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: November 17, 2019

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, "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: November 17, 2019

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, "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: November 17, 2019

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, "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: November 17, 2019

A Road not Taken: Patient Transport in the Rural

Patient transport in rural

Robert Frost’s left out road is much like the one, patients at Beltar PHC opt not to take. The reasons differ in some meaningful way. A child referred for evaluation and further management of sepsis after primary management is taken back home. The result is a misfortune, we usually blame to 49.2 kilometers of the road not taken the distance between Beltar PHC and a tertiary care hospital at Dharan. A severely anemic patient who clearly requires evaluations far more advanced than Beltar could offer was referred to a tertiary care. A day later, news of her demise at home ignited a discussion that has been going on since the establishment of the PHC itself. My intentions today are to discuss the possible reasons transport in rural areas is such an over looming problem. Some reasons are generic, while others are more specific to Beltar.

I vividly remember a case I suspected of stroke and decided to refer to a higher center. There are myriad of decisions and hurdles to work around in order to make the referral smooth. I remember being worried about my patients back in internship about not getting the 30 minutes earlier slots for CT scan. That compared to sending my patients to a different city for the scan seems like a funny worry. Even when you convince a patient that a referral is necessary, which is in itself a rigorous and overwhelming process for both the health practitioner and the patient party, there arises many hurdles to the process. Convincing a patient that half of his monthly income is worth the ambulance ride to a city with CT scan facility that will cost him his other half of the salary can never be an easy process. That combined with the possibility that the CT will come out to be normal is paradoxically a nightmare. Hurdles start to emerge from the least expected places. Spinal board to transfer patient to the ambulance, a simple start to make sure the patient does not move when the ambulance speeds on a bumpy road, oxygen cylinder for the travel, all are privileges that patients at Beltar PHC scarcely have.

Condition of Roads in Beltar
Condition of Roads in Beltar
Vehicles submerged during rainy season
Vehicles submerged during rainy season

Rivers surround Beltar; that means during the rainy season, transportation is very limited. So much so that, “We are referring your patient to a higher center” is a euphemism for, “We are sorry, that is all we can do here.” A gravid mother with thick meconium liquor was once referred in coordination with the municipality with the use of an excavator to cross the river. A proper functioning bridge across the river can solve this problem. The story of Beltar is many things; what it is not is a story without solutions. A common theme rather is a logical solution not implemented. Some reasons behind it are painfully obvious; others are yet to be explored.

Ambulance at Beltar PHC
Ambulance at Beltar PHC
Interior of ambulance at Beltar PHC
Interior of ambulance at Beltar PHC

Beltar PHC offers one ambulance at the subsidized fee of Rs. 4500 (US$ 39) for patient transport. It also has a fund of Rs. 50000 (US$ 432) for patients who can’t afford the fee for an ambulance. One ambulance is surely not enough for a PHC looking after 150 patients a day. What we could come up with is contacting the private vehicle owners of the area and using them in place of an ambulance. Although not as equipped, an oxygen cylinder tied to the back seat and the seat folded enough so that the patient can lie down converts any vehicle into a functioning ambulance. They charge more fare for the transport, which is another hurdle patients at Beltar face.

Patient being transported in private vehicles
Patient being transported in private vehicles

Many who visit the PHC view it as an alternative to more expensive and time-consuming tertiary care centers. That belief roots in the lack of knowledge about the hierarchy of medical care provided. This ties into the problem with rural transport because these patients view referral as a horizontal transfer rather than an upgrade of care.

Cite this article as: Carmina Shrestha, "A Road not Taken: Patient Transport in the Rural," in International Emergency Medicine Education Project, September 6, 2019, https://iem-student.org/2019/09/06/a-road-not-taken-patient-transport-in-the-rural/, date accessed: November 17, 2019

The Research of Predicting Septic Shock

How computational medicine is changing critical care in 5 questions

Participating in Research

As a new school year approaches, many medical students are opting to take a gap year dedicated to research. This trend is unique for students not in MD/PhD programs in the USA who have a deep interest in understanding and participating in research. A popular emerging field for the future of health care and medicine, known as computational medicine, is become an integral part of patient care. Regardless of location, students, as well as interns and health care professionals around the globe who are interested in emergency and critical care medicine, should consider this unique area of study as a part of their research gap year.

In this blog entry for the International Emergency Medicine Education Project (iEM), I discuss the role of computational medicine in detecting sepsis, one of the most important diagnoses to detect early, with Professor Rai Winslow, Director of the Institute for Computational Medicine at The Johns Hopkins University. As outlined on the Institute’s website, computational medicine “aims to improve health care by developing computational models of disease, personalizing these models using data from patients, and applying these models to improve the diagnosis and treatment of disease.” Patient models are being used to predict and discover novel sensitive and specific risk biomarkers, predict disease progression, design optimal treatments, and discover novel drug targets. Applications include cardiovascular and neurological diseases, cancer, and critical care and emergency medicine (1).

Rai L Winslow, Director Institute for Computational Medicine, The Raj & Neera Singh Professor of Biomedical Engineering, The Johns Hopkins University

How is computational medicine changing critical care?

5 Questions

5 Answers

Why Sepsis

What was the starting point for your work on sepsis and septic shock in adults?

A starting point for my work on sepsis and septic shock was reading a paper that demonstrated how every hour of delayed treatment in patients with septic shock could lead to an eight percent increase in mortality, per hour. That statement really stood out because what it told me was the natural time course of evolution of the disease, and whatever was happening in septic shock, was happening very quickly. Because of this rapid disease progression, this suggested that accurate prediction of those patients with sepsis who would progress to septic shock must be based on data collected from the patient on a time scale of minutes rather than hours. The challenge was that this high-rate data is not routinely collected in hospitals.

Data and algorithms

What live data are the algorithms capturing from patients for studying and understanding sepsis and septic shock?

Today’s electronic health record (EHR) is typically used to store data such as vitals and lab results and clinical observations made at irregular intervals and at low rates. Given the rapid evolution of septic shock, we hypothesized that advanced prediction and early detection of septic shock must be based on data collected at the minute rather than hour time scales. This was the driving interest in developing a novel software platform called PhysioCloud. PhysioCloud captures physiological vital signs data at minute intervals from patient monitors. These data are then stored in a specialized database that is designed to capture large numbers of real-time data streams at high-rate. Data collection also includes waveforms, such as ECG, respiratory rates, and SpO2, sampled at 125 times per second. Nowhere else in the USA that I am aware of, is capturing these physiological data from patients, making them a part of the patient electronic health record. Our algorithm uses these high rate data, as well as low-rate data from the patient EHR, to predict those patients with sepsis who will develop septic shock.

The importance of the transition state to septic shock

Computational medicine and algorithms can be uncomfortable terms for medical students, interns and researchers who do not have experience with it. Simply put, how do research and studies such as this help doctors in emergency medicine and critical care units, in managing their patients?

