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

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

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

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

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


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

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

Discussion Questions:

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

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

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

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

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

Mental Health in the International Community - Presented by Alexander Gallaer

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

Discussion Questions:

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

References:

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

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

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

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

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

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

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

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

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

Discussion Questions:

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

References:

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

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

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

Wrap up!

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

Thank you to our authors and presenters!

Jonathan Kajjimu, MS5

Jonathan Kajjimu, MS5

Mbarara University of Science and Technology

Alexander Gallaer, MS4

University of Connecticut School of Medicine

Ellen Chiang, MS4

Ellen Chiang, MS4

UNC Chapel Hill

Jeff Downen, MD, MS

Jeff Downen, MD, MS

PGY-2 University of Florida, Jacksonville
Blog Editor

Keep in Touch:

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

Journal Club 1/10+1/31/21: Sustainability and Language Justice

Tropical Diarrheal Illnesses in Children by Ying Ku

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

Discussion Questions:

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

Language Barriers and Epistemic Injustice in Healthcare Settings by Savanna Hoyt

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

Discussion Points:

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

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

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

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

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

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

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

Who LIVES? Who dies

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

Poverty constrains choice, often in a brutal fashion.

 

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

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

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

Discussion Points:

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

Wrap up!

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

Thank you to our authors and presenters!

Ying Ku, MS3

Ying Ku, MS3

Campbell University School of Osteopathic Medicine

Savanna Hoyt, MS2

Savanna Hoyt, MS2

Northeast Ohio Medical University

Sreenidhi  M Vanyaa, MS4

Sreenidhi M Vanyaa, MS4

PSG Institute of Medical Sciences and Research

Halley J Alberts, PGY2

Halley J Alberts, PGY2

Blog Editorial Lead
University of South Carolina
Prisma Health Midlands

Keep in Touch:

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

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

The Global Burden of Schistosomiasis presented by Farah Mechref

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

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

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

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

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

Discussion Questions:

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

Resource Equity in a Disease Outbreak by Alison Neely

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

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

Discussion Points:

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

Wrap up!

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

Thank you to our authors and presenters!

Farah Mechref, MS4

Farah Mechref, MS4

Texas Tech University Health Sciences Center

Alison Neely, MS4

Alison Neely, MS4

Albert Einstein College of Medicine

Keep in Touch:

Cite this article as: Global EM Student Leadership Program, "Journal Club 11/08/21: Resource Equity in a Pandemic," in International Emergency Medicine Education Project, January 12, 2023, https://iem-student.org/2023/01/12/journal-club-11-08-21-resource-equity-in-a-pandemic/, date accessed: February 1, 2023

Emergency Medicine Perspectives of Students – North America

Dear EM family,

The International Emergency Medicine Education Project (iem-student.org) has completed three years. As you may know, the iEM Education project aims to promote Emergency Medicine and provides copyright-free resources to students and educators around the world. Now we have reached more than 200 countries. We would like to thank again our contributors. Without them, such a project would not be possible. This experience has shown us once again how passionate our international EM community is to help and teach each other.

In May 2021, we started the fourth year of this journey. To celebrate, we are pleased to announce alive activity series, Emergency Medicine Perspectives of Students Around the World. Our guests for the third session are Kayla M. Ferguson, Brenda M. Varriano, and Dr. Halley J. Alberts.

Together, we can understand the experiences and needs of medical students from different backgrounds and discuss potential solutions.

Here are the video and audio records of this session. 

Cite this article as: Arif Alper Cevik, "Emergency Medicine Perspectives of Students – North America," in International Emergency Medicine Education Project, May 23, 2022, https://iem-student.org/2022/05/23/emergency-medicine-perspectives-of-students-north-america/, date accessed: February 1, 2023

Emergency Medicine Perspectives of Students – Central and South America

Dear EM family,

The International Emergency Medicine Education Project (iem-student.org) has completed three years. As you may know, the iEM Education project aims to promote Emergency Medicine and provides copyright-free resources to students and educators around the world. Now we have reached more than 200 countries. We would like to thank again our contributors. Without them, such a project would not be possible. This experience has shown us once again how passionate our international EM community is to help and teach each other.

