual who does not believe such issues exist, or that such disease processes can affect them?
  • How can we raise awareness of PTSD in populations with traditionally low recognition of mental illness? Should we do this?

References:

1) Kessler RC, Berglund P, Demler O, Jin R, Merikangas KR, Walters EE. Lifetime prevalence and age-of-onset distributions of DSM-IV disorders in the National Comorbidity Survey Replication. Arch Gen Psychiatry. 2005;62(6):593.

2) Bahadirli S, Sagaltici E. Post-traumatic stress disorder in healthcare workers of emergency departments during the pandemic: A cross-sectional study. Am J Emerg Med. 2021 Dec;50:251-255. doi: 10.1016/j.ajem.2021.08.027. Epub 2021 Aug 14. PMID: 34416516.

3) Marshall GN, Schell TL, Elliott MN, Berthold SM, Chun CA. Mental health of Cambodian refugees 2 decades after resettlement in the United States.JAMA. 2005;294(5):571.

4) Fanai M, Khan MAB. Acute Stress Disorder. [Updated 2021 Jul 17]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2022 Jan-

The Unique Challenges of Mental Health and Multidrug Resistant Tuberculosis- Presented by Ellen Chiang

Calculating disability adjusted life years (DALY) aims to quantify disease burden in terms of both mortality and morbidity. This calculation is an important tool in global health work and as with all tools, it has limitations. Attempts to quantify disability from mental health disorders demonstrate the constraints of the DALY. 

Our understanding and definition of what classifies a mental illness is influenced by our sociocultural context. The Diagnostic and Statistical Manual of Mental Disorders (DSM) is therefore impacted by politics and prejudice. While DALY calculations include sex and gender as weighted factors, many other social factors are not considered. Additionally, much of the medical research published in the major psychiatric journals center on Euro-American study populations, which limits the cross-cultural application of findings. 

Without full consideration of what is not captured by our quantitative measurement of choice, global health interventions can have unintended, significant consequences. The book chapter highlights this by discussing the emergence of multidrug resistant tuberculosis (MDTRB) from the implementation of the DOTS protocol in Peru, which was supported largely by the cost effectiveness paradigm. 

Global health experts should understand the limitations of the DALY when using it to identify priorities and create and evaluate interventions. Remaining aware of what falls outside of the DALY can help create more context appropriate health interventions and new measurements that factor in important social dimensions of disease burden

Discussion Questions:

  • Is it possible to create a metric for disease burden that accounts for social context?
  • When implementing a large-scale health intervention, what are some ways to maintain the flexibility needed to address unexpected challenges?

References:

Ji, Jianlin, Arthur Kleinman, and Anne Becker. “Suicide in Contemporary China: A Review of China’s Distinctive Suicide Demographics in Their
Sociocultural Context.” Harvard Review of Psychiatry 9, no. 1 (2001): 1– 12.

Anand, Sudhir, and Kara Hanson. “Disability-Adjusted Life Years: A Critical Review.” Journal of Health Economics 16, no. 6 (1997): 685– 702.

Sen, Amartya. “Missing Women: Social Inequality Outweighs Women’s Survival Advantage in Asia and North Africa.” British Medical Journal 304, no. 6827 (1992): 587– 588.

Wrap up!

We thoroughly enjoyed the discussion sparked by these three mentees and are proud to be to present a brief summary of their work here! Please stay tuned for more article summaries and details about our upcoming meetings.  Connect with us through one of our contact options listed below if you are interested in attending!

Thank you to our authors and presenters!

Jonathan Kajjimu, MS5

Jonathan Kajjimu, MS5

Mbarara University of Science and Technology

Alexander Gallaer, MS4

University of Connecticut School of Medicine

Ellen Chiang, MS4

Ellen Chiang, MS4

UNC Chapel Hill

Jeff Downen, MD, MS

Jeff Downen, MD, MS

PGY-2 University of Florida, Jacksonville
Blog Editor

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Cite this article as: Global EM Student Leadership Program, "Journal Club 3/21/22: Mental Health in the International Community," in International Emergency Medicine Education Project, January 25, 2023, https://iem-student.org/2023/01/25/journal-club-3-21-22-mental-health-in-the-international-community/, date accessed: October 1, 2023