Everyday critical care and emergency medicine physicians ask two questions of every patient they see: what is the state of my patient?; how will their state change over time? The latter is a prediction problem of the sort that data scientists often confront. In the context of sepsis, the physician would like to know if their patient will at some future time develop septic shock, or will their condition improve. If an algorithm can reliably predict those patients with sepsis who will develop septic shock at some future time point, then physicians will have a window of time in which they can intervene to prevent this transition from happening. Our goal was to develop such an algorithm. To do this, we utilized the obvious fact that if a patient has sepsis and their condition is getting worse and possibly evolving towards septic shock, it means their physiology must be changing over time as they get sicker. We, therefore, decided to develop a “risk score,” a number ranging between 0 and 1 that is the probability that a patient will develop septic shock. This risk score was computed in an optimal way from the minute by minute physiological vital signs data complemented by clinical data from the EHR. If this risk score exceeds a threshold value, then we decide that this patient with sepsis will develop septic shock at some future time point. This approach works very reliably, achieving high sensitivity and specificity. It’s the worlds simplest machine learning method. Predicting the transition from sepsis to septic shock can enable physicians the ability to follow their patients and see how various states are evolving over time, so that they can intervene to deliver earlier care. Right now, this approach is being applied in retrospective studies using patient data. In the future, we plan to compute this risk score in real-time, generating alerts for caregivers when the risk score exceeds threshold signaling that patients are likely to go into septic shock.

Pre-Shock

In a recent publication in Scientific Report (2), the new concept of a pre-shock state was outlined. How was this possible to do?

Our work hypothesized that it was possible to identify the presence of a physiological signature in sepsis patients before the clinical onset of septic shock was diagnosed. We were able to identify a signature to calculate a risk score for the pre-shock state. The changes in variables such as lactate and heart rate are so small; they are still statistically significant, but so small. When discussed with physicians, some say that they would not have noticed it. These variables are changing together in a small way, but the algorithm is able to catch the changes together and compute it into a risk score and make useful predictions. Some of our very new work not published yet shows that post-threshold, changes in patient risk score happen very quickly (30-60 minutes) and are very large. We have shown that the larger the post-threshold risk score, the more reliable is our prediction that the patient will go into shock. Positive predictive value can be as high as 80-90%.

Fluids and Vasopressors

Evidence-based studies and protocols such as the SOFA score (3), Surviving Sepsis Campaigns (4) are listed on the American College of Emergency Physician (ACEP) website (5) as well as the SALT-ED (6) and SMART (7) trials. These are referred to by emergency physicians in the emergency department, and EM residents are trained with these resources. How do these studies tie into computational medicine, machine learning and predictive analysis for developing septic shock?

Our algorithm looked at tens of thousands of patients, and computationally phenotyped them through every minute of data using the international consensus definition of septic shock, and based on early warning times, found clinical ground truth. We also discovered that the Sepsis 2 definition had a property that was temporarily unstable. This is to say that the state of a patient with sepsis as defined by Sepsis 2, was changing all the time, and it was not possible to predict ground truth. With found the Sepsis 3 definitions to be temporarily stable with few state transitions. The major factor was that the criteria in Sepsis 2 had included a diagnosis of SIRS before sepsis was considered as a diagnosis, and it was removed from 3. We believe that SIRS was causing frequent state changes, as an ambiguous diagnosis.

We are able to predict those patients with sepsis who will transition to shock many hours before they go into shock. We are also able to identify distinct temporal patterns of the risk score corresponding to patient populations with high (up to 60%) versus low (10-20%) mortality. For each of these groups, we looked at comorbidities, diagnoses such as kidney failure and cancer, but we do not know what the relationship is or what is different about these patient groups and the fact that they are in the 60% mortality pool. We know their physiology is saying they are in the mortality pool, but not why. What this means is how these patients are being treated could be the issue (physicians with different levels of training, and other factors involved in treatment decisions). In our work, patients were classified into high and low risk. We found that patients in the low risk received vasopressors and adequate fluid resuscitation and for patients in the high-risk pool, fewer had received vasopressors or fluids. The question is, why are these patients not getting these things. Our algorithm to predict the transition to septic shock can positively influence treatment decisions made by many physicians, to confirm the value of treatment and prevent the development of septic shock. We’ve also identified and know the time to look for proteomic and genomic biomarkers for the early predictive shock signature that could correlate with this high risk/these measures are not routinely done clinically, and this line of work could be very helpful in understanding the fundamental biology of the very rapid change in patient state when they cross the risk score threshold.

Thank you to Professor Winslow for taking the time to discuss the research involved in computational medicine and investigating the transition from sepsis to septic shock. In closing, regardless of medical specialty interests, medical students around the globe interested in taking a gap year to gain research skills will find the experience invaluable and will be introduced to new ways of thinking, writing, and understanding the scientific influences on patient management and health care. Research such as this in the USA can also be implemented at international hospitals and remote clinics, to further aid patient care and management. There are many areas of interest in which research is taking place in critical care units and emergency departments, and discovering the technology involved such as machine learning and computational medicine, is a step towards understanding the potential advances in the future of medicine and patient care.

Please feel free to share your own particular research area(s) of interest and pose any questions you may have in the comments section below.

References and Further Reading

  1. The Institute for Computational Medicine (ICM) –  https://icm.jhu.edu/
  2. Liu R, Greenstein JL, Granite SJ, Fackler JC, Bembea MM, Sarma SV, Winslow RL. Data-driven discovery of a novel sepsis pre-shock state predicts impending septic shock in the ICU. Scientific reports. 2019 Apr 16;9(1):6145. – https://www.nature.com/articles/s41598-019-42637-5.pdf
  3. Faust J. No SIRS; quick SOFA instead. Annals of Emergency Medicine. 2016 May 1;67(5). – https://www.annemergmed.com/article/S0196-0644(16)00216-X/pdf
  4. Surviving Sepsis Campaign (SSC) – http://www.survivingsepsis.org/Pages/default.aspx
  5. ACEP Statement on SSC Hour-1 Bundle – https://www.acep.org/by-medical-focus/sepsis/
  6. Self WH, Semler MW, Wanderer JP, Wang L, Byrne DW, Collins SP, Slovis CM, Lindsell CJ, Ehrenfeld JM, Siew ED, Shaw AD. Balanced crystalloids versus saline in noncritically ill adults. New England Journal of Medicine. 2018 Mar 1;378(9):819-28. – https://www.nejm.org/doi/full/10.1056/NEJMoa1711586
  7. Semler MW, Self WH, Wanderer JP, Ehrenfeld JM, Wang L, Byrne DW, Stollings JL, Kumar AB, Hughes CG, Hernandez A, Guillamondegui OD. Balanced crystalloids versus saline in critically ill adults. New England Journal of Medicine. 2018 Mar 1;378(9):829-39. –  https://www.nejm.org/doi/full/10.1056/NEJMoa1711584
Cite this article as: Bryn Dhir, "The Research of Predicting Septic Shock," in International Emergency Medicine Education Project, August 12, 2019, https://iem-student.org/2019/08/12/the-research-of-predicting-septic-shock-how-computational-medicine-is-changing-critical-care-in-5-questions/, date accessed: November 17, 2019