In May 2021, we started the fourth year of this journey. To celebrate, we are pleased to announce alive activity series, Emergency Medicine Perspectives of Students Around the World. Our guests for the third session are Henrique Herpich from Brazil, Genesis Soto Chaves from Costa Rica, and William Gopar Franco from Mexico..

Together, we can understand the experiences and needs of medical students from different backgrounds and discuss potential solutions.

Here are the video and audio records of this session. 

Cite this article as: Arif Alper Cevik, "Emergency Medicine Perspectives of Students – Central and South America," in International Emergency Medicine Education Project, May 16, 2022, https://iem-student.org/2022/05/16/emergency-medicine-perspectives-of-students-central-and-south-america/, date accessed: February 1, 2023

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

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

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

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

– Portability; relatively inexpensive starting at $2000

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

– Rapid, noninvasive

– No ionizing radiation exposure

– Improves success and safety of bedside procedures

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

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

Some of the disadvantages include:

– Requirement of formal training

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

– Handheld US requires a smartphone

– Supplies (US gel)

– Upkeep and repair

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

– Ethical considerations? 

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

– Cost-effectiveness: some resources are deemed too expensive

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

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

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

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

Discussion Questions:

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

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

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

        – Potential costs of training

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

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

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

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

Discussion Points:

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

Wrap up!

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

Thank you to our authors and presenters!

Holly Farkosh, MS4

Holly Farkosh, MS4

Marshall University School of Medicine

Cody Ritz, MS2

Cody Ritz, MS2

Drexel University College of Medicine

Keep in Touch:

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

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

The Global Burden of Schistosomiasis presented by Farah Mechref

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

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

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

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

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

Discussion Questions:

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

Resource Equity in a Disease Outbreak by Alison Neely

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

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

Discussion Points:

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

Wrap up!

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

Thank you to our authors and presenters!

Farah Mechref, MS4

Farah Mechref, MS4

Texas Tech University Health Sciences Center

Alison Neely, MS4

Alison Neely, MS4

Albert Einstein College of Medicine

Keep in Touch:

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

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

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

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

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

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

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

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

Discussion Questions:

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

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

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

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

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

Discussion Questions:

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

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

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

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

Discussion Questions:

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

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

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

 

Wrap up!

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

Thank you to our authors and presenters!

Denise Manfrini, MS4

Denise Manfrini, MS4

University of Florida

Andrew McAward, MS2

Andrew McAward, MS2

Marshall University, Joan C. Edwards School of Medicine

Rachael Kantor, MS4

Rachael Kantor, MS4

The Medical School for International Health at Ben Gurion University

Sources and Further Reading:

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

 

Keep in Touch:

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

Journal Club 10-04-21 : Health Equity, Medical Tourism, and Maternal Mortality in LMICs

Welcome back! The first GEMS LP  journal club of the season took place on October 4th, 2021. During each meeting, we discuss a journal article, a global health clinical topic, and a book chapter from one of two books: An Introduction to Global Health Delivery by Joia Mukherjee or Reimagining Global Health: An Introduction by Paul Farmer, Jim Yong Kim, Arthur Kleinman, and Matthew Basilico.

The goal of journal club is to expose our mentees to fundamental global health concepts and their applications in the real world. Having a diverse cohort of participants allows for lively and engaging discussion based on each participants’ life experiences. Below is a summary of each section presented at journal club. Be sure to join us at our next meeting, taking place November 8th, 2021.

Many of the global health disparities that exist today are a result of centuries of exploitation of developing countries that can trace its roots to the slave trade. As slavery ended in the 19th century, the extraction of people was replaced with the extraction of resources as European nations divided up Africa amongst themselves. By the 20th century, centuries of exploitation had robbed newly independent countries of the resources needed to provide healthcare for their citizens. Newly liberated countries came to rely on Western monetary institutions for loans, which often came with strings attached. Loans from the World Bank and the International Monetary Fund limited the amount of public expenditures on vital healthcare infrastructure, medication, and personnel. Healthcare in developing countries was further undermined by the neoliberal policies promoted by Western countries beginning in the 1980s. Developing countries were compelled to fund healthcare through above-cost user fees, which reinforced unequal access to care and widened healthcare inequality. The neoliberal approach also championed the concept of sustainability, which focused on low-cost preventative care instead of treatment. By the 1990s, this approach had led to widening healthcare inequity between the developed and developing worlds.