Journal Club 1/10+1/31/22: Sustainability and Language Justice

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Tropical Diarrheal Illnesses in Children by Ying Ku

Tropical diarrheal illnesses (TDIs) are major health concerns around the world, especially in resource-limiting countries, resulting in approximately 500,000 child deaths annually. TDI is a gastrointestinal infection caused by pathogens that are prevalent in the tropical regions, with diarrhea being the main presentation. Most commonly, these diseases are spread by contaminated food and water due to inadequate sanitation and poor hygiene. Among various microorganisms that can result in TDIs, Rotavirus and E. coli are the most common agents causing moderate to severe diarrhea in children in resource-limiting countries. Some common signs and symptoms are diarrhea, nausea &amp; vomiting, cramps, fatigue, fever, and chills. However, TDIs may result in death secondary to severe dehydration. When assessing TDI patients, it is crucial to determine  dehydration status and identify the type of diarrhea (watery or dysentery) given the different treatment approach. The most important treatment is rehydration with oral rehydration salts (ORS). ORS can be made with: 1 L water + ½ tsp salt + 6 tsp sugar. The more detailed treatment algorithm can be found in the Clinical Care Guideline for Integrated Management of Childhood Illness. Strategies in preventing TDIs can be summarized into blocking common transmission factors such as feces, fingers, flies, fields, fluids, and food via proper sanitation and hygiene. Lastly, we can help with this global health concern via donation/fundraiser for the organizations working to improve access to safe drinking water and sanitation, as well as being involved in projects to help develop prevention and control strategies in different locations.

Discussion Questions:

  • What are the challenges in promoting better hygiene in developing countries?
  • Despite the widespread use of ORS, mortality associated with severe dehydration in children remains significant. What are some factors contributing to this challenge?

Language Barriers and Epistemic Injustice in Healthcare Settings by Savanna Hoyt

  • Introduction
    • Language injustice is one of the most significant challenges facing national health systems.
    • Language barriers between patients and practitioners can have significant adverse impacts on quality of care.
    • Every phase of the healthcare process relies on effective communication.
  • Language and Healthcare: Complex Dynamics
    • In diverse societies, healthcare challenges stem from the fact that while language is a human commonality, it manifests through a wide range of languages.
    • Culture influences every aspect of illness, including interpretations of symptoms, explanations of illness, seeking help, adherence to treatment, and patient-provider relationships.
  • Linguistic Epistemic Injustice:
    • An example of testimonial injustice (misjudgement of how a person speaks), is when a patient and physician do not share a first language, but must communicate in it due to a lack of translation services.
    • Different concepts of illness across languages can result in hermeneutical injustice (misjudgement of what a person says).
  • Linguistic Epistemic Humility:
    • Linguistic epistemic injustice can be countered by linguistic epistemic humility.
    • In healthcare, epistemic humility involves becoming aware of your own capacities within your own language, with other languages, and actively searching for ways to overcome language barriers.
    • When considering patient-physician relationships across language barriers, the physician can facilitate positive relationships and deliver better care by recognizing their own language ability, acknowledging language needs of the patient, and attempting to correctly pronounce the patient’s name.
  • Conclusion
    • A more language-aware healthcare process can further advance the health of the general population, ensuring practice and research are carried out in a more equitable manner.

Discussion Points:

  • How can we as future physicians work towards eliminating language barriers in healthcare?
  • What are the possible outcomes of addressing language barriers in healthcare?

Social Forces and their Impact on Health Presented by Sreenidhi Vanyaa Manian

In medical school, we learn about the causes of various diseases usually falling into categories of infectious, genetic or immune-mediated processes. However, when it comes to causes often it is enclosed under the broader umbrella of social forces that impact health—defined as the social ‘determinants’ of health.  

“The unequal distribution of power, income, goods , services, globally and nationally, the consequent unfairness in the immediate visible circumstances of people’s lives-their access to healthcare, schools, and education , their conditions of work and leisure , their homes , communities, towns and cities – and their chances of leading flourishing life.”

