Pursuing clinical research as a medical student

Pursuing clinical research as a medical student

It all started as an undergraduate medical student.

I am an Assistant Professor of Emergency Medicine and Critical Care at Addis Ababa University, College of Health Sciences. As an Emergency Medicine physician, I am committed not only to develop my clinical skills in the Emergency Department but also to improving my skills in clinical research, which all started as a final year medical student during my undergraduate studies.

temesgen beyene

Emergency Medicine (EM) is a completely new specialty in Ethiopia by the time when I have started to pursue my specialty training, with not much research base exists to support our practice. Clinical research done elsewhere is rarely relevant here and many of the research questions asked elsewhere do not apply in our setting. As the practice of EM develops in Ethiopia, research to support that practice must develop also. I wanted to become an expert in the field of clinical research, so I can lead that development.

While I was having my three poster presentations at the International Conference on Emergency Medicine (ICEM 2016) in Cape Town South Africa and also participating in a two-day pre-conference workshop in Research Methodology, I heard news of my acceptance for a one year Harvard Medical School Global Clinical Scholars Research Training Program 2016/17.

temesgen beyene

This was after my own web-based search and application for clinical research training in addition to my residency training.

Global Clinical Scholars Research Training Program (GCSRTP) offered by Harvard University Medical School Office of Global Education is highly competitive clinical research training for clinical research scientists from all over the country. I am one of 113 advanced trainees from around the world selected for their ability and interest in pursuing clinical or epidemiological research. Students are drawn from hospitals, clinics, and academic communities globally and bring the unique perspective of their home country and institution to address research issues in a clinical or population-based setting.

temesgen beyene

This is a year-long intensive program is designed for clinicians and clinician-scientists aimed to achieve three goals: 

  1. To build skills in clinical research, 
  2. To provide knowledge to address issues critical for success in contemporary clinical research, and 
  3. To develop a global network. 

The GCSRTP consists of three on-site workshops (two in London, UK, and one in Boston) as well as 85 online lectures, 5 team assignments, 20 quizzes covering lecture content, a midterm and a final exam, as well as 2 or 3 interactive webinars per month in biostatistics, epidemiology, biostatistical computing, ethics and regulatory approaches, leadership, applied regression, longitudinal analysis and correlated outcomes, survey design, causal diagrams, and advanced quantitative methods. Additionally, I have selected an elective and a concentration and completed my own course work related to those tracks. The program requires an original research proposal as a Capstone Project. Graduation from the program relies on successful completion of this project. And thus, I had successfully completed my capstone project titled Diuretics Options in Acute Coronary Syndrome as a requirement for my successful graduation.

Through the Harvard Medical School Tuition Reduction Program, I was able to negotiate a 50% reduction in the usual tuition of $11,900 for the program. Additional expenses for travel and accommodation and supplies were my responsibility.

How all of the above came into fruition as a start base from my undergraduate study in Medicine?

There was a medical student mentorship research program of the Medical Education Partnership Initiative as a part of the NIH funded grant in 2013. For the same, I have assessed an undergraduate medical student’s clerkship rotation in Emergency Medicine as an Ethiopian experience. This paper, which was also published in the African Journal of Emergency Medicine, was a gateway for all of my clinical research experiences to date. There is a blog post about my clinical research experience in the same journal as well as I was a speaker on the most recent African Conference on Emergency Medicine in Kigali Rwanda, 2018.

My subsequent future as a clinical researcher:

I completed my residency in January 2018. With the skills developed in the GCSRT and my clinical qualification, I was well-positioned to apply for further clinical research fellowship at Addis Ababa University and got accepted for a Junior Faculty Research Fellowship under an NIH funded grant of Medical Education Partnership Initiative 2019-2020. I hope to begin developing research projects, possibly multi-site within Ethiopia that will address the many questions that are relevant to Emergency Medicine as it is practiced in our low-resource setting.

Cite this article as: Temesgen Beyene, Ethiopia, "Pursuing clinical research as a medical student," in International Emergency Medicine Education Project, February 28, 2020, https://iem-student.org/2020/02/28/pursuing-clinical-research-as-a-medical-student/, date accessed: March 29, 2020

A case of decreasing resistance in ER

a case decreasing resistance in er

I keep games on the 4th home screen of my cell phone. The third screen is blank. A minuscule of energy required to swipe my thumb has prevented me one too many times from mindlessly launching an RPG. Only to realize 2 hours later I had other plans for those 2 hours. An American comedian, the late Mitch Hedberg famously joked once,

Mitch Hedberg (1968-2005)
Mitch Hedberg (1968-2005)

I have always believed that the subtle truths kneaded so artfully in seemingly light, small-talk-worthy jokes are what makes a comedian a genius. How many times have you thought that you need to pick up that particular grocery or fill up that one conference form only to instead get consumed by what was easily available?

Our mind is built so that it follows the path of least resistance no matter how insignificant the resistance is. Although smudged all over the canvas of self-help, non-fiction genre, medicine somehow isn’t used frequently to exemplify the path of least resistance.

Today, I present to you a case that inspired us at Beltar, to remove one such small resistance from our workflow. The implications as you will see were no less than life-saving.

Rural Health System : Oversimplified

Before I present to you the case, a small preamble: Health care in rural Nepal is still run mostly by paramedics. No matter what spectrum you fall in terms of appreciating their work, the fact remains that they are the major workforce we have at the rural. It suffices to say that they are the portal of entry to the health system of our country for many. All emergency cases, once screened and declared complicated, the medical officer (usually a MBBS doctor) at the PHC sees the patient. Majority of cases are seen only by paramedics – considering 3 to 5 paramedics, usually and barely one medical officer in most PHCs.

A mobile game I wouldn't play

Now that the characters are in place, let’s dive right into the no less than a fairy tale land of the rural health system. Lamenting about the obvious lack of resources has been so old school that I don’t even make a typo while typing about it these days. We had one ECG machine at Beltar. The old ECG machine with its squeaky sound and myriad varieties of artifacts stood with all its mighty bulk inside a locked door of a room. The key protected from no one in particular by the office assistant who would open the door, drag the machine out, bring it to the bedside. The paramedic who decided to do the ECG would then untangle the wire glazed with what little of gel we had applied to the previous patient. He would then connect the limb leads and the pre-cordial leads with the trusty suction knobs which hopefully has some gel left from the previous use and then comes the biggest connection to be made: connecting the machine to the power grid. “Don’t you keep your machine charged!?”, you ask. We do. But the Li-ion battery probably has undergone autophagy, or whatever fancy name the process is given. That is a lot of steps and by extension, a lot of resistance. If this were a mobile game, I don’t think I would be addicted to it.

A Race Against Time

A patient with diabetes who had visited our ER a couple of times before was being monitored for chest pain at around 7 AM on a Saturday morning. I was washing my clothes on the first floor unaware that my Saturday is not going to be about laundry and daily chores. When I was called to check the patient, she was already deteriorating at a rate far greater than our PHC could ever catch up. We tried to borrow the speed of an ambulance and refer the patient to a higher center. An ST elevation in any two contiguous lead is an MI. Our paramedics knew that. To everybody’s surprise, ECG was not done! Given the fact that we did not have cardiac enzymes available at the PHC and Aspirin was all we could have prescribed before discharge anyway: we gave the patient 2 Aspirin tablets to chew and referred her as fast as we could. My paramedic colleagues have demonstrated utmost clinical competence and professionalism too many times to doubt any of that. The work environment was still error-prone and the circumstance demanded a change. Could we have changed the outcome given the same resources and clinical scenario? Maybe we need to decrease the resistance I thought. Changing how we store ECG (shown in the picture below), making it more accessible not only increased the frequency with which it was being used but also served as a reminder. A physical question hanging down the IV stand asking anyone who is attending a case, “Do you need to use me?”

ECG machine in plain sight with IV stand holding the limb and pre-cordial leads for accessibility

Workarounds: Because Solutions are Late to the Party.

If you have been following my writings, you’d have noticed this as another small tweak, a workaround, a nudge to the existing system so to speak that isn’t the substitute for the actual sustainable solution. Robust training that helps hard-working paramedics conceptualize and understand the protocols related to the use of basic yet life-saving diagnostics like ECG can be a start. We tried printing and pasting some protocols on the walls; another workaround we hope would help make patient care better until it actually sustainably improves. Another workaround that a friend suggested was: everyone who aches above the waist, gets an ECG. Such simplification works well to decrease the resistance in learning complex protocols. I am sure there are plenty of workarounds used worldwide, a necessity, after all, is the mother of invention. I leave you with a thought: What effect do you think will a systematic sharing of such workarounds among the rural healthcare workers will produce?