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

Discussion Questions:

·Reflect on prior medical service trips you may have gone on or may be offered by your university. In what ways do these trips reflect the legacy of colonialism? How can we “de-colonize” global health in medical education? 

·Should all medical interventions in lower-income and developing countries be “sustainable”? 

Medical tourism is a modern practice in healthcare that is exacerbating global health inequity. For centuries, people of higher socioeconomic classes commonly visited higher developed countries to receive care for their medical ailments. Their journeys are much more expensive than an ordinary citizen could afford but with the advent of air travel and a rapid development of the middle class with a larger share of disposable income, many more people are travelling for medical services today than ever before. The propagation of medical tourism is exacerbating the divide in quality of care in developing countries. As private hospitals primarily attract international patients, they attract more doctors with higher salaries and benefits paid for by medical tourists’ bills. This develops a positive feedback loop that continues to neglect the care of the poorest patients who need the most advanced care and rely on public hospital systems that are already overburdened. Rather than focusing on bettering the care of public hospitals and working for the native populations, private hospital systems and governments encouraging medical systems are further dividing the health gap between socioeconomic classes and contributing to health inequity.

Discussion Questions:

What are some ethical issues developed by private healthcare systems motivated by financial incentives?

• How can medical professionals in our country educate patients about the risks of medical tourism?

 

Global health disparity is apparent in the care of pregnant individuals, with 94% of all maternal deaths occurring in low and lower-middle-income countries. A leading cause of maternal and perinatal mortality in these regions is hypertensive disorders of pregnancy, especially pre-eclampsia and its spectrum of diseases. Crucial to the screening and diagnosis of these disorders are regular antenatal care and assessment of risk factors, such as advanced maternal age, obesity, diabetes, and existing hypertension. For pre-eclampsia and eclampsia, the WHO has released evidence-supported recommendations for both preventative measures, such as calcium supplementation in areas with low intake, and treatment, such as using magnesium sulfate over other anticonvulsants. In low resource settings, some of the barriers that hinder the care of pregnant individuals with hypertensive disorders are a shortage of specialty-trained healthcare workers, inadequate transportation to healthcare facilities, limited antenatal care, and traditional cultural practices. While much work still needs to be done in tackling many of these challenges, especially in improving basic obstetric emergency treatment at primary community settings, innovative strategies such as task-shifting to train community health workers (CLIP initiative) in providing regular antenatal care and community cost-sharing schemes to eliminate financial barriers to obstetric care in Mali have been shown to have positive outcomes.

Discussion Questions:

· What other non-health related barriers may contribute to maternal mortality?

· What roles can emergency services/emergency medicine physicians play in improving the outcome of obstetric emergencies?

Wrap up!

As you can imagine, our mentees had a wonderful discussion surrounding these three topics! We are thrilled to be able to present a brief summary of their work here. Please stay tuned for details about our upcoming meetings, the next of which is taking place November 8th, 2021.  Connect with us through one of our contact options listed below if you are interested in attending!

Thank you to our authors and presenters!

Brian Elmore, MS4

Brian Elmore, MS4

Medical University of South Carolina

Jai Shahani, MS2

Jai Shahani, MS2

Rutgers New Jersey Medical School

Luxi Qiao, MS4

Luxi Qiao, MS4

Washington University School of Medicine

Sources:

  • Mukherjee, Joia. “Chapter 1: The Roots of Global Health Inequity.” An Introduction to Global Health Delivery: Practice, Equity, Human Rights, Oxford University Press, New York, NY, 2018.
  • Mutalib, Nur & Ming, L C & Yee, Esmee & Wong, Poh & Soh, Yee. (2016). Medical Tourism: Ethics, Risks and Benefits. Indian Journal of Pharmaceutical Education and Research. 50. 
  • 261-270. 10.5530/ijper.50.2.6.
  • http://ijper.org/sites/default/files/10.5530ijper.50.2.6.pdf
  • WHO. Maternal mortality evidence brief, 2019.
  • WHO. WHO recommendations for prevention and treatment of pre-eclampsia and eclampsia, 2011.
  • Fournier P, Dumont A, Tourigny C, Dunkley G, Drame S. Improved access to comprehensive emergency obstetric care and its effect on institutional maternal mortality in rural Mali. Bull World Health Organ 2009; 87: 30-8
  • von Dadelszen P, Vidler M, Tsigas E, Magee LA. Management of Preeclampsia in Low- and Middle-Income Countries: Lessons to Date, and Questions Arising, from the PRE-EMPT and Related Initiatives. Maternal-Fetal Medicine 2021; 3(2): 136-50.
  • Firoz T, Sanghvi H, Merialdi M, von Dadelszen P. Pre-eclampsia in low- and middle-income countries. Best Pract Res Clin Obstet Gynaecol 2011; 25: 537-48.
  • Milne F, Redman C, Walker J, et al. The pre-eclampsia community guideline (PRECOG): how to screen for and detect onset of pre-eclampsia in the community. BMJ 2005; 330: 576-80.