A Medical Student’s Encounter with Disaster

a medical student's encounter with disaster

25th April 2015

A 7.8 magnitude earthquake struck Nepal on 25th April 2015, affecting 35 of the 77 districts of Nepal and causing a death toll of over 8000 lives with 22,309 people reported as injured and an estimated 2.8 million displaced. The following article is based on the first-hand experience of a then fourth-year medical student from Patan Academy of Health Sciences, a tertiary care center in Lalitpur District, one of the worst-hit districts in Nepal.

Rescue work following 7.8 Richter scale earthquake. Image by Omar Havana via https://www.theatlantic.com/photo/2015/04/nepal-after-the-earthquake/391481/
Rescue work following 7.8 Richter scale earthquake. Image by Omar Havana via https://www.theatlantic.com/photo/2015/04/nepal-after-the-earthquake/391481/

Reflection

25th April 2015, started off as a casual Saturday morning. At the boy’s hostel, everyone was preparing for the inter-medical college football tournament which was to start off that day, until the first jolt changed plans for the whole day and many more days to come. Our first response was to rush out of the hostel and make sure our family members and friends were okay. Just as all of us were frantically, unsuccessfully so, trying to contact our families, a friend of mine came running and informed that all medical students were to go to the hospital with their aprons. We had not even considered going to the hospital until my friend arrived; maybe because none of us had faced such a situation before or because we were yet to come back to our right state of mind.

Students ready to receive disaster victims. Image by Online Khabar via http://www.pahs.edu.np/patan-hospital-earthquake-disaster-relief-fund/photo-gallery/
Students ready to receive disaster victims. Image by Online Khabar via http://www.pahs.edu.np/patan-hospital-earthquake-disaster-relief-fund/photo-gallery/

As we reached the hospital, it was already flooded with injured patients from the disaster. Everyone started doing what they could. Some started giving analgesics to people who were agonized by the pain, some started talking and trying to calm down people who were on the verge of hyperventilation, some took gauge pieces and pressed it against the bleed on people’s head and some helped in patient transportation. There were a lot of people doing a lot of things, but neither was I in very observant state of mine nor could I recall enough now to mention the minute details. One thing I remember with absolute clarity is that me and my friends (as I found out in the after talks) forgot that we were trying to contact our families when we were called.

Students providing wound care. Image via http://www.pahs.edu.np/patan-hospital-earthquake-disaster-relief-fund/photo-gallery/
Students providing wound care. Image via http://www.pahs.edu.np/patan-hospital-earthquake-disaster-relief-fund/photo-gallery/
Medical students providing Tetanus Toxoid injection to victims. Image via http://www.pahs.edu.np/patan-hospital-earthquake-disaster-relief-fund/photo-gallery/
Medical students providing Tetanus Toxoid injection to victims. Image via http://www.pahs.edu.np/patan-hospital-earthquake-disaster-relief-fund/photo-gallery/

A lady was lying on the floor, covered with mud, she wasn’t moving at all. My friend and I suspected she was seriously injured but didn’t see any obvious wound from where we were standing. We went near and tried to feel the carotid pulse. Never in my life had I even remotely imagined that one day I will confuse whether or not the carotid pulse is present. But there I was. I didn’t feel the pulse, but I was reluctant to admit that she didn’t have one; so we decided to ask one of our teachers. We did and got the obvious answer. Now we were to put the black tag on her and take her to the black area. She was the first to be taken to the black triage. Before putting her down from the stretcher, we took the pulse again. It was one of my first encounters with death declaration.

I came out of the front door and was among a lot of injured patients; nerve wrecked students and doctors trying to help people in the best possible way. It was then that most of us remembered that we hadn’t contacted out families yet; maybe sadness had taken over our survival instinct or maybe we were learning to keep our professional duties up ahead. This continued for the day and the next day was nearly the same; only a little more organized. Basically, the name of the game for the couple of days that followed was help in all that you are capable of.

Apart from being the most traumatizing experience of our life until now, this earthquake also taught us some lessons and profoundly so. I knew that survival instinct takes over everything at first when you perceive a threat to our life; however, once you are just out of the instinct and see before you, the circumstance that you are trained to deal with, you prioritize things and work in the line of your training.

Survival instinct takes over everything at first when you perceive a threat to our life...

Students raising awareness to prevent possible outbreaks. Image via http://www.pahs.edu.np/patan-hospital-earthquake-disaster-relief-fund/photo-gallery/
Students raising awareness to prevent possible outbreaks. Image via http://www.pahs.edu.np/patan-hospital-earthquake-disaster-relief-fund/photo-gallery/

a need for disaster curriculum to be rigorously taught to every medical student.

One thing that I realized while trying to help the casualties that will help me every time I sit to study is: no matter how much you memorize stuff until you really understand something well, you won’t be able to use the knowledge when it is most needed. The disaster drill that we performed a few months before the disaster helped us make sense of triage, proper transportation and of what was happening. I realized the importance of training and keeping myself updated on skills that we need at times when we are less likely to think rationally. Also, I felt a need for disaster curriculum to be rigorously taught to every medical student. Medical students formed an important workforce during this disaster. Having occurred on the weekend, medical students were the most readily and adequately available resource. However, with limited knowledge and skill, medical students left to work unsupervised are prone to cause harm to themselves and patients; hence proper training and work delegation are required so that they can become a better-skilled workforce.

This was yet another example for me to ponder and reinforce upon myself that not everything will go on as planned; hence, I need to keep myself updated and work on my improvising skills. This event as devastating as it was also made me feel proud of what I am training to become and instilled in me more passion towards my profession.

Further Reading

  • World Health Organization, Regional Office for South-East Asia. Nepal earthquake 2015: an insight into risks: a vision for resilience. New Delhi, India: World Health Organization, SEARO; 2016. Available from: https://apps.who.int/iris/handle/10665/255623
  • Sheppard PS, Landry MD. Lessons from the 2015 earthquake (s) in Nepal: implication for rehabilitation. Disability and Rehabilitation. 2016 Apr 23;38(9):910-3.
  • Nepal earthquake of 2015 – link
Cite this article as: Sajan Acharya, "A Medical Student’s Encounter with Disaster," in International Emergency Medicine Education Project, August 5, 2019, https://iem-student.org/2019/08/05/a-medical-students-encounter-with-disaster/, date accessed: November 17, 2019

Why Emergency Medicine?