We witness these social forces everyday and millions across the globe experience its impact on health. Insufficient food, inadequate safe water and discrimination based on race, gender and ethnicity are obstacles on the road to health. 

Rudolph Virchow investigated a typhus epidemic which he later called the ‘artificial epidemic’ as he identified the role played by factors such as lack of access to food, education, employment, as well as political isolation with the spread of disease rather than the microbe itself. 

“Medicine is a social science and politics (is) nothing but medicine on a grand scale”

Who LIVES? Who dies? 

Structural violence creates and perpetuates ill health, suffering and death. It is an unfair and evil entity that victimizes the underserved communities creating a lasting impact on their emotional, social, physical and mental well-being. Structural violence is inherently political and is fundamentally about resources and power. 

Poverty constrains choice, often in a brutal fashion.

 

Communities with lower socioeconomic status have been shown to have higher rates of accident, drug use depression and anxiety compared to those in higher socioeconomic groups. 

In 1848 Rudolf Virchow identified the lasting impact of social forces on health. How do we combat this? The answer is biosocial approach to global health wherein the healthcare provider attempts to understand the patient’s experiences, including the social forces present in the life of the person; as well as the impact of illness in the context of his/her daily life. This necessitates a deep historical, political and social understanding of the community

We all have heard the quote “Health is Wealth.” But we must understand that some degree of wealth is required in order to attain health that gives people a fair chance on their journey to liberty, peace and the pursuit of happiness.  

Discussion Points:

  • Any social movements that you know that led to better chances for good health in your community?
  •  What will you suggest (given the power) to the government to mitigate adverse social determinants?
  • What do you think is the greatest barrier to achieve equitable health?
  • During history taking, what are the other questions that can be asked to the patient for a more holistic approach to treatment?

Wrap up!

As you can imagine, our mentees had a wonderful discussion surrounding these three topics! We are thrilled to be able to present a brief summary of their work here. Please stay tuned for details about our upcoming meetings.  Connect with us through one of our contact options listed below if you are interested in attending!

Thank you to our authors and presenters!

Ying Ku, MS3

Ying Ku, MS3

Campbell University School of Osteopathic Medicine

Savanna Hoyt, MS2

Savanna Hoyt, MS2

Northeast Ohio Medical University

Sreenidhi M Vanyaa, MS4

Sreenidhi M Vanyaa, MS4

PSG Institute of Medical Sciences and Research

Halley J Alberts, PGY2

Halley J Alberts, PGY2

Blog Editorial Lead
University of South Carolina
Prisma Health Midlands

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Cite this article as: Global EM Student Leadership Program, "Journal Club 1/10+1/31/22: Sustainability and Language Justice," in International Emergency Medicine Education Project, January 18, 2023, https://iem-student.org/2023/01/18/journal-club-1-101-31-21-sustainability-and-language-justice/, date accessed: October 1, 2023

Journal Club 11/29/21: Ethics of Humanitarian Work

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POCUS in Resource-Limited Settings presented by Holly A. Farkosh

POCUS, or point-of-care ultrasound, is a focused exam performed and interpreted by an examiner usually at the bedside, that must answer a specific question (is there a pleural effusion, yes or no?). The diagnosis must also be 1) relevant to consecutive treatment decision-making and 2) easily and accurately recognizable by the physician applying the US without extensive training.

There are many advantages to using POCUS in a resource-limited setting, including but not limited to: 

– Portability; relatively inexpensive starting at $2000

– Limited access to other diagnostic imaging equipment (XR, CT, MRI–all of which require additional training to read and use/operate)

– Rapid, noninvasive

– No ionizing radiation exposure

– Improves success and safety of bedside procedures

– Can easily be repeated, quickly, and without increasing radiation exposure, especially if clinical status or physical exam findings change 

– Particularly cost-effective (in the United States) in pediatric appendicitis and trauma (found to have decreased time to OR, decreased CT scans in the pediatric population, shortened length of hospital stay)

Some of the disadvantages include:

– Requirement of formal training

– Issue of how to power/charge and reliable access to this

– Handheld US requires a smartphone

– Supplies (US gel)

– Upkeep and repair

– Image portability (inability to print or save images for patients to share with other healthcare providers)

– Ethical considerations? 