 

Keep in Touch:

Cite this article as: Global EM Student Leadership Program, "Journal Club 10-04-21 : Health Equity, Medical Tourism, and Maternal Mortality in LMICs," in International Emergency Medicine Education Project, November 1, 2021, https://iem-student.org/2021/11/01/health-equity-medical-tourism-and-maternal-mortality-in-lmics/, date accessed: February 1, 2023

Dermatological emergencies : Stevens-Johnson Syndrome

stevens johnson syndrome

Every medical student has three categories of topic division

Category 3 catches you by surprise when it makes it an entry in the ED and serves as a reminder of why it is essential always to know something about everything. Stevens-Johnson Syndrome was one of those for me. Although rare, dermatological emergencies are essential to spot and can be life-threatening if left untreated.

Stevens-Johnsons Syndrome is a rare type 4 hypersensitivity reaction which affects <10% of body surface area. It is described as a sheet-like skin loss and ulceration (separation of the epidermis from the dermis).

Toxic epidermal necrosis and Stevens-Johnsons Syndrome can be mixed. However, distinguishing between both disease can be done by looking at % of body surface area involvement.

  • < 10% BSA = Stevens-Johnsons Syndrome
  • 10-30% BSA = Stevens-Johnsons Syndrome/Toxic epidermal necrosis overlap syndrome
  • > 30%= Toxic epidermal necrosis – above image is an example of toxic epidermal necrosis.

Pathophysiology is unknown

Pathophysiology is not clearly known; however, some studies show it is due to T cells’ cytotoxic mechanism and altered drug metabolism.

Causes

The most common cause of Stevens-Johnsons Syndrome is medications. Examples are allopurinol, anticonvulsants, sulfonamide, antiviral drugs, NSAIDs, salicylates, sertraline and imidazole.

As one of the commonest cause is drug-induced, it is a vital part of history taking. Ask direct and indirect questions regarding drug intake, any new (started within 8 weeks) or old medications and previous reactions if any.

Other causes are malignancy and infections (Mycoplasma pneumonia, Cytomegalovirus infections, Herpesvirus, Hep A).

Risk Factors

The disease is more common in women and immunocompromised patients (HIV, SLE)

Clinical Presentations

  • Flu-like symptoms(1-14 symptoms)
  • Painful rash which starts on the trunk and spreads to the face and extremities.
  • Irritation in eyes
  • Mouth ulcers or soreness

Clinical Exam Findings

  • Skin manifestation – Starts as a Macular rash that turns into blisters and desquamation.
  • An important sign in SJS is Nikolsky’s sign: It is considered positive if rubbing the skin gently causes desquamation.
  • 2 types of mucosa are involved in SJS – oral and conjunctiva, which precede skin lesions.
  • Other findings in the examination may include –
  • Oral cavity – ulcers, erythema and blisters
  • Cornea – ulceration

Diseases with a similar presentation – in children, staphylococcal scalded skin syndrome can be suspected as it has a similar presentation and can be differentiated with the help of a skin biopsy.

Diagnosis

Clinical awareness and suspicion is the cornerstone step for diagnosis. Skin Biopsy shows subepidermal bullae, epidermal necrosis, perivascular lymphocytic infiltration, which help for definitive diagnosis.

Management

Adequate fluid resuscitation, pain management and monitoring of electrolytes and vital signs, basic supportive or resuscitative actions are essential, as with any emergency management.

The next step is admitting the patient to the burn-unit or ICU, arranging an urgent referral to dermatology and stopping any offending medications. If any eye symptoms are present, an ophthalmology referral is required.

Wound management is essential- debridement, ointments, topical antibiotics are commonly used to prevent bacterial infections and ease the symptoms.