Emergency Medicine in Brazil is still a small baby. In some states, it’s crawling, like here in Brasília. But even so, it already made my eyes shine. In Brasilia, we are moving to graduate the first group of emergency physicians. Several people were struggling for this to happen. And today, I’m going to talk a little about them, and why I decided to do emergency medicine, even though I’m still in the fourth year.

It is quite common for many medical students to have doubts about which residency to choose as if this decision were unique and definitive, and that weighs heavily. During the fellowship of an Airway course, I overheard one student from the last year say, “I have not yet found the specialty that makes my eyes shine.” And that made me think about how lucky I am because I’ve already found it. My intention here is not to make you choose Emergency Medicine as your only option, but to show you that the most serious patient needs the best doctor and the best treatment. It is to show you that the emergency department has to be ready for all the patients who can open through emergency doors, from the child to the elderly. And if you’re like me, who did not settle for a specialty that focused on only one part of the human body, you’re going to fall in love with the Emergency Medicine as well.

why emergency medicine 2
[BLS class offered by EMIG for medical freshmen] A great opportunity to improve knowledge, train and even teach!

I arrived at the emergency department of a hospital in the capital as a confused student, who still had no idea of my rotation. And whoever accepted me was the most fantastic doctor I could meet, no less than the boss of the state’s Emergency Medicine residency program. Well, I did not know that great detail of the time. But watching her play that “red room” was like watching an orchestra. Each bed is an instrument, which she commanded with mastery. I had never seen anything like it. She knew what she was doing. She was young and a strong woman. That by the standards of Brazil, borders the absurd, but there she was. In a public hospital, she was treating each patient as royalty. She maintained a firm posture, taught the students, and knew how to lead the team. It was beautiful to see. I knew that’s where I wanted to be; I knew I wanted to be at least 20% of the doctor she was. Despite the initial fear I had of her, little by little, she became my mentor. It was a big milestone in my life. She showed me what Emergency Medicine is and what is still going to be here in Brazil. And so, I was diving more and more into Emergency Medicine.

jule santos 2
Dra. Jule Santos
why emergency medicine 4
Rebeca is President of EMIG in Brasilia (LEM.DF : Emergency Medical League of the Federal District). They are medical students of different years who meet every two weeks for classes and practices focused on Emergency Medicine, with the help of doctors, teachers and proctors of different areas.

She taught me that the emergency department is not the messy garage entrance of a hospital. At least it should not. Here in Brazil, we face the overcrowding of emergency department and lack of resources. So an emergency physician here needs to be more than good, needs to be creative and resilient. However, generally in the country, the doctor who takes care of these patients is the most inexperienced. It’s usually the one who just got out of college and needs to work to earn money. And this needs to be changed. Some doctors saw this inconvenient situation and fought for it to be changed. But every change hurts, and it takes a lot of strength. Gradually, the movement grew. After several battles, Emergency Medicine managed to have an association of its own that finally took on the role of creating it. That’s why students with interest in the area are so valued, after all, it’s us who will keep this legacy.

jule santos 3
[Airway Management Course] Offered by "Emergencia Rules," blog by Jule Santos. Contact with residents and the participation of various events will open up several opportunities for you, such as assisting in the organization of for an important course for Emergency Medicine.

I also learned from her the importance of being humble and training whenever possible. After all, the best professionals in each area spend more hours training than acting. Perfecting your technique, strengthening your mindset, is a must in medicine. Train, study, and be humble to recognize that you don’t know everything. Being an emergency physician is having to deal with every situation. You don’t have to deliver a diagnosis now, but the patient has to be stabilized until someone else can take over. And to reach this level of saying to death “not today,” you need to study and train!

why emergency medicine 3
[Rebeca B. Rios and Jule Santos] On the poster it says: I am the person you will want on call the day you have a heart attack. A phrase from Jule's book: Born to be Wild

If you are a Brazilian medical student and interested in the area, here are some tips. Be part of an EMIG (Emergency Medicine Interest Group). Thus, you will have contact with residents and preceptors of the area. Engage in the different opportunities within the Emergency Medicine field that arise, such as events and courses. Look for the associations in Brazil, and also outside the country. Accompany shifts with an emergency physician, so you can feel a little of the specialty and understand what your day to day life will be like. After graduating from college, you must take the test for the Emergency Medicine Residency. The residency lasts three years and already exists in several Brazilian states. After three years of residency, you must take the specialty exam (title test), to become an Emergency Medicine specialist. And if you can find your Emergency Medicine mentor in college, know that your path will become clearer, know that you will enter a world where you can hardly get out, because that’s the Emergency Medicine. A world far beyond only the doors of the emergency department.

Dedicated to Jule Santos.

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Cite this article as: Rebeca Rios, "Why Emergency Medicine?," in International Emergency Medicine Education Project, July 22, 2019, https://iem-student.org/2019/07/22/why-emergency-medicine/, date accessed: November 17, 2019

Adventures on the Annapurna Circuit

For this blog entry, I want to share two issues I encountered while traveling in Nepal, just shy of my graduation from medical school: acute mountain sickness (AMS) and responding to a wilderness medicine incident as a medical trainee.

There is nothing more glorious

There is nothing more glorious than the period just after finishing medical school and before residency! For me, the highlight was being able to hike in Nepal. With the long travel time from Canada, and the multi-day itineraries most hikes necessitate, the post-grad period seemed like the ideal opportunity to make my dream of visiting the Himalayas come true.

Courtesy of Helene Morakis
Courtesy of Helene Morakis

I wrote my medical licensing exam, hopped on a flight and got ready to soak up the change of pace. While traveling, I found time to relax, (tried my best to) practice mindfulness and experienced the incredible kindness of Nepali people. Traveling was the perfect recharge that now has me geared up and excited for residency.

Annapurna Circuit

A few weeks before leaving for my travels, I began researching the Annapurna Circuit (APC). Having grown up at a staggering 240m above sea level in the Canadian prairies, I felt threatened by the Thorong La pass, which at 5416m is the highest part of the trek. My highest previous experience at altitude was 4200 meters, where I (unfortunately) developed Acute Mountain Sickness (AMS). My history of having AMS and following a typical itinerary for the APC put me at moderate risk for AMS(1). I decided to heed the Wilderness Medicine Society’s recommendation to take acetazolamide 125mg every 12 hours as prophylaxis(1).