Guides to ECG electrode placement and protocols
Cite this article as: Carmina Shrestha, Nepal, "A case of decreasing resistance in ER," in International Emergency Medicine Education Project, February 21, 2020, https://iem-student.org/2020/02/21/a-case-of-decreasing-resistance-in-er/, date accessed: March 29, 2020

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Why Me? The Story of My Burnout – Part 3

Why Me? The Story of My Burnout - Part 3

The story continues from link (Part 2).

I must take a deep breath. I must ask for help.

The Self-Knowledge Path

I could go away and work in another hospital. We have many good hospitals in Brazil. Some even employ emergency physicians who are local graduates. I really could. In truth, there would be no shame if I left the hospital. But I decided to give it one more try.

I just want to make clear that there is no single route back from burnout. It is a multifactorial treatment. You need emotional power. Some you may already have, or you can develop with a mental health specialist’s help. Some you will gather alone, or family and friends will help you to recover if you are lucky enough. Read, talk, discuss, and share with your community. You will never be alone because it is the system that is inflicting moral injury and burning you, and everybody, out.

Each person needs different means and tools to recover. We have to acknowledge that not everybody can afford all of them. Not everybody can pay for a therapist or even leave their work. I was one of the lucky ones. I could.

I promised myself and others that I would get better, and I wouldn’t give up. I felt obliged to improve the system that had harmed me. The system that made me afraid; afraid that I would fail.

It was not easy! It wasn’t “just not thinking about it.” It wasn’t “just a phase.” It wasn’t “just yoga.” It wasn’t “just wanting.” It was more than all the above. It took a long journey of self-knowledge: Who was I? What did I want? How could I achieve that?

Gradually, intertwined with relapses,​ the healing process began. I returned to therapy. Thanks to all support from my amazing friends, -virtual friends, present friends, distant friends- mentors, mentees, students, residents, followers, I was overwhelmed with affection and understanding. There were messages of encouragement everywhere I looked and listened. I did not plan this. It happened organically from across our community, and sometimes unintentionally, as I reached out to others, who always found time to help me.

Kindness can save a life! If you feel so, just go around saying how important people are in your life. I assure you that the kindness and positive comments of these people saved me.

I improved gradually in small steps. With empathy and determination, I took one step after another. Each step led me to find new perspectives. With each small victory​, I felt a small but important​ celebration in my heart​. ​

Yet, I wanted to make sense of it all. How to endure the moral injury? How to continue working here? I desperately needed to make sense of my job.

Why Me?

jule santos

In addition to therapy, I went on leave. I flew away and spent time in Mozambique, an LMIC, with many more difficulties, compared to Brazil. They were just beginning to develop the first emergency medicine residency program, and they had a lot more work to do. They were seemingly starting from scratch, and they had fewer resources than we had in Brazil. I found their enthusiasm and resourcefulness more inspiring than I thought possible.

It wasn’t because I could see how lucky we are in Brazil, but they did their best even though they were aware of their problems. I knew that there was no way that I could give up after seeing them.

I returned to Brazil, where people were eager to work with me. I felt they had missed me. They showed me that I made a difference.

I was fortunate to see my work environment improved. The administration had started to ‘get it,’ and now they cared about what we do. They realized that efficient systems saved money, so they were helping us achieve better care for our patients. Our department was renovated. They hired more people, and we got better medications. It all helped. It felt as though they were listening.

So recovering from burnout not only helped me to accept that problems are a part of the system but also made me realize people make the system. Therefore we can change it to accommodate our needs. Not the contrary. We need to END moral injury by addressing it and demanding solutions! We don’t need to be resilient to it!

In the beginning, I understood that I needed to be ​present​ in all my tasks, but that’s a challenge in the hectic world of emergency medicine. In truth, we are not as good at multitasking as we let ourselves think. However, we get better at prioritizing and scheduling tasks as we develop as clinicians. More importantly, we learn to give each task the proper time and attention it deserves.

As time passed, my most challenging feelings diminished. I redefined my responsibilities and my choices, redefined my motivation, my ambition, my purpose. I adjusted my expectations. I found a new power.

Then, ​gradually​, the love for Emergency Medicine and the energy to become the doctor I aspire came back. However, I still had to face my demons and deal with the most painful side of emergency medicine: Delivering bad news.

“Most of the time, the fact that you care is enough”​ is one of the most effective pieces of advice that I ever received. It helped me relieve the intense pain that I didn’t even know it was there. I still remind others and myself of it regularly.

For example, I dealt with the tragic case of pediatric cardiac arrest, brought in by another medical team. We did CPR over an hour, as this was a very delicate situation with a child. At the debriefing, I was careful with both teams from the other hospital and our own. Although I was worried about having the conversation I did, I was shocked and stunned to hear the reply. The doctor shrugged and said:

– Yeah, right. Can I go now?

He was in a rush. He didn’t even want to hear the debriefing. He didn’t appear to care! The disdain broke my spirit, and the whole team felt the same anger. It made everything harder to cope.

I took a deep breath, thanked the team for all the effort, asked them to prepare the body, and went to the waiting room to talk once again with the father. I had been there a lot of times, talking through everything as we were trying to resuscitate, so he already knew me, and immediately recognized my expression of bad news. I sat next to him and told him everything we did. I was trying to remedy the anguish while allowing time for understanding.

– There was nothing more we could do. I’m so sorry, but he died.

The father stared at the floor for a while.

– My wife is eight months pregnant. What should I do now?

He was in despair. Next came tears. I waited. Present. Then, he looked at me with honest:

– Thank you, doctor, for everything you did.

I will never forget them.

“Most of the time, the fact that you care is enough.”

I can’t stop people from getting sick. I can’t even guarantee who will survive, much less, meet the expectations of families. I can’t fix all the system by myself. Yet, I can show that we care, which is now my purpose and mantra.

Now, when I have to deliver bad news, I try my best to be there and look in the eyes. I patiently wait to make sure until there is no doubt. I don’t try to hide my feelings, ​and I finally feel I’m always telling the truth:

– We are doing everything we can.

I ensure that they know​ we care.​ I make a difference there. My pain eases as theirs alleviates even a little.

“Most of the time, the fact that you care is enough.”

I can’t stop people from getting sick. I can’t even guarantee who will survive, much less, meet the expectations of families. I can’t fix all the system by myself. Yet, I can show that we care, which is now my purpose and mantra.

Finding My Ikigai

ikigai

Ikigai is a Japanese concept that means “a reason for being.” In English, the word roughly means “thing that you live for” or “the reason for which you wake up in the morning.” Each individual’s ikigai is personal and specific to their lives, ​values​ , and ​beliefs​. It reflects the ​inner self​ and faithfully expresses that, while simultaneously creating a mental state​ in which the individual feels at ease.

The thing I like most about ikigai is that it is for everyone. You have to understand yourself to achieve this deeply. Seeking self-knowledge can be the most challenging part.

– Am I doing something that I love?
– Am I doing something that the world needs?
– Am I doing something that I am good at?
– Am I doing something that I can be paid for?

YES!

So, where am I now?

Well, I still love heart attacks! I love the look of amazement of the interns when we save a life. I love the self-satisfaction of the residents when they can do something correctly for the first time. I love how happy the team gets when we can do perfect resuscitation. I love the peculiarities of each patient, their life, culture, and beliefs. I love to learn something new every day. ​And that’s why Emergency Medicine!

I love heart attacks! But when we can't save, when the system fails, when the patient dies but I feel that I softened the pain, even a little bit, by showing that we care, I know I can endure.

And that's why, me.

Cite this article as: Jule Santos, Brasil, "Why Me? The Story of My Burnout – Part 3," in International Emergency Medicine Education Project, January 6, 2020, https://iem-student.org/2020/01/06/emergency-medicine-why-me-the-story-of-my-burnout-part-3/, date accessed: March 29, 2020

Why Me? The Story of My Burnout – Part 2

Why Me? The Story of My Burnout - Part 2

The story continues from link (Part 1)

I had already been tired and sad. Now, I was also feeling wronged.

The Dangers of Burnout

It meant that heart attacks stopped being exciting. I started to resent them as they now caused me to suffer. I have nowhere else to refer the patient, or the specialty doctors criticized me. 

They mistreated me, perhaps because of a lack of trust, or they too were damaged by the system. Maybe it was about payments and expenses. I did not know, but the effort of constant fighting was exhausting.

The system hit me hard. It was clear: irritation, stress, discontent, three quarrels with my team and my superiors in one week. I was burned out. That was putting my good work at risk.

Sad person

I felt like everything I was doing was meaningless. I aspired to become the best possible doctor through studying, traveling and sharing, but I always returned to the conditions that made me feel that all was in vain. My stagnant environment was full of burnout people, unjust deaths and endless problems regarding insufficient resources versus higher and higher demand.

That saddest thing in medicine is a doctor without hope.