Complications

  • Liver, renal and cardiac failure
  • Dehydration
  • Hypovolemic or septic shock
  • Superimposed infection
  • Sepsis
  • Disseminated intravascular coagulation
  • Thromboembolism
  • Can lead to death if left untreated

Prognosis

Prognosis of a patient with Stevens-Johnson Syndrome is assesed by the SCORTEN Mortality Assesment Tool. Each item equal to one point and it is used within the 24 hours of admission.

• Age >/= 40 years (OR 2.7)
• Heart Rate >/= 120 beats per minute (OR 2.7)
• Cancer/Hematologic malignancy (OR 4.4)
• Body surface area on day 1; >10% (OR2.9)
• Serum urea level (BUN) >28mg/dL (>10mmol/L) (OR 2.5)
• Serum bicarbonate <20mmol/L (OR 4.3)
• Serum glucose > 252mg/dL (>14mmol/L) (OR5.3)

Predicted mortality based on the above total:

  • 0-1 Point = 3.2%
  • 2 Points = 12.1%
  • 3 Points = 35.3%
  • 4 Points = 58.3%
  • 5 Points = 90.0%

References and Further Reading

Cite this article as: Sumaiya Hafiz, UAE, "Dermatological emergencies : Stevens-Johnson Syndrome," in International Emergency Medicine Education Project, February 15, 2021, https://iem-student.org/2021/02/15/stevens-johnson-syndrome/, date accessed: February 1, 2023

Recent Blog Posts by Sumaiya Hafiz

Things You Should Know Before Your First ED Shift

Things You Should Know Before Your First ED Shift

I recently posted a question to the Twitterverse:

“Imagine that an Emergency Medicine intern asked you for advice before his/her FIRST SHIFT. What would be your FIRST ADVICE?”

I also raised the same question in Turkish. In a couple of days, I received nearly 100 answers from reputable names of Emergency Medicine working worldwide. I highly benefited from these advice, and I think that our site’s valuable readers can also benefit. I tried to select the most inspiring ones and divided them into main categories. Under each advice, you can find the name of the tweet owner and the link to the original tweet. Let’s start.

Core

Enjoy being on the frontline by helping patients who are seeking your help in their most difficult time. This is a great privilege and responsibility that we should never forget.

Arif Alper Cevik (@drcevik) Tweet

Never forget what a privilege and responsibility it is that people don’t know you ask for your help on the WORST DAY OF THEIR LIFE.

In the Emergency Department, you may be worried about 'why am I here?' one day, but you may think that you are doing the best job in the world another day. Now you have a lifetime which every day and every patient is different. Love your profession EVERY WAY, glorify knowledge and skill, and always be at peace with your job.

Education

Never be afraid to say, "I don't know." It's why you're here to be taught. If you already knew everything, then you wouldn't need residency.

Justin Hensley, (@EBMgoneWILD) Tweet

Trust yourself as if you know everything, try to learn as if you know nothing.

Want to get smart? Do 2 things: 1) Read up on at least 1 patient every shift. 2) Ask lots of questions to residents, attendings and consultants.

Feel free to ask me (or another senior) about anything (/everything). When I was at that stage I wish I’d asked more. I suspect some people think asking is a sign of ignorance or weakness. Actually, it helps us to be safe & to appreciate other perspectives.

This is the Emergency Room; this is the lion’s den; first, you have to protect yourself, and you will do this with your knowledge. So don't think ‘I'll practice, I'll fill my knowledge gap in 3-5 months', sit down, and read the textbook.

Göksu Afacan Öztürk (@Goksu_Afacan) Tweet

First compel yourself to read at specific points, and gradually you will find your appetite for reading. You are the one primarily responsible for your education!

Never feel shy to ask or say I don't know. It's your chance to make mistakes and learn, share the knowledge you have and don't keep it to yourself.

Of course, you cannot know everything, but you can start learning.

Ozlem Guneysel (@oguneysel) Tweet

80% of “KNOWLEDGE” is "INTEREST"

Ayhan Özhasenekler (@Aozhasenekler) Tweet
Resilience

Resilience

The Emergency Medicine career is a marathon, not just the first few years of residency. Don't waste your energy inordinately for things you can't fix. Invest in the future self.

When you dance with the bear you can't stop until the bear wants to stop.