Tying it all Together: Ethical Considerations for POCUS in Resource-Limited Settings

– Cost-effectiveness: some resources are deemed too expensive

– Resource limitations and differences in standard of care between the United States and other countries 

– Practitioners who may be teaching US may have limited knowledge of practicing in resource-limited settings, or there may be discrepancies in both knowledge of using the technology/resources available as well as the common presenting diseases in that region

– Sustainability: in relation to implementing training programs– what happens after instructors leave? Requires adequate planning for system integration and ongoing supervision and skill maintenance

– Limited capacity and inconsistent availability of follow-up care; screening without available treatment

Discussion Questions:

  • What other ethical considerations are there to implementing POCUS in resource-limited settings?

       – Advantage: lack of need for significant infrastructure; skills can quickly be acquired; real-time video training/support between the United States and other countries

        – Limited support for continued supervision/continual mentorship on improving skills; sustainability of training programs

        – Potential costs of training

  • What to do when you come across findings not consistent with physical exam– how to advocate for further diagnostics/evaluation?
  • Using US for central lines: lack of US availability; no formal US training; need to teach how to use US, but also important to teach things such as sterile prep/technique

Why do we have a desire to work in Global Health? By Cody Ritz

Chapter nine from Reimagining Global Health: An Introduction aims to explore a few different answers to this complex question. It’s possible that many of our desires to work in Global EM stem from some of the moral frameworks or values systems presented in these pages. The chapter lays them out as such:

Depending on your own personal motivations, you may identify with one, many, or none of these moral frameworks or value systems. This list is not meant to be exhaustive, and it barely scratches the surface of the many nuances included in each of these philosophies. While we could go to much greater lengths to wholly explore these schools of thought, I believe the greatest benefit in naming them is not solely for the purpose of categorization. Rather, by taking the time to compare these sources of motivation, we can equip ourselves with a vocabulary and mindset that helps give form to our innermost determinations. While this form develops, we can begin to understand the foundations of our own interest to work in not only global health but medicine at large. As we come to better understand ourselves, let us hope this allows us to better understand others as well.

Discussion Points:

  • With which of these frameworks/value systems do you identify personally? – One? Multiple? None of them at all? – and how has that framework informed your own perspective and approach to global health?
  • Imagine that you’re in an interview for a position you want in the future and the interviewer asks—Why do you have these interests in global health when there is already great need within your own backyard?— How do you respond? In what ways could you explain your motivations within the frameworks discussed in this chapter?

Wrap up!

As you can imagine, our mentees had a wonderful discussion surrounding these three topics! We are thrilled to be able to present a brief summary of their work here. Please stay tuned for details about our upcoming meetings.  Connect with us through one of our contact options listed below if you are interested in attending!

Thank you to our authors and presenters!

Holly Farkosh, MS4

Holly Farkosh, MS4

Marshall University School of Medicine

Cody Ritz, MS2

Cody Ritz, MS2

Drexel University College of Medicine

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Cite this article as: Global EM Student Leadership Program, "Journal Club 11/29/21: Ethics of Humanitarian Work," in International Emergency Medicine Education Project, April 6, 2022, https://iem-student.org/2022/04/06/journal-club-11-29-21-ethics-of-humanitarian-work/, date accessed: October 1, 2023

Journal Club 11/08/21: Resource Equity in a Pandemic

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The Global Burden of Schistosomiasis presented by Farah Mechref

Endemic in 74 countries across Africa, the Middle East, South America, and Asia, schistosomiasis is a neglected tropical disease caused by flatworms or blood flukes known as schistosomes. About 440 million individuals are infected with these trematodes, which reside in the blood vessels of their definitive host and lead to different clinical manifestations depending on the species. In regions endemic for schistosomiasis, the most prevalent form of the disease is
chronic schistosomiasis, resulting from repeated immunological reactions to eggs trapped in organ tissues. Infection begins when individuals enter bodies of water that contain contaminated snails that have released infectious cercariae. These cercariae penetrate the skin of the human host and produce an allergic dermatitis at the site of entry or a “swimmer’s itch.” Antigens are then released from their eggs, which stimulates a granulomatous reaction composed of T cells, macrophages, and eosinophils, resulting in the clinical disease. 