I felt that each patient brought more pain than joy, even when we had excellent outcomes. It made me sick. I felt like I had unlearned hope. To make matters worse, I could not contain these emotions.

One day a patient asked me, “Am I going to die, doctor?”

I had just seen the results. It suggested cancer, but what would happen now? We wanted an expert to lead him, necessitating an evaluation by the oncologist. Still, the oncologist would not see the patient until the biopsy result, despite the imaging strongly suggested cancer. That meant we had to ask the general surgeon to do the biopsy, but in return, he asked us to refer the patient to another surgical specialty, based on the location of the tumor. So we tried, but this type of specialist did not serve in our region.

The patient’s and our growing stress and conflict eventually led the general surgeon to do the biopsy, but the patient had to wait 30 to 45 more days for the result. Only then, he would be able to go back to the oncologist. When he did, tho oncologist asked us for phenotyping. One more week passed until we finally get the patient to oncology, only to be declared too sick for treatment.

I had experienced this so many times before. Meanwhile, patients were getting more sick, and repeatedly ended up in the emergency department, sometimes got admitted, only to treat infections or pain. In the end, they were sent by the internist to die in our emergency room. They could not do end-of-life care properly. I frequently talked to an enraged family, not because of cancer, but because they were led to believe there was a chance of treatment.

My opinion is that the problem wasn’t lying to the patient about cure cancer, but how often the system don’t even give them this chance of a fight, lying about a chance to treat, but in really being just harmful for everybody because disorganization, corruption, and for didn’t care.

We do not cure death. Ever.

Sometimes we can prolong life. We hope for a good life with meaning, so that they can enjoy some more years, months, weeks or days of celebration, and prepare their wishes for a decent death with their family.

My opinion is that this realization is important not only when we talk about cancer, but any condition, even like a heart attack. We do not cure death, ever.

Coming back to that new patient, the words and the questions bounced in my head:

– Am I going to die, doctor?
– Don’t think about it now. We will take care of you.

I don’t know what the patient saw in me. To me, It felt like lying. When I said we would do our best, it wasn’t me but the system lying. Even if we as emergency physicians or I as an individual did everything possible, I felt the system didn’t care. I knew the system could do better. What could I say when I knew that the journey I want for my patients is so unachievable in the system I work in. I no longer knew what to say under these circumstances, and I felt the patient recognized that in my soul.

I felt hurt, guilty, beaten, and bitter.

That saddest thing in medicine is a doctor without hope.

I never thought this could happen to me. Not with me! How could this happen to me? I was in love with Emergency Medicine! Wasn’t I?

I’d said a billion times how I loved Emergency Medicine and didn’t know how to live without it. I’d shared my passion, convincing others that Emergency Medicine was the answer. Now, it felt like Emergency Medicine was killing me. And worst, I felt that I was not doing good for my patients as my lies were hurting them.

I must take a deep breath. I must ask for help. ...to be continued...

Cite this article as: Jule Santos, Brasil, "Why Me? The Story of My Burnout – Part 2," in International Emergency Medicine Education Project, January 3, 2020, https://iem-student.org/2020/01/03/why-me-the-story-of-my-burnout-part-2/, date accessed: March 29, 2020

Why Me? The Story of My Burnout – Part 1

why me - the story of my burnout

This story starts like almost every other: I fell in love.

The thing is, I LOVE heart attacks!

I know this is a weird statement, maybe even a little ​overstated. I know that people can get uncomfortable when I say this. When I said it for the first time, full of enthusiasm and with sparkling eyes, my ex-fiance looked at me in a concerned and puzzled way: ‘Can you say that?​’ – He asked, wondering if it was appropriate for a doctor to say that they actually enjoyed the experience of people being so unwell.

Clearly, as a doctor, I have nothing against people. Quite the contrary, I unceasingly fight for them to survive and thrive. Yet the paradox is real, despite my battle to save my patients, I am so in love with heart attacks!

Why? Perhaps I love the puzzle behind it. When the patient arrives, I see the position of the body, the hand on the chest, fingers tightly pressed against the skin, the skin color, the sweating… I consider the nuances of pain types, the comorbidities, the risk factors… All are informing my judgment and decisions even before I get to look at the ECG.

I love knowing the diagnosis as it reveals itself. I love that I can treat it. And when it works, I’m the queen of my craft. The scores of survival game change. 1 for me, 1 for my patient, and 0 for the heart attack!

So that’s why you would see me so happy when a patient arrives in my ED. I love this feeling. I love this adrenaline rush that is emergency medicine and me! I love leading a code, guiding actions, organizing my team to the point of ROSC. I love that roaring energy that runs through the whole team as we effortlessly move to the next stage of resuscitation.

This is why I love Emergency Medicine.

Emergency Medicine is new In Brazil. The general assumption is that ED is where junior physicians serve until they choose another specialty or other specialists work to earn additional income. Until recently, working in the ED was a difficult job with no career advancement. So, when I realized that I was so in love with more than heart attacks that I could not leave my work as an Emergency Physician, people started to ask me, “Are you sure? Do you want to work forever in an ED in Brazil? What about when you get older? Don’t you think you will get tired and burned out?”

jule santos

I don’t think so. I reply, I love my job. When you love your job, you don’t ever get tired.”

How naive I was.

Emergency medicine is tough, sometimes even painful. Deaths, we can’t help. Diagnoses of incurable diseases. Bad news. The pressure to be good, perfect, productive. Adding to that, many of us work in corrosive health systems: The result? Emergency Medicine can burn you to your core.

Being in love​ with Emergency Medicine is enough to protect us?

Emergency Medicine can burn you to your core.

Leaving the Comfort Zone

I am a curious soul. While I learned more about emergency medicine, I discovered another world with worldwide Emergency Physicians, who could understand my difficulties and help me learn remotely from them. I fell in love again with #FOAMed.

Hearing the experiences of my colleagues from all around the world inspired me to travel and meet those people. I wanted to learn with them and to compare how Emergency Medicine is in those places.

I love #FOAMED

My newly found calling took me to Sydney in Australia, such a lovely country, which had beautiful and polite people, good public transportation, beautiful scenery, and even a public healthcare system too!

I was lucky enough to spend time in an excellent hospital in NSW. I witnessed them receiving a trauma patient and listened to them as they plan patient management. I was speechless. I felt a sudden sadness to the degree that I wanted to crawl back to my mother’s womb.

When I tell this story, people often react, “You don’t need fancy stuff to practice Emergency Medicine,” but it was not what I saw there. What was it? It wasn’t the video laryngoscopy. It wasn’t the infinite bougies and disposable LMAs. That’s true: The facilities in Australia were incredible and so much more were available than back home in Brazil. But it was still the people.

When the paramedic team arrived, the whole team discussed the patient plan. They were so courteous and respectful to each other, focused only on doing the best for the patient. They were excited about the case, energized, and happy for doing their best.

I’m not saying their life is easy. I’m not saying they don’t suffer moral injury. But I’m sure they don’t show ill-will to their peers and most importantly, to their patients. I want so badly to be able to do that kind of medicine, but the realization of this new health system made me feel envious and perhaps even hopeless. Their experience was so positively different from mine.

Teamwork

I spent the next day in my room, lying depressed in bed, staring at the ceiling, trying to figure out what to do now: “How I would love to have that experience in my hospital!”

I thought a lot about what happened there. Why did it hit me so hard? I knew that not all hospitals were the same in Australia as some hospitals had problems and struggles like in Brazil. I already knew that we had hospitals in Brazil better than mine. Why did I feel so hopeless then?

Now, looking back, I can understand better. I was pushing my comfort zone further than I ever did in my entire life. I was discovering a lot about myself and my capabilities. I was achieving success through FOAM. And so, I saw my limitations, I strumbled in a deep Impostor Syndrome and lost some excellent opportunities. I was in such a fragile mindstate that I felt like the system was unfair to me.

Sad Clown

In my hospital, which is always overcrowded, I work with physicians that don’t have the mindset of Emergency Medicine. When a trauma patient arrives, it feels like a battle. Physicians challenge paramedics: ​“Why did you bring this patient here when we don’t have bed enough?”​ or​ ​“​we don’t have enough surgeons!” or “why does nothing here work?”

All too frequently, the team ends up shouting at each other.

I tried hard to spread the ideas and visions I was learning. One time, I asked for an ultrasound machine, my boss laughed in my face: “Where do you think you are?” Everybody seemed so consumed by pessimism and fatigue that they lost all hope.

I had already been tired and sad. Now, I was also feeling wronged. ...to be continued...