Nurettin Özgür Doğan (@DrOzgurDogan) Tweet

Calm down. Every shift eventually ends.

Mustafa Ercan Günel (@mercangu) Tweet

Rest and eat, whenever you get the opportunity. The Emergency Room is like a HIIT, you need to slow down first to speed up.

Burcu Yılmaz (@Burcu_Yilmazzz) Tweet

If you are a parent, sleep when the child sleeps.

Empathy

Empathy

Don’t judge patients or consultants without walking a mile in their shoes.

Think of every patient as your relative. Balance your professional authority with your kindness.

Communication is important. Tell the patient and one of his/her relatives what you already did and what you plan to do, and ask if there is anything they want to ask.

Altuğ Kanbakan (@prothemanes) Tweet

Peter Rosen once said, “Nobody woke up this AM decided to ruin your day.” Happiness is YOUR choice. Be happy, stay positive.

Remember, when you see a patient in the middle of the night who requests you to apply his/her prescribed topical cream on his/her back because –apparently- he/she can’t, that person is the joy of the night.

Follow up on your patients. This will reinforce your learning. Call patients at home to see how they’re doing. They will love it, and it reminds you of why you chose this profession.

Remember to acknowledge that you most likely are a stranger to your patient. It only takes a few minutes to reassure someone that you are there to help them through their ER experience as a team. We tend to forget this in the busy ER.

Values

Values

Nobody expects you to know much (yet). But it is expected you to be 100% reliable. Never EVER EVER EVER lie. If you don’t know something or you don’t do something, be honest.

Your attitude to this advice will determine your path through our specialty. The blindingly following advice will bring as much peril as ignoring it all. Emergency Medicine requires you to consider impacts on patients, professionals & the populations - no one approach fits all.

Damian Roland (@Damian_Roland) Tweet

Never EVER EVER EVER be arrogant. You will be wrong many times in your career. Learn humility NOW.

What I like most about emergency medicine is how it allows us new perspectives every day. In the pandemic, we are treating the same disease all the time, but each patient and their family brings a different story, and every time I feel more humble in the face of life, the disease, and the future. Being in a LIMC country can be so challenging, so painful to treat and suffer along with inequalities and lack of resources... But we have the opportunity to be our best, as I said yesterday to my residents: we don’t have the best hospital, but we can be our best and give the patient what they may not have in the best hospital: treatment with dignity and respect and love. For me, being able to show my patients that I care, and receiving their gratitude has been undoubtedly the only possible prevention of Burnout. So I would say: Our specialty is beautiful, the opportunity for growth is vast, but it takes humility and perseverance to complete this journey.

Jule Santos (@julesantosER) Tweet

Never allow senior residents of other departments to treat you as if you are their junior.

Dr Erdi Kadir Y. (@DrEKYacil) Tweet

Our fingers are not equal, and so are the attendings whose hands you train on are not the same nature. There is the gentle one who loves you and there are critics who believe that development comes only with criticism and a dose of pain. Your job is not to try to classify them but to do what is required of you and to benefit from everyone.

We want you to be the brain of a machine in which none of its cogs can work properly. Sometimes, even if you don't know how to swim, you will find yourself in the ocean surrounded by the waves, but most of the time, in the hardest moments, you will find a huge army with you. Welcome...

Barış Murat Ayvacı (@emresuspack) Tweet

If you think a senior is wrong about something, give him evidence, but don’t be obstinate...

Ali Kaan Ataman (@erdrkaan) Tweet

You may be untutored, but never be uninterested. Because knowledge definitely comes to those who have interest.

Mustafa Ipek (@dr_mustafaipek) Tweet

Appear weak when you are strong and strong when you are weak. Look weak when strong; look strong when weak. Also don't forget to look at vital signs 😉

Osman Avşar Gül (@mefisto_avsar) Tweet

Don’t be a d*ck.

Enjoy your junior days, qualify for your senior days.

Patient Records

Patient Records

(Carefully) Fill out the patient records. What will save you from everything are these records.

Spoken words fly away, written words remain. Record everything...

Şervan Gökhan (@servangokhan) Tweet

What is not written is deemed not done. First, protect yourself and then protect the patient. Choose a good role model.

Ozge Duman Atilla (@ozgedumanatilla) Tweet

Workup

No workup can replace a good physical examination.