Table reproduced from Luks, A. M. et. al 2019

While on the trek, I overheard many myths about AMS and sensed a general reluctance to take acetazolamide as prophylaxis(2). Himalayan Rescue Association does free daily teaching about AMS on the APC in Manang and on the Everest Base Camp trek as well(3). As we moved to higher altitudes, many guest houses and Annapurna Conservation Area Project outposts had accurate information about AMS and its consequences (High Altitude Pulmonary Edema and High Altitude Cerebral Edema). Surprisingly, despite this teaching and the availability of acetazolamide on the trail for purchase, there are still hikers that routinely require evacuation due to AMS, some by helicopter.

On the day before crossing the Thorong La Pass, I stopped for lunch with some trekking mates at Thorong Phedi (4538m). A few minutes passed before someone came into the guesthouse, visibly worried, requesting help from a doctor. It took me a few seconds (and my friends practically lifting me off my seat) to register that I could help! I was thankful to be hiking with an experienced nurse and we went to see the hiker together.

We were asked to see a fit hiker in his 60’s whose foot had been the victim of a rockslide. I clarified my training as a fourth-year medical student before asking details about the mechanism of injury and his past medical history. The hiker and his family were concerned and asked me to “rule out” a fracture. With positive Ottawa Ankle Rules findings, I wished for an X-Ray machine to rule out a clinically significant fracture(4). Keeping in mind there was no road access – the nearest road before the camp was in Manang (3500m, 15km away) or in Muktinath (3800m, 16km away) after the pass – the only ways out were by donkey or helicopter.

From a wilderness medicine standpoint, the injury was by all measures considered stable and the patient did not require an evacuation [reproduced from Isaac & Johnson 2013](5):

  • No deformity or instability on exam

  • No sense of instability reported by patient

  • Able to move and weight bear after accident

  • Distal circulation, sensation, movement (CSM) intact

  • Slow onset of swelling

  • Pain proportional to apparent injury

After a discussion with the patient, we decided that treating the injury as “stable” was reasonable and accepted the risk of delaying healing of a potential fracture. I recommended 24 hours of rest, ice (which kept the patient’s family busy fetching snow!), and elevation. I gave them ibuprofen to be administered on a regular schedule and instructed them to monitor CSM and plan an evacuation if there were any signs of impairment. I told the patient to continue the hike the following day if the pain did not increase with activity and to obtain medical follow up once they had returned to the city.

In hindsight, I recognized that I should have documented the encounter. I had written down the dosing of ibuprofen for the family, but I did not write a detailed SOAP (subjective, objective, assessment and plan) note. Properly documenting wilderness medicine encounters was a skill I learned in Advanced Wilderness Life Support. When we met the patient, he was generally well other than his foot injury. What if the patient’s condition worsened? What if the family forgot the plan in the stress of the situation?

I also found myself wondering about this patient long after I had left them. Reflecting upon this, I recognized that it is easier to “discharge” someone from an urban Canadian ED, where I have had most of my clinical experience because I know they can access good care if things change. The huge potential on the trail for loss to follow up made documentation much more vital in this case.

Later on, I pondered about the potential legal ramifications of helping this hiker. In Ontario, Good Samaritan laws protect health care professionals who provide first aid(6). From my understanding, there are no similar laws in Nepal, and there have been calls to define the rights and duties of those who witness or are requested to aid with an injury in the country(7).

In Nepal, I had a much-needed change of pace from medical school and plenty of time for reflection. I was inspired to see many organizations work together to educate guides, locals and hikers about AMS and hope to spend some time volunteering at the Himalayan Rescue Association in the future. Even after wilderness medicine training, being asked to provide first aid on the trail as a soon to be medical graduate caught me by surprise. I was happy to help and be able to have an approach to the patient in a low resource setting – and now recognize the importance of documentation.

I would like to hear your comments on this article: any experiences dealing with AMS, tips and tricks for musculoskeletal injuries in the wilderness setting, advice for navigating giving medical treatment outside of a hospital as a trainee or anything you would have done differently.

Courtesy of Helene Morakis

References

  1. Luks, A. M., Auerbach, P. S., Freer, L., Grissom, C. K., Keyes, L. E., McIntosh, S. E., … Hackett, P. H. (2019). Wilderness Medical Society Practice Guidelines for the Prevention and Treatment of Acute Altitude Illness: 2019 Update. Wilderness & Environmental Medicine. https://doi.org/10.1016/j.wem.2019.04.006
  2. Kilner, T., & Mukerji, S. (2010). Acute mountain sickness prophylaxis: Knowledge, attitudes, & behaviours in the Everest region of Nepal. Travel Medicine and Infectious Disease, 8(6), 395–400. https://doi.org/https://doi.org/10.1016/j.tmaid.2010.09.004
  3. Himalayan Rescue Association. (2019). [online] Available at https://himalayanrescue.org.np/ [Accessed 30 Jun. 2019].
  4. Stiell IG, Greenberg GH, McKnight RD, Nair RC, McDowell I, Worthington JR. A study to develop clinical decision rules for the use of radiography in acute ankle injuries. Ann Emerg Med. 1992; 21:384–90.
  5. Isaac, J. E., & Johnson, D. E. (2013). Chapter 13: Musculoskeletal Injury. In Wilderness and Rescue Medicine (pp. 84–85). Burlington, MA: Jones & Bartlett Learning.
  6. Good Samaritan Act, Government of Ontario (2001). Retrieved from the Ontario e-Laws website: https://www.ontario.ca/laws/statute/01g02
  7. Pandey, S. (2014). Good Samaritans. [online] The Kathmandu Post. Available at: https://kathmandupost.ekantipur.com/news/2014-07-13/good-samaritans.html [Accessed 30 Jun. 2019].

Further Reading

Cite this article as: Helene Morakis, "Adventures on the Annapurna Circuit," in International Emergency Medicine Education Project, July 12, 2019, https://iem-student.org/2019/07/12/adventures-on-the-annapurna-circuit/, date accessed: November 17, 2019

A becoming specialty – EM in Tanzania

We all pass through milestones of growth and every stage is a hurdle to the next, how we choose to view it is our own choosing. Imagine seeing it from a child’s perspective; a five-month-old wobbly reaching for a shiny new toy that seems just a grasp away, falls flat on his face cries then realises; ooh wait there is that shiny new toy again. Picks up from where he left off and with every advance sitting transforms to crawling.

Joshua Yonazi 2014
Currently doing her Paediatric Cardiology Fellowship

As a medical student, I had no exposure to Emergency Medicine as a specialty. We had an OPD that was functional 24 hours. Paediatrics was what I set my mind to do, and Dr. Stella Mongella, who remains a role model to date influenced a lot of what I am today in my timeliness and responsibilities. It was a see admire and try to become not her but myself in the best way I could. 

After completing my medical school, which is a five-year program, the next step was to go for my one-year internship training. I moved from a mostly public health facility to a private health facility. It was until 2014 when I was employed as a Resident Medical Officer at the Accidents and Emergency Department of the Aga Khan Hospital Dar es Salaam when I met Dr. Yash Dubal, an Emergency Physician who had just joined the hospital that same year. He had graduated from Muhimbili University of Health and Allied Sciences (MUHAS) and working with him is what made me realise what a becoming speciality Emergency Medicine is and in less than a year I decided to join the same residency program he had graduated from.