Cite this article as: Jule Santos, Brasil, "Why Me? The Story of My Burnout – Part 1," in International Emergency Medicine Education Project, December 30, 2019, https://iem-student.org/2019/12/30/why-me-the-story-of-my-burnout-part-1/, date accessed: March 29, 2020

Epistaxis on a Flight

Epistaxis On A Flight

A couple of days ago, a friend told me about an incident that had occurred on a plane where a middle-aged man was found to have epistaxis (bleeding from the nose) midway between a 4-hour flight. Although epistaxis has various degrees of severity and only a small percent are life-threatening, the sight of blood, no matter the amount, is a cause of panic and anxiety for everyone. Hence, the cabin crew was called and helped in managing the patient until the flight landed.

Some of the causes of epistaxis on a flight are dryness in the nose due to changes in cabin pressure and air conditioning. Other causes depend on patients’ previous health problems, which may include medications such as warfarin, bleeding disorders, nose-picking.

As important as it is to learn the emergency management of epistaxis in a hospital setting, often you come across a scenario such as this, in your daily life and its essential to know how to manage it, out of the hospital setting or even in the emergency department, while taking history or waiting to be seen.

The following are a few steps you can take for initial conservative management of epistaxis:

  • Make sure they are breathing normally and not in any distress, asses their condition and if you think this could be a major emergency, contact the doctor or call for an ambulance
  • Ask them to bend forward toward their waist while sitting up (to prevent swallowing of blood)
  • Place cotton wool or tissue into the bleeding part of the nose
  • Pinch the soft part (alae tightly against the septum) of the nose just above the nostrils for 10-15 minutes
  • Blowing the nose to expel blood and clots
  • Additionally, an ice pack can be pressed on the bridge of the nose to stop bleeding

If the following measures fail, further medical management may be advised.

Overview

Epistaxis is acute hemorrhage from the nose, nostrils, nasopharynx, and can be either anterior or posterior, depending on the source of bleeding. It is one of the most common Otolaryngological Emergencies.

Anterior bleeds are the most common, and a large proportion is self-limited. The most common site is ‘Little’s area’ also known as Kiesselbach’s plexus (Anastomosis of three primary vessels occurs in this area: the septal branch of the anterior ethmoidal artery; the lateral nasal branch of the sphenopalatine artery; and the septal branch of the superior labial branch of the facial artery).

Posterior bleeds are less common and occur from posterolateral branches of the sphenopalatine artery and can result in significant hemorrhage.

Causes of epistaxis

Nose picking, dryness, allergic or viral rhinitis, foreign body, trauma, medications (anticoagulants), platelet disorders, nasal neoplasms, hereditary hemorrhagic telangiectasia (Osler-Weber-Rendu disease), aspirin.

Assessment and Management

  • ABC approach is a standard. Fluid resuscitation in severe cases
  • History: severity, duration, previous episodes, trauma, medications, family history, infections
  • Initial conservative management: as mentioned earlier including spraying the nares with oxymetazoline
  • Examination: mental status, signs of shock, and coagulopathy and examination of the nose
  • Treatment options: Chemical cautery is usually performed with silver nitrate, Nasal Packing, Nasal Tampons, Gauze Packing, Nasal Balloon Catheters, Tranexamic acid, Thrombogenic foams and gels
  • Treatment specific to posterior bleeds : Balloon catheter, Foleys catheter, Cotton Packing

References and Further Reading

Alter Harrison. Approach to the adult epistaxis. [December 24th, 2019] from:  https://www.uptodate.com/contents/approach-to-the-adult-with-epistaxis

Cite this article as: Sumaiya Hafiz, UAE, "Epistaxis on a Flight," in International Emergency Medicine Education Project, December 27, 2019, https://iem-student.org/2019/12/27/epistaxis-on-a-flight/, date accessed: March 29, 2020

Advantages of Global Health and International Emergency Medicine Outreach Experiences

Bryn Dhir - Global Health

Wherever you go, be all there

– Jim Elliot

International medicine is among the most valuable experiences not only for residents and students, but for physicians from all specialties. Emergency medicine (EM) physicians, in particular, have previously been highlighted with critical qualities and characteristics essential to successfully providing medical aid and care in some of the most remote regions, rugged wilderness, and disaster zones. In recent years, the practice of physicians travelling overseas with the goal of outreach, and professional and personal development, has been met with the flux of international patients travelling to the United States and Canada in search of medical treatment, as well as international physicians seeking to develop their own clinical skills and enhance medical practices to take back home. Physicians and patients both face challenges associated with these new experiences: the stresses of traveling, financial concerns, family obligations, cultural practices, and preparing for the unknown. As such, it is important to remember that patients also encounter anxiety, cultural and communication differences, have concerns for the continuity of care associated with filling in missing gaps in their own medical records and fluctuating medical aid providers and often lack medical knowledge and understanding of health issues. Interactions that patients have with visiting physicians can also allow patients to gain insight into new practices, cultures and traditions. These experiences can be life-changing for everyone involved.

While global outreach, international medicine or disaster preparedness isn’t for everyone, it is important to remember that global health does not equate to the definition of international medicine, and that there is a strong need for domestic medical outreach in rural America and Canada, in locations that present with similar challenges of underserved patient populations and with limited resources. Nonetheless, the benefits of medical work in new environments outside of comfort zones can provide tremendous benefits and contributes to the overall continuous development of a well-rounded physician. The advantages of participating in global health and international medicine are extensive, and this article highlights only some of the major benefits.

Strengthen leadership, communication and interpersonal skills

Before EM physicians begin their medical work with patients, the potential to strengthen leadership, communication and interpersonal skills through interactions with local residents is often experienced with language being a major factor in effective communication. This includes not only the spoken word, knowledge of key phrases in the native tongue, but the use of body language, eye contact, and hand gestures. Understanding different approaches to patient scheduling, staff and local perceptions about meal, travel and leisure times, administrative and medical support, and negotiation and conflict management skills, allows for a more productive and enjoyable experience. Further, not only are individual skills, but so is teamwork and an understanding of the functional dynamics. Participation in outreach contributes to the development of many skills including independent decision making, project management (from funding to administration, allocation of materials and supplies, to public relations and follow up), and creativity in the face of limited resources.

Team building and group dynamics
Team building and group dynamics through icebreakers and interactive games for medical volunteers. The ability to draw on previous training and skill sets outside of clinical practice is beneficial for ease flexibility, adaptability and cooperation.

Cultural Competency

Exposure to patients contributes to cultural awareness, understanding of the impact of socioeconomic factors on health care, historical and geographical issues, and puts to use clinical and language skills while immersed in a new environment. Participating in local events is a valuable learning experience, and clinical work in the developing world or remote rural locations in North America can contribute to a physician’s ability to understand and advocate for patient health care needs.
These basics will allow for a better understanding of cultural differences, institutional and policy barriers, communication barriers, managing through unknown and incomplete medical records, financial constraints which can limit tests and treatments, and influence management as medical work begins. Numerous resources are available for emergency physicians entering new environments for the first time to help provide insights regarding gender issues, cultural practices, religion, politics, current social events to name a few. It is important to do thorough background research into patient populations and to be aware of the community you will be entering. For EM physicians in rural North America, opportunities to work with nongovernment organizations and refugees can provide exposure to international and global patient populations who need your clinical skills and medical training. The American College of Emergency Physicians(1), Emergency Medicine Residents Association(2), Society for Academic Emergency Medicine(3), offer thorough information and resources for rotations and fellowships for international emergency medicine, and the American Academy of Family Physicians lists resources for physicians interested in Global Health(4). A list of additional reading and resources is provided below.

understanding cultural differences
Getting acquainted with local surroundings, understanding cultural differences and being open to participate in traditions while maintaining the security of your team and yourself.

Exposure to new practices and health care systems

Physician shortages and limited financing of healthcare are global concerns; however, there is an excellent benefit for physicians who learn to treat and understand a variety of patient populations despite these limitations.

This is an essential obligation of EM physicians. International medical rotations are a concept that has slowly been incorporated into medical schools. Nearly ten years ago, a survey published in Academic Medicine concluded that international rotations broadened medical knowledge and reinforced physician examination skills(5).

International rotations broadened medical knowledge and reinforced physician examination skills.

– Academic Medicine

Further, learning about other healthcare systems, medication preferences and availability, and equipment as well as protocols and practices, can allow for incorporating practices back home, as well as suggesting sustainable changes for improvement overseas.

The challenge of thinking outside the box and learning to be resourceful with equipment is yet another benefit to international medicine, where poverty-related diseases demand thoughtful consideration to resources and long-term management of patient cases. Distinguishing differences among clinical practice and procedural skills in a respectful, intuitive manner and with an understanding of varying standards of care and limited resources is also essential for international outreach. While dealing with these issues may be frustrating, maintaining confidence in one’s own training, calling on previous life experiences and harnessing multi-disciplinary teams with diverse cultural backgrounds, will prove to be beneficial in providing effective patient treatment. Besides, exposure to other health care systems can allow for research into the best strategies for administration and management, for not only physician practices, but for patients and health care systems at large.