Acute schistosomiasis typically presents with sudden onset of fever, malaise, myalgia, headache, fatigue, and abdominal pain lasting 2–10 weeks, with eosinophilia noted on lab findings. Chronic infection cause granulomatous reactions and fibrosis in affected organs, which results in clinical manifestations
that include: 

-In S. mansoni and S. japonicum: upper abdominal discomfort that then shows palpable, nodular hepato-spenlomegaly with eventual development of portal hypertension from fibrosis of portal vessels and resulting ascites and hematemesis from lethal esophageal varices.

-In S. haematobium: hematuria, which is so endemic that it’s thought to be a natural sign of puberty for boys and confused with menses in girls, with eventual development of squamous-cell carcinoma of the bladder.

Currently, the only control measures available include (1) mass treatment with Praziquantel (Biltricide) in communities where schistosomiasis is endemic, (2) introduction of public hygiene programs to provide safe water supplies and sanitary disposal of stool and urine, (3) snail eradication programs using molluscicides, and (4) vaccination development to create a more durable and sustained reduction in transmission.

Discussion Questions:

  • Knowledge of transmission and preventative measures play an important role in schistosomiasis control, what other endemic conditions could be better tackled with improved patient education?
  • With 230 million actively infected patients and another 200 million with latent infections, is a vaccine worth the resource distribution or should funding go towards expanding the anti-parasitic classes available for treatment? 

Resource Equity in a Disease Outbreak by Alison Neely

The Ebola virus disease of 2013-2016, centered in West Africa, was considered one of the most threatening cases of infectious disease outbreak in modern history up until the emergence of Covid-19 in 2019. Due to the high case fatality rate of Ebola, the core element of the outbreak response was effective case identification and rapid isolation; treatment centers were quickly overwhelmed and experienced limited bed supply and staff time. A study drawing from interviews with senior healthcare personnel involved in this Ebola outbreak response aimed to identify the ethical issues involved in such a response and to create a framework of ethical guiding principles for future responses.

The framework proposed after analysis of the participants’ interviews was split into four categories: community engagement, experimental therapeutic interventions, clinical trial designs and informed consent. Community engagement stood out as a key element both in the framework and in the journal club discussion that followed. Engagement can include promotion of collaboration and open dialogue, incorporation of community insights into decision-making processes, encouragement of transparency, building trust, and reflecting on context-specific cultural values. As future physicians with special interest in global medicine, these ideas of respecting cultural context and complete inclusion of the local community in response efforts were highlighted as very relevant to our future practice.

Discussion Points:

  • Have the principles presented here been followed in the global response to the Covid-19 pandemic?
  • Our discussion also focused on the parallels and differences between this Ebola response and the global response to the Covid-19 pandemic, calling attention to the ways that the response both followed and diverged from the framework presented in this article. As the idea of a disease outbreak has become part of daily conversation in the last 2 years, investigations and discussions such as this will become increasingly relevant and important. We also touched on the idea that our global response to Covid-19 may have been very different, and potentially weaker, if the Ebola outbreak had not occurred when it did.
 

Wrap up!

As you can imagine, our mentees had a wonderful discussion surrounding these three topics! We are thrilled to be able to present a brief summary of their work here. Please stay tuned for details about our upcoming meetings.  Connect with us through one of our contact options listed below if you are interested in attending!

Thank you to our authors and presenters!

Farah Mechref, MS4

Farah Mechref, MS4

Texas Tech University Health Sciences Center

Alison Neely, MS4

Alison Neely, MS4

Albert Einstein College of Medicine

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Cite this article as: Global EM Student Leadership Program, "Journal Club 11/08/21: Resource Equity in a Pandemic," in International Emergency Medicine Education Project, February 23, 2022, https://iem-student.org/2022/02/23/resource-equity-in-a-pandemic/, date accessed: October 1, 2023

Journal Club 10/18/21: The Global Burden of Disease

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Global Health and the Global Burden of Disease presented by Denise Manfrini

Global burden of disease is the quantity of disease (conditions, illnesses, injuries) and their impact on a population. The impact is measured in disability-adjusted life years (DALYs), which is the years of life lost from premature death and years of life lived in less than full health. There are other metrics used as well to compare countries, such as incidence, prevalence, mortality, and fertility rate.