This three-year residency program is a core competency-based training in research, trauma, paediatric care, leadership skills, bedside ultrasound, recognition and treatment of toxicological, obstetric and medical emergencies. Offers elective exchange opportunities for residents to go abroad for observership as well as those from abroad coming to Tanzania. Muhimbili National Hospital first and the only hospital to date to have an Emergency Medicine Residency Program in Tanzania and first to have initiated an Undergraduate Emergency Medicine Rotation in 2014. Since the presence of this fully capacitated Emergency Medicine department, there has been great change in the delivery of services and outcome within the hospital and its graduates are part of regionalisation of emergency care in Tanzania.

To date there are nine health facilities with fully functional 24 hours emergency departments with Emergency Physicians available at; Muhimbili National Hospital, Bugando Medical Center, Kilimanjaro Christian Medical Center, Arusha Lutheran Medical Center, Mount Meru Hospital, Mbeya Zonal Referral Hospital, Bombo Hospital, Benjamin Mkapa Hospital and The Aga Khan Hospital. Development of EMS is in progress with basic ambulance providers, attendants and dispatch training complete.

Muhimbili National Hospital
Mbeya Zonal Referral Hospital
Benjamin Mkapa Hospital
Kilimanjaro Christian Medical Center
Emergency Medical Services
The Aga Khan Hospital Dar es salaam

Emergency Medicine is a Becoming Specialty with core values to safely deliver those critically ill and injured from the community to the acute care units for resuscitation, stabilization and transfer to specific units for definitive care.

Cite this article as: Kilalo Mjema, "A becoming specialty – EM in Tanzania," in International Emergency Medicine Education Project, June 24, 2019, https://iem-student.org/2019/06/24/a-becoming-specialty-em-in-tanzania/, date accessed: November 17, 2019

Laceration Repair: A Rural Encounter

The word “emergency” carries some connotation with it. A lack of time to act, a situation that demands speed, a sense of acuity. Medicine on the other hand is related to healing, soothing and improving, a slow and gentle process. I sometimes wonder if the name of the specialty (Emergency Medicine) is an oxymoron.

Etymology aside, this specialty of medicine has meant at least two different things to me at two different settings. I have worked as an intern at Patan Hospital, a tertiary care center and as an in-charge of emergency services of Beltar Primary Healthcare Center (PHC), a government establishment in rural Nepal. I intend to describe my perspective and illustrate what different experiences of emergency medicine in different settings has to offer. I hope in doing so, I’ll be able to illustrate some of my workarounds that make the difference less overwhelming.

I have been posted at Beltar PHC, Nepal for the past 18 months. The center has been running primary emergency services. Initial stabilization and proper referral are two major ways Beltar PHC helps to save lives. The nearest city where cases are referred to are Dharan (50.5 km away) and Biratnagar (92 km away). Emergency personnel includes one doctor on call, one paramedic, two sisters for delivery and one office assistant. Laboratory and X-ray services are not available apart from office hours. Emergency investigations available include ECG, UPT and Obstetric USG. The government freely supplies medical equipment and a limited number of medicines.

Entrance to Emergency Services at Beltar PHC
Emergency Setup at Beltar Primary Healthcare Center

A 27-year-old male

A 27-year-old male with a cut injury on his right forearm was brought to the PHC. It was a quiet day at the Emergency Department (ED) and most of the cases were OPD cases that did not make it on time.

One-way ED helps people here, albeit not an ideal way, is to act as a rescue for patients who travel long distances to get to the OPD if they do not make it on time.

The patient had a clean wound, about 5 cm long with smooth edges. We washed the wound using tap water; a practice equally efficacious to using saline but way more affordable for a rural setup. To suture the wound, we made our equipment ready. A long suture thread was cut from a nylon thread roll sterilized in betadine, some gauze pieces prepared by our office assistant that had been autoclaved and stored in an old dressing drum were taken out.

Suture materials at Beltar PHC
Dressing Drums at Beltar PHC

The thread was inserted into a needle, probably too big (turns out what needle size to use and when was a dilemma of privilege). Sometimes, we use needles that come with 2 ml syringes instead; they are sharper for skin penetration than the big suture needles our government freely supplies. The wound was sutured and the patient discharged.

That night I reflected on how things would have been subtly but significantly different at Patan Hospital. A sterilized suture set, autoclaved, packed and ready to use along with a ready to use surgical suture would be available. The procedure would have taken place in a more private space and not where visitors had the opportunity to peak in through our foldable privacy screen. Maybe the patient would have had to wait longer to get attention but the difference would not have been much, considering the time it takes to prepare every instrument here.

Each minor aspect of this difference deserves to be heard, talked about and their solution sought for. I plan to write about each of these as a series of article that follows. Proper resource allocation is a time and economy intensive goal; nevertheless the ultimate one. Maybe small workarounds are what we need during the period of transition, especially for places like Beltar.

Laceration repair is a common procedure in every emergency department. Setting differs and with it the availability of resources. Nevertheless, the core principles that govern patient care and the science behind it remains the same. While we wait for more convenient and sophisticated solutions, which all patients deserve, here are some points to remember regarding laceration repair that can help provide an acceptable standard of care even in resource-limited settings.

  • While working in rural, one should be well aware of its limitations. Some lacerations that require surgical consultation and need to be referred include (1):
    • Deep wounds of the hand or foot
    • Full-thickness lacerations of the eyelid, lip, or ear
    • Lacerations involving nerves, arteries, bones, or joints
    • Penetrating wounds of unknown depth
    • Severe crush injuries
    • Severely contaminated wounds requiring drainage
  • Non-contaminated wounds can be successfully closed up to 18 hours post-injury while clean head wounds can be repaired up to 24 hours after injury (2).

  • Drinkable tap water can be used for wound irrigation instead of sterile saline. At least 50 to 100 ml of irrigation solution per 1 cm of wound length is needed at a pressure of 5 to 8 psi for optimal dilution of wound’s bacterial load. The wound can be put under running water or can be irrigated using a 19-gauge needle with a 35 ml syringe (3).

  • Local hair should be clipped, not shaved, to prevent wound contamination(4).