Medical clinic on Station Hill, Mayreau Island
Medical clinic on Station Hill, Mayreau Island in the Grenadines. This isolated island is only accessible by boat. Island size: 0.46 square miles, population 271. The number of patients care for during an outreach clinic was approximately 70.
global health

Medical Knowledge, Self-Sufficiency, Resources and Equipment

Caring the patients reveal the diversity of diseases and disorders and provide insight on the local health care issues. The variety of cases differs between hospital and ambulatory settings. EM physicians have the opportunity to see and manage rare diseases and disorders uncommon back home, with a highlight on cases involving infectious diseases, toxicology, advanced diseases. Knowledge of disease presentations, prevalence, and exposure to the seemingly foreign diseases has been a recent consideration with the migration of people not only at the international scale, but at the local level across the States. Social, mental, and financial support is another layer that health care systems are working to provide for these vulnerable patient populations. Moreover, the added pressure of finding solutions for medical cases requiring advanced procedures can be disheartening, and EM physicians must become the nurse, specialist, social worker, therapist, surgeon, administrator, pharmacist and physical therapist all in one. Creative uses of equipment, thinking outside the box, and making use of what is available are other factors that will be frequently tested while in the field. Training in the wilderness and extreme medicine, as well as rural family medicine practices is advantageous for physicians in the global setting where multiple uses for one instrument is applied in various situations. Nonetheless, adhering to the training in medical school and residency is the basis for all medical work and ethical best practice, professionalism and management are the foundation to providing patient care regardless of location.

Learning to do IV
Learning to do IV placements using self-designed, mock equipment and the understanding of the importance of improvisation, flexibility and limited resources.
Knowledge of how to operate medical equipment
Knowledge of how to operate medical equipment without support staff is beneficial.

In response to the growing interest and need for physicians in underserved global populations, there has been an increase in funding opportunities.Prior to embarking into unknown territory and patient scenarios, it is recommended that a physician’s own resources are known, including potential health risks, and that support systems are in place in order to maintain a mental and physical balance to provide care where it is desperately needed. Culture shock, grief and sadness, personal debriefing and reflection, and adjusting to life back home is an additional element to tend to.

neonatal care and pediatric care
There is a great need for neonatal care and pediatric care on a global scale. Experience with these patients will be an asset in the field.

Outreach, Education, Research, Mentorship

The opportunity to provide preventative and screening information directly to patients through clinics and to physicians at training sessions allows for direct two-way communication, clarity and the sharing of knowledge bases. Additional outreach at clinics and mobile health units often add to the overall value and maximizes a physician’s ability to provide outreach and education. Furthermore, opportunities may exist for collaborations with clinicians and scientists as well as health policy advisors. Although the notion of global health has attracted the fad of medical tourism and entails a certain novelty of volunteering abroad, emergency physicians have a great opportunity to make a lasting difference on the lives of their patients as well as those of international colleagues who are either interested in practicing in North America(6) or who will stay with the communities and health systems they are in. Therefore, building and fostering a network of connections for the future is an important and positive outcome, with the potential to provide up to date journal articles, resources to evidence-based medicine and free online medical education, and can allow you to incorporate global health initiatives and outreach back home. At the end of the day, physicians who are driven to extend their medical knowledge and clinical skills into regions with a desperate need for health care and vulnerable patient populations are often those who have made the commitment to serve as an emergency physician.

Basic wilderness training
Basic wilderness training with a focus here on evacuating an injured victim in remote communities (here in northern Nunavut, Canada).
positive lasting impacts on youth.
Global outreach and international medicine opportunities can include taking the time to travel out of the clinic and visit schools to train and share knowledge with younger students. Creating interest and awareness can have a positive lasting impacts on youth.
Youth often appreciate visits to their schools
Youth often appreciate visits to their schools, and their interest in health care, medicine, prevention can be highlighted with education in emergency services, as well as through games and storytelling.

The experience of a global project and working in a clinic on an international scale enables EM physicians and students from all levels of training to provide care in emergent situations from disaster and humanitarian relief to outreach clinics. For physicians and students who opted to pursue medical education in a global setting, as an international graduate or for North American physicians who thrive on global health and international outreach, the experiences are unlike those in North America, and there is an abundance of personal and professional learning and development to gain. Experiences outside of comfort zones, whether in rural America or overseas, create a global community to better medical practices and often advocacy for health care continues long after a global project has concluded.

The Model of the teaching hospital, which links research to teaching and service is what's missing in global health

– Paul Farmer

This article touched on the advantages and benefits of stepping outside comfort zones to provide medical care to vulnerable patient populations, and a follow up to this article will be how to overcome the challenges and barriers that physicians may encounter. Have you participated in a global health project or international outreach? Please feel free to share your own thoughts and reflect on your experiences in the comments section below.

A Piton climb for the view, St Lucia.
A Piton climb for the view, St Lucia. Medical outreach and travel is a demanding endeavor, however quiet moments to enjoy the process and experiences will make it a rewarding one.

Additional Reading and Resources

  • What is International Emergency Medicine? Academic Life in Emergency Medicine – link
  • International Emergency Medicine Section, American College of Emergency Physicians – link
  • The Practitioner’s Guide to Global Health, American College of Emergency Physicians – link
  • US Residents: Discover the World with Emergency Medicine, Emergency Medicine Residents Association – link
  • Fellowship Database, Society for Academics Emergency Medicine – link

Link To References

Cite this article as: Bryn Dhir, USA, "Advantages of Global Health and International Emergency Medicine Outreach Experiences," in International Emergency Medicine Education Project, December 4, 2019, https://iem-student.org/2019/12/04/advantages-of-global-health/, date accessed: March 29, 2020

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Rubik’s Cubing an Emergency Room

rubik's cubing

Lush green land and open spaces, fresh air that reminds us of how artificial our all-natural room fresheners smell, and quiet nights decorated with twinklings of a starry sky and the musical buzz of crickets. That is how most would imagine a village. Few of these imaginations remain borrowable if anyone were to engage in the same exercise in regards to an ER in the village. For starters, nights aren’t as quite, color and smell changes depending on what patient you are treating that day and the space of the room shrinks in proportion to the distance you traveled to reach that village.

Former Emergency Setup at Beltar PHC
Former Emergency Setup at Beltar PHC

Two years ago, when I was posted at Beltar Primary Health Care Center (PHC), little did I know that a sparsely populated village’s abundance of space rarely follows through to the emergency room. The obvious lack of infrastructure is, of course, the major problem. In the health system of Nepal, emergency services are designed to be provided at the hospital level. However, keeping the need for emergency services in mind, health workers in the rural areas are left to run makeshift ERs. At our PHC, what was supposed to be the waiting lobby for patients was used for an ER. The lack of a four-walled room meant that the only sense of privacy was provided by the patient’s fumbling awareness owing to intense pain and the physician’s focus completely overwhelmed by trying to be resourceful amidst obvious lack of resources. Hordes of curious onlookers crowding to see what was going on is a common scene in our ER that one would start ignoring after a month or two.

After banging our heads on problems that require far more resources and policies than that within our reach, we are left to take a sensible path – focusing on one small thing at a time and changing it for the better. Today I present to you an incident that inspired us to make an effort into making one such change happen.

A 28-year-old male

Like any on-duty doctor, I found myself rushing to the ER after a call. A 28-year-old male was brought after a sudden loss of consciousness while playing football. We quickly realized that CPR was in order and jumped right at it. Quite literally so, as the arrangement of beds in the ER was such that you could only deliver quality compressions if you are on the patient’s bed.

Elephant in the room

When I asked our paramedic to start bag and mask ventilation, he looked at me in confusion – the bed was placed against the wall and he would have to jump across the patient to provide one. Our nurse had to squeeze her way through the crowd of onlookers to find the needed medication. In the end, all of us were disappointed. Exhausted physically and mentally yet pondering on things we could have done differently, like any other resuscitation team would, after an unsuccessful CPR. After ruminating on the quality of CPR, availability of better equipment, training and all other aspects of a good resuscitation, we finally addressed the elephant in the room.

Bigger space or ...

The most obvious solution of shifting our ER to a bigger space was simply not an option. What we could do was make small changes that could make things a bit better. The nature of problem-solving has to be such that the biggest constraints remain (because we rarely can do anything about them). What is it that a bigger space adds? Big space adds orderliness. As I was pondering on this question, I had an idea that felt like an epiphany. I remembered one of my toys as a kid – a Rubik’s cube. We do not expand our Rubik’s cube to make it orderly. We rearrange it – you get to manipulate the pieces but not the whole cube. Thus, we started the mission of Rubik’s cubing our ER.