In order to determine these metrics to measure global burden of disease and see where a country’s health system should focus, disease surveillance is required. This led to the creation of the Global Burden of Disease (GBD) Project in 1992. It aims to develop a consistent way to estimate disease burden in eight global regions (established market economies and formerly socialist economies) using the metrics described above, particularly the DALY. The project initially quantified 107 conditions and over 400 sequelae and has been expanding and updating its findings in the following years. This level of detail has allowed tracking of disease changes over the years and given insight into which interventions are effective. Initial results have shown high disease burden, premature mortality, and health disparities when comparing established market economies and impoverished countries; notably, developing countries suffered more from infectious and parasitic diseases, respiratory infections, and maternal and perinatal disorders. Developed countries suffered more from diseases due to poor lifestyle, such as cardiovascular disorders. Results from 2019 indicate shifts. Overall health is improving worldwide since those results in 1994 (GBD 2019 Diseases and Injuries Collaborators 2020). As seen in the chart, diseases affecting primarily children, such as respiratory infections, diarrheal infections, measles, neonatal disorders, tetanus, malaria, have decreased significantly. The prevalence of diseases affecting older adults, such as ischemic heart disease, diabetes, stroke, lung cancer, has increased and indicates that health care systems need to be prepared to manage an older patient population.

An alternative approach advocated for the right to health of every individual as envisioned in the Universal Declaration of Human Rights. The 1978 Alma Ata Declaration proposed that the fulfillment of these rights belongs to the international community through international collaboration. The past several decades has seen an increasing movement towards this idea and away from one based on economics. An example of this would be the recognition in the 1990s that citizens of developing nations with HIV are inherently as deserving of treatment as those from developed nations. By taking an approach rooted in human rights, the international community was able to lower the cost of HIV medication and provide treatment for patients in the developing world.

Change in worldwide burden of disease from 1990 to 2019. Red - infections/perinatal/maternal conditions; Blue - noncommunicable disease; Green - Injuries/accidents. Source: GBD 2019 Diseases and Injuries Collaborators. (2020). Global burden of 369 diseases and injuries in 204 countries and territories, 1990–2019: a systematic analysis for the Global Burden of Disease Study 2019. The Lancet, 396, 1204–1222.

Once burden of disease can be quantified, how do we decide how to tackle it? Enter priority setting to determine how to best allocate resources. A few models have been proposed. In 1971, Abdel Omran posited four stages through which developing countries progress, called the epidemiological transition. The four stages are: age of pestilence and famine; age of receding pandemics; age of degenerative and manmade disease; and age of delayed chronic disease. Developed countries would be categorized in this final stage. However, the stages do not have clear divisions nor is the progression so clear-cut; a country can be in more than one stage simultaneously. For example, developed countries are currently suffering from the Covid pandemic and from chronic diseases. Thus, priority setting based only on the epidemiological transition would provide incomplete aid to countries encountering more than one stage. Another model is the idea of cost-effectiveness. For an intervention to be considered cost-effective, it must cost no more than 3x the per capita health costs. This is difficult to achieve in countries where the per capita health cost is extremely limited and not enough to cover a worthwhile intervention. After recognizing that poor health leads to limited economic development and to address the challenge of figuring out which interventions need investing, the Disease Control Priorities (DCP) Project was created. It aimed to enable countries to choose and prioritize interventions that maximally impact disease burden and that are supported by their health budgets. The latest DCP project promotes equity and advocates for universal health coverage. Both the DCP and GBD projects are ongoing.

Discussion Questions:

•To what extent should developed countries provide economic support to developing countries?

•Which diseases can we anticipate becoming a larger portion of the burden of disease and what can we do to prepare? 