  • Strict sterile techniques are unnecessary to be followed during laceration repairs. The instruments touching wound (sutures, needles, etc.) should be sterile, but everything else only needs to be clean(1). Clean non-sterile examination gloves can be used instead of sterile gloves during wound repair(5).
  • Local anesthesia with lidocaine 1% or bupivacaine 0.25% is appropriate for small wounds while large wounds occurring on limbs may require a regional block (1). Epinephrine should not be used in anatomic areas with end arterioles, such as fingers, toes, nose, penis, and earlobes.
  • Maximum doses of local anesthetic are as follow (6):
    • Lidocaine (without epinephrine): 3 – 5 mg/kg
    • Lidocaine (with epinephrine): 7 mg/kg
    • Bupivacaine (without epinephrine): 1 – 2 mg/kg
    • Bupivacaine (with epinephrine): 3 mg/kg
  • The suture used for skin repair include non-absorbable sutures (nylon and polypropylene) while absorbable sutures (polyglactin, polyglycolic) is used to close deep lacerations. For skin closure, silk sutures are no longer used because of skin abscess formation, their poor tensile strength and high tissue reactivity. In general, a 3–0 or 4–0 suture is appropriate on the trunk, 4–0 or 5–0 on the extremities and scalp, and 5–0 or 6–0 on the face (6).
    • Sterilization of sutures can be done by complete immersion in povidone-iodine 10% solution for 10 minutes followed by rinsing in sterile saline/water. Sutures that can be sterilized or re-sterilized include monofilament sutures (Prolene or Nylon) and coated sutures (Vicryl, Ethibond) (7).

Timing of Suture Removal (6)

Wound Location Time of Removal (Days)
Face
3 - 5
Scalp
7 - 10
Arms
7 - 10
Trunk
10 - 14
Legs
10 - 14
Hands or Feet
10 - 14
Palms or Soles
14 - 21

Tetanus Prophylaxis (8)

Wound Previous Vaccine Tetanus Vaccine
Clean Wound
Previous vaccine ≥3 doses - The last dose within 10 years
No Need
Previous vaccine ≥3 doses - The last dose more than 10 years
Yes
Previous vaccine ≥3 doses - NOT RECEIVED
Yes
Contaminated Wound
Previous vaccine ≥3 doses - The last dose within 5 years
No
Previous vaccine ≥3 doses - The last dose more than 5 years
Yes
Previous vaccine ≥3 doses - NOT RECEIVED
Yes + TIG

Factors that may increase chances of wound infection (9)

  • wound contamination,
  • laceration > 5 cm,
  • laceration located on the lower extremities,
  • diabetes mellitus

Antibiotics

  • Prophylactic systemic antibiotics are not necessary for healthy patients with clean, non-infected, non-bite wounds(10). 
  • Prophylactic antibiotic use is recommended for (11): 
    • human bite wounds 
    • deep puncture wounds
    • wounds involving the palms and fingers
  • Topical antibiotic ointments decrease the infection rate in minor contaminated wounds. 

References and Further Reading

  1. Forsch RT. Essentials of Skin Laceration Repair. Am Fam Physician. 2008 Oct 15;78(8):945-95
  2. Berk WA, Osbourne DD, Taylor DD. Evaluation of the ‘golden period’ for wound repair: 204 cases from a third world emergency department. Ann Emerg Med. 1988;17(5):496–500.
  3. Wheeler CB, Rodeheaver GT, Thacker JG, Edgerton MT, Edilich RF. Side-effects of high pressure irrigation. Surg Gynecol Obstet. 1976;143(5):775–778./ Moscati RM, Reardon RF, Lerner EB, Mayrose J. Wound irrigation with tap water. Acad Emerg Med. 1998;5(11):1076–1080.
  4. Howell JM, Morgan JA. Scalp laceration repair without prior hair removal. Am J Emerg Med. 1988;6(1):7–10.
  5. Perelman VS, Francis GJ, Rutledge T, Foote J, Martino F, Dranitsaris G. Sterile versus nonsterile gloves for repair of uncomplicated lacerations in the emergency department: a randomized controlled trial. Ann Emerg Med. 2004;43(3):362–370.
  6. Forsch RT, Little SH, Williams C. Laceration Repair: A Practical Approach. Am Fam Physician. 2017 May 15;95(10):628-636.
  7. Cox I. Guidelines for Re-Sterilising Sutures. Community Eye Health. 2004;17(50): 30.
  8. Kretsinger K, Broder KR, Cortese MM, et al. Preventing tetanus, diphtheria, and pertussis among adults: use of tetanus toxoid, reduced diphtheria toxoid and acellular pertussis vaccine recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR Recomm Rep. 2006;55(RR-17):1–37.
  9. Quinn JV, Polevoi SK, Kohn MA. Traumatic lacerations: what are the risks for infection and has the ‘golden period’ of laceration care disappeared? Emerg Med J. 2014;31(2):96–100.
  10. Cummings P, Del Beccaro MA. Antibiotics to prevent infection of simple wounds: a meta-analysis of randomized studies. Am J Emerg Med. 1995;13(4):396–400.
  11. Worster B, Zawora MQ, Hsieh C. Common Questions About Wound Care. Am Fam Physician. 2015 Jan 15;91(2):86-92.
Cite this article as: Carmina Shrestha, "Laceration Repair: A Rural Encounter," in International Emergency Medicine Education Project, June 21, 2019, https://iem-student.org/2019/06/21/laceration-repair-a-rural-encounter/, date accessed: November 17, 2019

SMACC Sydney 2019: A Student Volunteer Experience

Lucas Oliveira J. e Silva Medical student at Universidade Federal do Rio Grande do Sul (UFRGS), Brazil. President of International Student Association of Emergency Medicine (ISAEM)
Lucas Oliveira J. e Silva: Medical student at Universidade Federal do Rio Grande do Sul (UFRGS), Brazil. President of International Student Association of Emergency Medicine (ISAEM)

I will never forget the first time I have heard about the concept of Free Open Access Medical Education (FOAMed). I was leading the organization of an Emergency Medicine (EM) student symposium in my city (Porto Alegre), and we decided to invite a student named Henrique Puls to give a lecture about his organization, the International Student Association of Emergency Medicine (ISAEM). 

At that point, he was an enthusiast about Emergency Medicine already, and he was the vice-president of ISAEM. He gave an excellent talk about ISAEM, but, most importantly, he introduced me to a “drug” that I would become addicted: the #FOAMed. After that lecture, we ended up becoming good friends and we started to work together. Our work has resulted in so many things that would never fit within this post. Throughout the time, one of the seeds that he has planted on me would blossom in the year 2019.

When I was introduced to the #FOAMed world, Henrique told me about a conference called SMACC – Social Media and Critical Care Conference. At that moment in my life, this conference didn’t make any sense to me: critical care experts giving TED-like talks and doing crazy simulations on stage. My thoughts were: Does this really exist? I kept watching SMACC lectures on YouTube, and year after year my interest would grow more and more. Then, Henrique and Daniel Schubert (another friend, current EM resident in Rio de Janeiro) were pioneers (as always) and participated as SMACC Junior volunteers in Berlin 2017. Every tweet and every post from them throughout the conference inspired me even more.