Rubik's cube

Rubik's Cubing

We had four beds in our ER. We wanted a separate resuscitation bed with enough surrounding space. We moved all three beds to one side of the room; installed two privacy screens instead of both a door and a wall (sorry onlookers!). We repaired and re-stocked the crash cart, placed each medicine in separate compartments in the drawers and labelled them properly.

Makeshift door using privacy screen
Makeshift door using privacy screen
Resuscitation area at Beltar PHC
Resuscitation area at Beltar PHC
Crash cart
Crash cart
Labelled medications
Labelled medications

A few weeks later, we performed CPR in another patient. The patient was rushed to our resuscitation bed, the privacy screens were drawn and the crash cart pulled near the bed. After we resuscitated the patient, we started the age-old culture of replaying the scene in our head and trying to figure out what else could be done. We obviously came up with a lot, this time too. But in terms of using the available resources, everyone was satisfied that they did the best they could make out of the situation.

Resuscitation will never be easy, but that is the precise reason we need to make it as orderly as possible. People who develop protocols and policies are doing their part. We, at Beltar, tried to do ours.

Cite this article as: Carmina Shrestha, Nepal, "Rubik’s Cubing an Emergency Room," in International Emergency Medicine Education Project, November 29, 2019, https://iem-student.org/2019/11/29/rubiks-cubing-an-emergency-room/, date accessed: March 29, 2020

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ACEM2019 and Incredible India

ACEM 2019 and increadible India

The 10th Asian Conference on Emergency Medicine was successfully completed in New Delhi, India, during the last couple of days. The conference hosted around 1700 attendees around the globe, mainly Asia. There were approximately 300 speakers from all continents. Dr. Tamorish Kole and Dr. Sirinath Kumar were the two Emergency Medicine professionals who behind the success of this conference. Both experts are also a member of the board of directors of the Asian Society for Emergency Medicine (ASEM). At the end of the conference, Dr. Kole took over the presidency from Prof.Dr. Yildiray Cete (Turkey) who served to ASEM for two years.

ASEM board
Asian Society for Emergency Medicine, Board of Directors

Vice-President of India, Venkaiah Naidu, opened the conference with promising support to the improvement of Emergency Medicine care in India as well as highlighting the implementation of Emergency Medicine into the undergraduate curriculum. As many countries in Asia, Indian medical graduates are working in acute care settings after graduation. Therefore, focusing on undergraduate education can help many countries in the same context. 

Venkaiah Naidu
Venkaiah Naidu, Vice-President of India

This topic one of the items discussed in the ASEM Board of Directors meeting. Creating a widely acceptable undergraduate curriculum is a necessity for Asian countries, especially those in the development stage of Emergency Medicine. ASEM board formed a sub-committee to work on this highly significant problem. Dr. Mohan Tiru (Singapore) and I will be leading board members to continue and finalize the process. Because the International Federation for Emergency Medicine (IFEM) currently working on a comprehensive update process for its’ undergraduate curriculum, there is no need to reinvent the wheel for ASEM. Taking the updated version of the IFEM undergraduate curriculum as the main framework and working on it to create a precise Asian undergraduate curriculum will be enough and probably the fastest way. However, there is a need to understand the current situation and needs in Asian countries. Therefore, the sub-committee of ASEM will work on learning needs assessment and current situation analysis until the IFEM undergraduate curriculum finalized. The expected time for the new updated version of the IFEM undergraduate curriculum is April-May 2020. Completing learning needs assessment and current situation analysis of Asia by March-April 2020 will give the Asian board a chance to move forward with updated IFEM undergraduate curriculum. Probably, developing the Asian curriculum will be possible in a short period of time until the end of 2020.

ASEM board meeting
Asian Society for Emergency Medicine, Board of Directors Meeting

While ACEM2019 continues, I was able to meet a couple of contributors to the International Emergency Medicine Education Project. I visited Rob Rogers’ well-known course, Medutopia, which aims to increase the quality of the teaching skills of educators. According to Dr. Rogers, this is the most enthusiastic and knowledgable group since the Medutopia journey has begun. Dr. Andy Little and Dr. Mike Giosondi were other two experts who gave the course with Dr. Rogers. You can read and listen to Dr. Rogers’ contributions to the International Emergency Medicine Education Project here.

I also came across to Dr. Simon Carley from Manchester, who is well-known for ST.EMLYN’s blog. He gave a couple of amazing talks during the conference, including one plenary presentation.

Simon Carley, plenary session
Simon Carley, plenary session
Arif Alper Cevik and Simon Carley
Arif Alper Cevik and Simon Carley

One of the surprising things was meeting with one of our blog authors Dr. Kaushila Thilakasiri (Sri Lanka) and her team. This energetic group was not only coming for ASEM to attend meetings, but they also came to compete in SimWars. And of course, they won the first prize.

Kaushila Thilakasiri and Sri Lanka team

Two days of workshops and three days of the busy scientific program passed like lightning. In addition to scientific activities, ACEM 2019 team prepared many social events for participants. I think, socially and scientifically, ACEM 2019 was a very busy conference. This created many networking opportunities.

One of the final event was graduation ceremony of 2018-2019 class of Emergency Medicine residents. Around 120 new graduated were appreciated with a nicely setted up ceremony with attendence of leaders of Emergency Medicine such as Prof. Lee Wallis (Past President of IFEM), Dr. Taj Hassan (Pas President of Royal College of Emergency Medicine) and Prof. James Ducharme (President of IFEM) as well as local leaders of Emergency Medicine of India.

2018-2019 Indian Emergency Medicine Graduates
2018-2019 Indian Emergency Medicine Graduates

As a summary, ACEM2019 was a successful gathering for international Emergency Medicine experts and Asian emergency physicians, residents and medical students.

ACEM 2021 will be in Hong Kong. ASEM board of directors decided to give ACEM2023 to Manila, Phillipines and ACEM2025 to Dubai, United Arab Emirates. We hope to see you all in these upcoming events.

Cite this article as: Arif Alper Cevik, "ACEM2019 and Incredible India," in International Emergency Medicine Education Project, November 13, 2019, https://iem-student.org/2019/11/13/acem2019-and-incredible-india/, date accessed: March 29, 2020

The Medical Emergency Simulation Olympics – G.SEM

the emergency medical simulation olympics

The use of realistic simulation on medical teaching is increasingly being used in the universities of Brasilia. The controlled environment training brings important benefits and develops the non-technical skills of participants. Therefore, the Congress of Medical Emergencies of the Federal District that took place this month in Brasilia, Brazil, promoted a realistic MEDICAL EMERGENCY SIMULATION OLYMPICS (literal translation: Gincana de Simulação em Emergências Médicas – G.SEM) with medical and nursing students. The participants felt tremendous satisfaction and acknowledgment of their own flaws that must be improved before they graduate.

However, what does realistic simulation mean? By definition, “it is the technique, not technology, for reproducing or amplifying real experiences by guided experiences that evoke or replicate substantial aspects of the real world in a fully interactive way.” That is, we set up environments of low, medium or high complexities that mimic reality. This way, the participant can emerge in practice without putting the patient at risk.

Through Kolb’s experiential learning cycle, we can understand how learning occurs during simulation.

kolb learning cycle

During the simulation, the participant takes part in concrete experience, being able to identify knowledge gaps in which he can work. At the debriefing, the instructor helps the gamer to contemplate his performance.

When the participant gives meaning to what has happened, he becomes able to abstract and modify his mental model, which will be tested with active experimentation, generating a concrete reaction.

When simulating, not only theoretical knowledge is required, but also practical knowledge, such as how to do and how to act when facing the proposed situation. Doing this kind of exercise, we can better assimilate the content in a playful and effective way. Through error, and the reframing of debriefing, the participant can retain the content with the experience that will come across in the real environment.

The simulation was first used in the aerospace industry, where one mistake could cost many lives. Therefore, the practice of simulation in medicine is indispensable since we work directly with human lives. Train, train and train! This is the emergency mantra! Because by the time you are in the Emergency Department, acting, you already need to know what to do. The time to make mistakes is in the simulation. Moreover, it’s important to keep in mind that an error-free simulation is not a simulation, it is just a theater.

It is possible to divide this learning method into some levels. Through Miller Pyramid, we can analyze the clinical capacity in four levels: know, know-how, show-how, and does. Simulation is increasingly used to teach the first three levels, as it enables the programming of specific environments and conditions to the needs of each participant, promoting a favorable outcome.

Is it like playing pretend? Yes. The simulation can be compared to a pretend play. We can’t reproduce the exact reality, so we set up a fiction contract, where the instructor admits that the simulation is not real but tries to reproduce it as faithfully as possible, and the participants agree to act as they would in real situations.