Tuberculosis: Global Policy and Impacts of COVID-19 presented by Andrew McAward

Prior to the current COVID-19 pandemic, tuberculosis was the leading cause of death from a single infectious disease. In 2020, 1.5 million people worldwide succumbed to TB, while an additional 10 million were infected with primary TB. However, major global health organizations agree that tuberculosis is both curable and preventable. For this reason, combating tuberculosis continues to remain at the forefront of global health efforts today.
The pathology of the TB is caused by Mycobacterium tuberculosis infection, which classically results in the development of granulomatous lesions in lung tissue. This disease can be latent, acute, or systemic/miliary in nature. Updated treatment protocols continue to recommend using derivations of the “RIPE” therapy regime for up to 6 months. The BCG vaccine is widely used in countries with high TB burden, providing strong protection against tuberculosis meningitis and miliary TB spread in children. However, this vaccine’s lack of effectiveness in adults and contraindication in both pregnant women and the immunocompromised has prompted the WHO to initiate new vaccine development. Additionally, the rising concern of multidrug-resistant TB has increased global efforts to establish new treatment options and a more effective vaccine.

Global health organizations have renewed their ambitions to mitigate the spread of TB. In 2014, the World Health Organization’s “End TB Strategy” set a goal to reduce TB incidence by 80% and death by 90% by 2030. The organization’s intention was to embolden local governmental policies and increase research efforts such as through the development of a new adult candidate TB vaccine, M72/AS01E. Similarly, the United Nations joined the WHO’s response by including the elimination of the tuberculosis epidemic on a list of 17 Sustainable Development Goals (SDGs) to be achieved by the year 2030. Despite these efforts, the progress made in battling TB has been halted by COVID-19. New cases of tuberculosis markedly fell in 2020 due to lack of access to diagnostic services, while global deaths increased for the first time in over a decade. The current COVID pandemic has also worsened prognostic outcomes of patients currently undergoing treatment for tuberculosis. Prior successes of global TB health policy, such as maintaining steady drug supply chain or providing healthcare personnel to assist with direct observation drug therapy, have been disrupted due to the economic and social implications of the current pandemic.
Since 2000, over 66 million lives worldwide have been saved through the diagnosis and successful treatment of tuberculosis. Despite dramatic setbacks caused by COVID-19, the global health community should remain optimistic about the long-term mitigation of this disease.

Discussion Questions:

• How can global health policies help to overcome the challenges caused by COVID-19 in the diagnosis and treatment of TB?

• How can healthcare professionals continue to further the progress made against TB burden in their own communities?

Journal Article: Five insights from the Global Burden of Disease Study 2019 Presented by Rachael Kantor

1. Double Down on Catch-up Development
Improvements in SDI have increased universally at an exponential rate since the 1950s. Originally (and predictably) we saw high SDI countries developing at a much faster rate than low SDI countries BUT since the start of the millennium counties of lower SDIs have been progressing at a rate much faster than those of high SDI statuses showing catch-up development. To close the gap, we must “double down” by increasing economic growth, expanding access to education, and improving the status of women in lower SDI countries. **Socio-demographic Index (SDI) is a measure used in the GBD to identify where a geographic area sits on the spectrum of development.
2. The Minimum Development Goal Health Agenda HAS been working
It’s no secret that since the early 2000s the global health community has focused heavily on decreasing mother and child mortality and decreasing the burden of communicable diseases (specifically TB, HIV, and malaria). The good new is these efforts have been incredibly successful BUT we owe it to ourselves to pay close attention to non-communicable disease (NCD) trends. Population growth and aging have led to a steady increased in NCDs.
3.Health Systems need to be more agile to adapt to the rapid shifts to NCDs and disabilities
As health profiles and SDI rankings change, universal health coverage must adapt to meet current health needs. This means increased focus on NCD coverage and greater attention to disorders causing functional health loss (MSK, substance abuse, mental health, etc.) to reduce the massive policy gap.
4. Public health is failing to address the increase in crucial global health risk factors
As global SDI has increased, many risk factors have seen a sharp decline. However, risk factors including High SBP, FBG, and BMI, as well as alcohol and drug use have increased alarmingly by > 0.5% a year.
5. Social, fiscal, and geopolitical challenges of inverted population pyramids
The GBD has estimated that by 2100 there will be over 150 countries whose death rate exceeds its birth rate; this compared to 34 countries in 2019. Many country populations will decrease—resulting in tremendous controversy regarding workforce maintenance, the ongoing immigration debate, and fertility incentivization2.