When SMACC organizers released that 2019 would be in Australia and it would be the last conference ever, I could not miss this opportunity. It would be my last chance to go. The application process was quite different and required a lot of creativity. I thought I would never pass. The email saying that I have been selected for the SMACC volunteer team made my heart start pounding really fast. 

Besides that, I have applied together with my girlfriend (Marianna Fischmann) and we ended up both being accepted. We would go to Sydney and we would be part of the SMACC Junior volunteer team.

The SMACC Junior team is made up of a committed and enthusiastic group of 25 medical/paramedic/nursing students who volunteer at the conference. SMACC 2019 was held in Sydney (Australia) from March 25 to March 29. We arrived in Sydney on March 23 (Saturday) after a very long journey: 36-hour travel, including airport and flight times. On Sunday, we had our first SMACC Junior meeting. At that point, I could feel the energy of the group. Students from eleven countries with totally different backgrounds, except for one similar interest: LEARN. 

First SMACC Junior meeting at the ICC Sydney Convention Center.

But what were the specific tasks we were supposed to do throughout the conference? What does a SMACC Junior volunteer mean?

Well, we were there to help on pretty much everything related to keeping the conference organized.

  1. Here a few of our specific tasks:
  2. Help with the registration of all attendees;
  3. Usher people throughout the conference to make sure they would be at the right place at the right time;
  4. Workshop support (eg. Manikin, time management, etc.);
  5. Help with backstage and on-stage activities;
  6. Represent the youth and inspired community of SMACC.
SMACC Junior material. We were supposed to be in blue T-shirts all the time, except when we were on Backstage (black T-shirts).

One small detail: we were supposed to be at the Convention Center every day at 06:00 AM and to leave it around 06:00 PM.

On Monday, the SMACC workshops started. As I am an Evidence-Based Medicine enthusiast and young researcher, I was allocated to the workshop called “Research Dark Arts.” It was focused on discussing the nuances and challenges behind the academic world. The faculty was mostly from the Australian and New Zealand Intensive Care Research Society (ANZICS) and included researchers like Paul Young, Steve Webb and John Myburgh. It was an amazing opportunity to somehow help these incredible researchers in their workshop. Besides that, I learned so much from them.

On Tuesday, I was allocated to one of the workshops I have always dreamt about: the SMACC Airway workshop. Emergency airway management has always been one of my main interests within the EM world. It was incredible to learn about the different techniques behind mastering the airway with people like Scott Weingart

Me and Scott Weingart after the SMACC Airway Workshop.

After a great day on Tuesday, we were rewarded with a dinner with all faculty members involved with the SMACC Workshops. The event was in a beachfront restaurant at the Cougee Beach. Besides the beauty of this place, this was a great opportunity for networking with people from all over the world.

Me and Marianna in the beachfront restaurant at Cougee Beach.

In the same evening, there was a party called GELFEST. This is a crazy party created by SMACC attendees. Medical education enthusiasts brought a lot of simulation entertainment to the party. The classic part is the famous SALAD simulator, created by James DuCanto. People were practicing his technique (Suction Assisted Laryngoscopy for Airway Decontamination) while drinking their Australian beer.

Marianna practicing SALAD with James DuCanto at the GELFEST party.

After two very intense days, the conference started on Wednesday morning. The anxiety was high because the volunteer group was responsible for registering almost 3000 people. We were very motivated and I think this was the reason why everything went so well.

SMACC Junior team ready to register the attendees.

It’s hard to write about the SMACC open ceremony. There is nothing similar to what happened. It’s even harder to believe that a medical conference could have done something like that. It’s also important to remember those who are reading my report that SMACC has a philosophy: there is only ONE THEATER for the main conference, and all the lectures and discussions happen there. There is no such thing as several rooms with several lectures happening at the same time. SMACC is not a classic conference.

SMACC Sydney Opening Ceremony

After a breathtaking open ceremony, the conference started. As volunteers, we had several tasks throughout the conference days, but almost always we were able to watch pretty much all the lectures. We just had to be aware of following our SMACC Junior Schedule. For example, I had to be at the SMACC Genius Bar during coffee breaks and lunchtime. SMACC Genius Bar was a booth to help attendees on getting into the #FOAMed world (e.g., Creating a Twitter account, etc.). Alyx, Claire and Xander were amazing SMACC Junior leaders, and they did a great job on keeping everyone on track.

Playing with simulation during the conference intervals.

Whenever there was free time, we often went to the simulation booths at the exhibition hall. Me and Floris (medical student from Belgium) had the chance of intubating a manikin inside a simulated crashed car. Quite fun.

On Thursday night, there was the SMACC Gala Party. And do you have any idea where that was? Inside one of the most famous amusement park in the world: Luna Park. Yes, the party was at Luna Park! Unbelievable. It was awesome — dancing, drinks and networking. Unique experience.

And here we go into the last day. On Friday, I had the opportunity of participating in one of the lectures on-stage. Ken Milne, the creator of the Canadian blog The Skeptics Guide to Emergency Medicine, asked for the SMACC Junior volunteers to cheer him up during his debate with Salim (REBEL-EM Blog) about several controversial EM topics. We suited up like Canadians and we had so much fun.

The SMACC Junior Team is cheering up on stage

Unfortunately, everything good comes to an end. But wait, was it really the last SMACC ever? Yes, it was. However, the SMACC leadership, Roger Harris and Oli Flower, had a surprise for the attendees at the end. They announced that the SMACC community would not come to an end, but it would start another journey, with another name and with a more ambitious plan. The name is CODA. They put together three giants of Medicine to create a forum geared toward tackling the main health issues around the world. These three are: SMACC community, New England Journal of Medicine and The George Institute.

Please check what the CODA is about: https://CODAchange.org

After this incredible journey, Marianna and I could explore the wonderful city of Sydney. It’s probably the most amazing city I have ever been to.

Surfing at Manly Beach after the end of the conference

I can’t deny, however, that I am little biased. Going to Sydney and having the chance of living every single moment throughout SMACC have changed my life. The people, the conversations, the lectures, every small piece of SMACC changed something on me. I am sure that this experience was life-changing for many people who attended it. We all left Australia with one common feeling: we are excited to be better versions of ourselves and, consequently, provide better care for our patients.

If I had to summarize what SMACC was, I would say four words: Emotion – Inspirational – Empathy – Humanity

Thank you SMACC for this incredible opportunity.

Oli Flower, Roger Harris and the whole SMACC Junior Team

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Cite this article as: Lucas Silva, "SMACC Sydney 2019: A Student Volunteer Experience," in International Emergency Medicine Education Project, May 20, 2019, https://iem-student.org/2019/05/20/smacc-sydney-2019-a-student-volunteer-experience/, date accessed: November 17, 2019