Therefore, if during a high complexity simulation, a patient with low oxygen saturation needs intubation, for example, the participant must act by observing vital signs on the monitor, asking for drugs, infusing, ventilating, and intubating the doll and not just saying what he would do.

The Chiniara et al Simulation Zone Matrix, commonly used to demonstrate the teaching of simulation in pediatric emergencies, can be extended to emergencies in general. Simulation becomes advantageous over other teaching methods in low-opportunity, high-severity situations, quadrants where emergency is, due to low student exposure and increased concern for patient safety.

With simulation, it is possible to practice technical and non-technical skills, for example, interaction with the multidisciplinary team, leadership, communication and crisis management, which is almost impossible in a classroom.

When we promoted the G.SEM – Emergency Simulation Gymkhana – held by the EMIGs in Brasilia, we had many positive feedbacks from participants, and proved to be effective in exposing to participants points that they needed to improve to raise the level of their clinical practice.

Participating in G.SEM was a very exciting experience for me, as I was able to review important concepts and behaviors in various pathologies, including the approach to cardiopulmonary arrest. It was also a very interesting emotional experience, as we had a short time to make decisions since all patients had life-threatening pathologies that needed fast decisions and actions. In this context, an adrenaline over-discharge and, consequently, tachycardia were generated, generating significant stress that leads us to the real process of approaching a critically ill patient. In addition, one of the most important positive points was the team performance, as the team consisted of 2 medical and one nursing student, so we needed to work together, respect each other and make our communication were efficient and clear. Through the scenarios, it was possible to see how much we improve as a team, and in the final scenario, we were already much more intertwined and acting in a much more organized way compared to the first one. I also emphasize the importance of the evaluator’s feedback at the end of each season, as this allowed us to identify the errors and to correct them in the following simulations and, of course, to future. Finally, it was a unique opportunity that certainly made me grow very intellectually and also allowed me to improve the relationship with the team, which is indispensable in a multidisciplinary context.

says Lucas, a medical student who participated in the simulation scenarios.
Winners

There were six simultaneous scenarios, including two pre-hospital scenarios that were assembled by firefighters. G.SEM took place at the Uniceplac Realistic Simulation Center, with the support of the DF Fire Department, and the International Student Association of Emergency Medicine (ISAEM).

Content and Details

  • 4 multidisciplinary teams, each consists of 3 medical students and 1 senior nursing student.
  • 6 simultaneous scenarios. All teams exposed to all scenarios. 1) Diabetic ketoacidosis in children, 2) Intra-hospital care for multiple trauma patients, 3) Acute myocardial infarction, 4) Sepsis, 5) Pre-hospital care for multiple trauma patients (car x bicycle accident), 6) Pre-hospital care for cardiopulmonary arrest and the patient suffering from penetrating trauma.
  • Each scenario had a total duration of 20 minutes
  • Each scenario had a checklist of actions and knowledge that was expected from the team in that situation.
  • In the end of each simulation, the team went through a quick debriefing, for about 8 minutes, with the station instructors.
  • After all scenarios, there was a debriefing with the residents of emergency medicine, in order to demonstrate to participants the reality of those situations in the emergency department
  • The winning team was the one with the most checklist points.
  • The teams were awarded according to their classification.

The simulation itself already causes some anxiety in the participant, since it demonstrates its flaws and puts in check all its theoretical knowledge that should be applied in a practical way. During our emergency simulation game, we noticed an increased level of anxiety and stress from participants. It is believed that the necessity of quick decision making that the emergency requires and the short time of the season were determining factors. However, participants reported that the multidisciplinary team made the simulation environment different, that’s because nursing students do not have realistic simulations as a requirement in their course, and it’s not common the integration between the courses in a simulation scenario.

As a lesson of this event, we conclude that it is extremely important to integrate the programs in the undergraduate years, and we can use the simulations as a convergence point. It’s important to remember that the Emergency Department only works with a cohesive multidisciplinary team. One of the goals of G.SEM was to demonstrate to students this reality and break the barrier between programs by showing that the work in the Emergency Department is teamwork and that always needs team training!

References and Further Reading

  1. Gaba DM. The future vision of simulation in healthcare. Simul healthc 2007;  2(2): 126-35
  2. Cheng A, Duff J, Grant E, Kisson N, Grant VJ, Simulation in paediatrics: An educational revolution. Paediatri Child Health. 2007; 12(6): 465-8
  3. Kolb DA. Experiential learning: Experience as the souce of leatning and development.  Englewood Cliffs, NJ: Prentice-Hall; 1984
  4. Zigmont JJ, Kappus LJ, Sudikoff SN. Theoretical foundations of learning through simulation. Semin Perinatol. 2011; 35 (2): 47-51
  5. Paizin Filho A, Scarpelini S. Simulação: Definição: Medicina (ribeirao Preto). 2007; 40(2): 162-6
  6. Miller GE. The assessment of clinical skillscompetence/performance. Acad Med. 1990; 65 (9 Suppl): S63-7
  7. Couto TB. SImulação realistica no ensino de emergências pediátricas na graduação. São Paulo. 2014.

Reviewed by: Bruna Martins, Jule Santos and Henrique Herpich

Cite this article as: Rebeca Rios, Brasil, "The Medical Emergency Simulation Olympics – G.SEM," in International Emergency Medicine Education Project, October 30, 2019, https://iem-student.org/2019/10/30/the-medical-emergency-simulation-olympics-g-sem/, date accessed: March 29, 2020

Macro-lensing the Emergency Department

Macro-lensing the Emergency Department

How do you remember the emergency department (ED) that trained you? Could it be that you have learned a lot more than just medicine there? Between worrying about the delayed laboratory report and explaining the need to rule out a myocardial injury to a visitor of a patient with peptic ulcer disease, you might have picked up other attributes. Subtle traits that have nudged your personality. Remembering the ED where I did my internship sparks nostalgia and makes me want to speed up my typing. As if I need to attend to something else right after this. Hopefully, I’ll give you a glimpse of what putting on different lenses can show even when we look at the same object.

Peeling yellow paint, some old cracks in the wall, and an acute sense of urgency lingering in the air are what I remember of the department. Patan Academy of Health Sciences has an ED where confused students scratching their heads to the witty professors’ question takes you to your own golden days. A subtle grin on the wise face of a grey-haired professor eagerly waiting for the next wrong answer makes you want to reach out to your old mentor. A know it all student on the verge of blurting out the answer physically holding himself behind makes you wonder what that one classmate of yours is doing these days. It is a place where teaching, helping people, running against time and having fun while at it, blends into an experience of a lifetime. Stories of eased pain, dodged suffering and narrow escapes from grave aliments enrich the history of the department.

One fine evening in the department as an intern I found myself seated in the doctor’s station, a rare but insightful experience. I found myself pondering about the lessons I can take from this part of the hospital: not just medical knowledge but lessons I can share with people from different facets of life. Below I list the common situations or sayings used in a typical ED and try to translate it for use in day to day life.

Think horses before zebras but watch out for zebras that can fly

A patient with mild fever, chest pain, and some respiratory distress probably has some sort of URTI. But the very fact that he/she landed up in the ED makes the doctor order an ECG because of the chest pain. The doctor will, of course, be leaning towards a more common diagnosis. Ruling out a diagnosis with grave prognosis, however, will be among the top priorities. 

searching zebra

This can translate into studying common exam materials while also being aware of the zebras. Zebras show up rarely, but when they do, they tend to be stubborn. Be aware of the topics that don’t usually show up in your exam but impact the outcome when they do. We can also borrow this idea while thinking about anything in general. We tend to assume the worst, but when your date is late to dinner, it probably is just the busy traffic.

Communication is the key

A medical officer reads the patient’s history to the professor using as few words as possible, pertinent negatives and a precise format. The information and condition of the patient are conveyed very accurately. When reporting history, we aim for effective communication at its best. 

communication

I wonder how many day-to-day problems can be solved if only we communicated that efficiently outside of history taking and reporting. Using clear words, very few fillers and addressing what we don’t mean beforehand can help in getting the intended message across.

Prioritizing

The most critical patients that visit Patan Hospital head for the ED. Recognizing them and treating the ones who need immediate attention is the second nature of a good emergency physician. Likewise, being able to focus on the most critical aspects of one’s life can be an attribute worth borrowing from the department. 

prioritising

How many times do we complain that we just do not have enough time to do things that are important to us? It’s mostly about deciding what comes first.

Resource allocation

This sort of ties into the previous one. Most experienced physician attends the most critical patient. More nurses are allocated to and the best USG machine is used in the red triage area. Time, money, physical or mental effort all are resources we use to get tasks done. Sometimes success differs from failure, not in how much effort is put but where it is used. Determining which task is most resource-intensive or most productive can be a worthwhile idea to learn from the ED.

resource allocation

Did you check your tools?