Discussion Questions:

•Many editorials/opinions call the neglect of chronic illness, and the exponential rise of preventable risk factors the “perfect storm” to fuel the COVID-19 pandemic.   What sort of policies (concrete or abstract) should be put into place to take urgent action against this “failure of public health,” making countries more resilient to future pandemic threats?

•The authors of this study have concluded that exposure to/smoking tobacco has fallen 1-2% a year worldwide since 2010 due to the major efforts to implement international tobacco control policies rather than providing information to consumers about the harms of tobacco. However, the rate of exposure to other risk factors are increasing by more than 0.5% a year. Given the successes/failures of the efforts to decrease tobacco exposure, what place does government and international legislation have in the efforts to reduce these other risk factor exposures?   

~This second discussion question provided an excellent conversation on the importance of individual autonomy and governmental policy influence, as well as those factors, including social determinants of health that limit both the individual and a government’s ability to take viable action to reduce risk factor exposure.  

 

Wrap up!

As you can imagine, our mentees had a wonderful discussion surrounding these three topics! We are thrilled to be able to present a brief summary of their work here. Please stay tuned for details about our upcoming meetings.  Connect with us through one of our contact options listed below if you are interested in attending!

Thank you to our authors and presenters!

Denise Manfrini, MS4

Denise Manfrini, MS4

University of Florida

Andrew McAward, MS2

Andrew McAward, MS2

Marshall University, Joan C. Edwards School of Medicine

Rachael Kantor, MS4

Rachael Kantor, MS4

The Medical School for International Health at Ben Gurion University

Sources and Further Reading:

  • Mukherjee, J. (2017). Chapter 4: Global Health and the Global Burden of Disease. In An Introduction to Global Health Delivery (pp. 89–105). book, Oxford University Press.
  • GBD 2019 Diseases and Injuries Collaborators. (2020). Global burden of 369 diseases and injuries in 204 countries and territories, 1990–2019: a systematic analysis for the Global Burden of Disease Study 2019. The Lancet, 396, 1204–1222.
  • Global Health CEA registry database with publications from different countries about cost-saving interventions – https://cevr.shinyapps.io/LeagueTables/
  • Kant, Surya, and Richa Tyagi. “The Impact of Covid-19 on Tuberculosis: Challenges and Opportunities.” Therapeutic Advances in Infectious Disease, vol. 8, 9 June 2021, p. 204993612110169., https://doi.org/10.1177/20499361211016973.
  • Kirby, Tony. “Global Tuberculosis Progress Reversed by COVID-19 Pandemic.” The Lancet Respiratory Medicine, 2 Nov. 2021, https://doi.org/10.1016/s2213-2600(21)00496-3.
  • Roy, A., et al. “Effect of BCG Vaccination against Mycobacterium Tuberculosis Infection in Children: Systematic Review and Meta-Analysis.” BMJ, vol. 349, no. aug04 5, 2014, https://doi.org/10.1136/bmj.g4643.
  • “Tuberculosis (TB).” Centers for Disease Control and Prevention, Centers for Disease Control and Prevention, 25 Oct. 2021, https://www.cdc.gov/tb/default.htm.
  • “Tuberculosis (TB).” World Health Organization, World Health Organization, 14 Oct. 2021, https://www.who.int/news-room/fact-sheets/detail/tuberculosis.
  • GBD 2019 Viewpoint Collaborators. Five insights from the Global Burden of Disease Study 2019. Lancet. 2020 Oct 17;396(10258):1135-1159. doi: 10.1016/S0140-6736(20)31404-5. PMID: 33069324; PMCID: PMC7116361.
  • Global age-sex-specific fertility, mortality, healthy life expectancy (HALE), and population estimates in 204 countries and territories, 1950–2019: a comprehensive demographic analysis for the Global Burden of Disease Study 2019. Lancet. 2020; 396: 1160-1203

 

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Cite this article as: Global EM Student Leadership Program, "Journal Club 10/18/21: The Global Burden of Disease," in International Emergency Medicine Education Project, December 13, 2021, https://iem-student.org/2021/12/13/journal-club-the-global-burden-of-disease/, date accessed: October 1, 2023