Monitor connected to a gradually stabilizing patient beeps rapidly, indicating a sudden collapse. As you run towards the patient with your ACLS neurons firing at a rate more rapid than the patient’s declining pulse, do take a look if the pulse oximeter is connected correctly. Translated in the world where things go south more frequently than not, decide if it is a perceived problem or a real one. How many times have you let yourself go into flight or fight mode only to realize that the threat wasn’t even there?

Give thiamine before glucose

Hypoglycemia kills. Glucose save lives. Even then, giving thiamine before glucose is the norm in most EDs. The biochemistry behind is simple; thiamine is a cofactor used by many enzymes in glucose metabolism and depleting more thiamine can cause Wernicke Korsakoff disease. Look at it with the lens of a student who needs to start preparing for an exam. Determine your thiamine (proper sleep, good food, exercise, enough water and probably mindfulness). Only then glucose supplementation (studying) will yield results.

The loudest screamer isn’t always suffering the most

“How do you triage when there are more people than you can attend to?” asked a professor. The answer was funny but made a point firmly. “You should ask the most critical patients to come forward. Then you attend those that are left behind!”. The idea being; sickest of them all won’t even be able to advocate for themselves. Similarly, we can be tactful when overwhelmed by problems. Try to come up with ideas to segregate the screamers (problems that seem to be the biggest) from the sickest (actual problems).

triage

Know your limits and ask for help

We manage acute exacerbation of COPD in the ED. Not all patients that feel relieved are discharged from there. Some patients require medical consultation and transfer. This, in no way, means that the ER physicians are incompetent in managing the disease throughout. Rather it is the evidence of understanding the job description and trust in the system as a whole. Asking for help when need be is critical to our wellbeing. Being able to ask for help shows courage and humility above all.

knowing limits
Cite this article as: Sajan Acharya, Nepal, "Macro-lensing the Emergency Department," in International Emergency Medicine Education Project, October 28, 2019, https://iem-student.org/2019/10/28/macro-lensing-the-emergency-department/, date accessed: March 29, 2020

Mozambique Emergency Medicine Is On The Rise

Mozambique Emergency Medicine Is On The Rise

Africa is a magical continent. It is filled with unique cultural energy. I promise you will never regret diving into this experience. Whether in a park celebrating a wedding, or simply celebrating life at a night club. Africans are master of this, the magic spreads through the air, and you can feel it.

Image by Idílio Chirindja from Pixabay

I had an incredible opportunity to experience Mozambique. In the middle of many English speaking countries, an island speaking Portuguese language.

The country is in the southeast of Africa. The capital is Maputo, which was invaded by Portugal in 1505 that established dominion until 1975 when Mozambique gained its independence. But after that, the country lived years of intense civil war until 1992. Since then Mozambique has lived in a period of relative political stability.

The official language of Mozambique is Portuguese but is spoken mainly as a second language about half of the population. Among the most common native languages are Macua, Tsonga and Seine. The population of about 29 million people is predominantly made up of Bantu peoples.

My story meeting Mozambique

Every time you have doubts about the work is done on the Internet, which many may think irrelevant, I want to say to you that I owe my medical career as an Emergency Physician to #FOAMed. Emergency Medicine was recognized as a specialty in Brazil only in 2015, after many years of struggle. So, we didn’t have much information about this specialty which is still unknown to many students who are currently choosing the specialty, as it was with me. But the fact that someone writes something down and makes it accessible on the internet can really change lives. What led me to understand who I was and what I wanted to do in medicine was this text by Joe Lex. I found my people. My tribe. I understood who I was and fell in love with Emergency Medicine.

After knowing so many amazing FOAMed blogs (emdoc, emcrit, rebelem, etc.), I was so inspired and wanted to do for emergency medicine in my country. I want to create a FOAMed content so that people like me could discover our specialty earlier. And it has to be in Portuguese.

English is important, but nothing so comforting than reading content in your own language. You can think and retain the new knowledge faster, and you can translate the knowledge better to the patient. Understanding is clearer, more accessible, and also brings a sense of belonging and appreciation.

So when I met Abigail Hankin-Wei, we were committed to producing emergency medicine content in Portuguese for the sake of our emergency medicine training programs. Abigail is an inspiring person, who is an emergency physician from the US working in Mozambique full-time to help build the country’s first emergency medicine training program. The residency program is the first one in the country established in 2016, with six young and passionate residents. So I went there to make our bond stronger.

The thing I love most in our specialty is the tribe feeling — the way we immediately recognize the passion in each other. So when you talk about medicine, you know, you understand, you feel belonging to a place, you know that you aren’t the only one crazy doctor that likes to take care of very sick patients. In my routine daily life, it is difficult to encounter this kind of bound.

So, coming to Mozambique and meeting these residents (Brito Gulela, Dino M. Lopes, Euridxe Barbosa, Maria Augusta Taimo, Hermenegildo de Jesus da Silva Macauze and Ezio Massinga) and two more physicians from US (Patrick Connel and Rodolfo Loureiro) were the same exactly how I felt. I was among friends, equals, and I felt like I was at home.

The Story

In Mozambique, we worked at the Mavalane Hospital. I assumed that it is a secondary level hospital, but with a real lack of support. The patients were respiratory failure, abdominal pain, fever, malaria, tuberculosis, lots of complications of HIV, acute stroke, high hypertensive emergencies, etc. They could only provide oxygen (with limitation), and some basic medications.

In the first week, the x-ray machine was broken, but the show must go on, and they did the best they could, treated the most likely disease in their environment with little room for a thorough investigation. They placed the sickest patients in a separate room, the only room in the department where they could get oxygen therapy, which came in two large cylinders. They transferred the most severe patients (which had to be very sick) with potential for recovery to the Central Hospital. As Patrick used to say, the work of the Emergency Physician is to separate the sheep from the goats, so they have to learn as best as they can.

One brilliant thing was the use of POCUS, which is a great value in this context, and I was able to learn a lot from them as I still developing my skills. In need of a CT imaging, the patient has to be referred to the Central Hospital (level one, but still with many limitations). It has to be really thought through because there are limited spots daily. Some conditions could be done, some conditions not. It should change treatment and outcome in a patient with possible good prognosis.

Sometimes the days were really harder, especially when you achieved a certain level of treatment, and you did not have more options to use. They couldn’t do fancy things like NIMV or intubation, or continuous infusion of drugs. They do what they could with their best, and we wait and hope.

The human body is amazing, they are particularly strong here, and one thing I brought with me from this experience is that some patients really get better despite our limitations.

Of course, it would be a lot better to help all patients get better faster and safer. But really, our job is not the most important part. The body is the king. We need to recognize this as quickly as possible in our careers and understand how much we should hasten an improvement and how much we should just wait from the body, without feeling resentful of ourselves when the body achieve its’ limitations, because, in fact, we (as doctors) don’t have that much power as sometimes we think we have.

The environment is harsh. The team has to be practical. Patients give themselves to care, and the team does what they need to do with what they have. Sometimes it was hard to see that cold reality. But again, I could testify how education and love can save the world! In one week, I could see the work of the residents changing everything, turning everything better, lighter, humanized with meaning. They educate the team; they treat the patients with passion and respect; the team wants to be like them: education is the power.

You have to celebrate each small victory

From time to time you should remember and appreciate people for the little good things they do, even if seems small in a big context. So, they don’t forget the small victories, that is what gave us fuel to keep going.

When I was about to leave, we set and talk about their expectations. I could not be more inspired by their clear awareness. They know the hard work that is ahead. But they have dreams about a more organized emergency health care system. They have a passion (inherent in the emergency physician). They have a good heart, strong determinations, vision, and they are smart.

They truly have the magic!

Patrick

They know there’s still a lot of uncertainty, will the specialty be recognized someday? Will be a place to work? Will the residency grow? Will they have a spot in the most important hospital? They don’t know yet. But they are studying, traveling, receiving people of around the world with humbleness, willing to learn, to improve, to be able to do the most exciting things for their patient and their country. 

I would like to remind that planting an unprecedented program in such an arid place is work for many people. And this team needs recognition, so my special thanks to Dr. Kevin Lunney, who creates PLeDGE Health ONG, that is helping support the residency program.

Special thanks to Sarah Mondlane to her work at PLeDGE Health, and for being the sweetest, kindest hostess in the world. Her love for this cause is pure inspiration.
And thank Dra Otilia Neves, member of the Ministry of Health, and coordinator of the program, who kindness accepted us in Mozambique.

I hope that the work of this team resonates forever in Mozambique.

Cite this article as: Jule Santos, Brasil, "Mozambique Emergency Medicine Is On The Rise," in International Emergency Medicine Education Project, September 16, 2019, https://iem-student.org/2019/09/16/mozambique-experience/, date accessed: March 29, 2020