Erdal Demirtaş (@Erdal_DD) Tweet

Never order a test that you won’t check the results.

Eyupkaraoglu (@drekaraoglu) Tweet

Know your tests! Know their rough sens/spec and when to trust them (and more importantly, when NOT to trust them)!! No test is 100%, and all are context-dependent!

Elias Jaffa MD MS (@jaffa_md) Tweet

Decision Making

Being efficient should never be at the expense of being thorough. You will eventually have to waste more time making things right.

Danya Khoujah (@DanyaKhoujah) Tweet

If someone brings up a concern, go to the bedside.

Sunny Elagandhala (@elegantdolla) Tweet

Think simple, make a quick decision. Determine the senior you will take as a model.

Ayhan Özhasenekler (@Aozhasenekler) Tweet

Once you suspect about a diagnosis, be sure to rule it out.

Do not forget to consider emergencies and other diseases while focusing on frequent diseases of the period, such as COVID. The most important thing that the emergency doctor needs to do is to look at the case from a wide perspective from the very beginning.

Gaziantep Acil Tıp (@AcilGaziantep) Tweet

Watch out for the last patient who came just before your shift ends.

Meltem Şahin (@onlakonusmayin) Tweet

In emergency medicine [and in life :)] the possibilities are 0% or 100% only in limited scenarios. You need to quickly learn managing probabilities, setting priorities, distinguishing acceptable and unacceptable risks. Also you need to learn reading the environment; because it usually gives many signs before the problem emerges.

Elif Dilek Çakal (@DrEDCakal) Tweet

Patient in the Resus is easy. Spotting the patient with a real emergency in minors is the tough one.

First rule of emergency response is to ensure your own safety!

SALİH KARABULUT (@drskbulut) Tweet

When in doubt or worried about someone, talk to floor senior physicians EARLY.

Rahul Goswami (@Rahul_Goswami_) Tweet

I would say to try your best to remain open-minded and try to be aware of your biases and blindspots. This applies especially to patients with psychiatric illness and substance use disorders. If you're explaining X symptom on Y problem, always ask yourself, "Does this actually make sense?

Elias Jaffa MD MS (@jaffa_md) Tweet

The most frequently overlooked diagnosis in the emergency room is the second diagnosis! Do not limit your perspective to one diagnosis. Most frequently missed fracture in the emergency room? The second one! Remember that the patient may have a second fracture!

Mehmet Ergin (@drmehmetergin) Tweet

While assessing only isolated parts, don’t miss to assess the patient as a whole. Do not evaluate the patient on a single system, single organ basis. Emergency Medicine requires ‘holistic assessment’.

Ayhan Özhasenekler (@Aozhasenekler) Tweet

Discharging

No hospital bed belongs to you. If in doubt, do not discharge the patient.

Haldun Akoglu (@IstanbulEMDoc) Tweet

Do not discharge the patient relying on what someone else is telling you without assessing by yourself!

Emre Salçın (@emresalcin) Tweet

Do not discharge the patient after midnight: You may be tired, you may overlook something, the patient and his relatives may not find a car or money to leave, or they may try to go to the town or another city but have an accident on the road, etc. Those all happened (Not my personal experience, but I have seen them), evidence based...

Ayhan Özhasenekler (@Aozhasenekler) Tweet

Before discharging the patient whose treatment is completed, make sure to think like that: ‘Is there any possibility that this patient will come back with a cardiac arrest before the shift ends?’ If you are hesitant, prolong the process.

The patient at the hospital is better than the patient at home’. Do not discharge if you are not sure.

Belgin Akilli (@AkilliBelgin) Tweet

Team Play

Emergency Medicine is teamwork. Get along well with your colleagues, your nurse, your intern, your staff and your secretary. Find yourself a role model, try to be a good example for others. And enjoy the Emergency Medicine.

Melih İmamoğlu (@melihimam) Tweet

You may learn a lot of thing from your nurse, act like a teammate.

Yusuf Ali Altuncı (@draltunci) Tweet

That’s all for now. By the way, what would your advice be?

Cite this article as: Ibrahim Sarbay, Turkey, "Things You Should Know Before Your First ED Shift," in International Emergency Medicine Education Project, July 13, 2020, https://iem-student.org/2020/07/13/things-you-should-know-before-your-first-ed-shift/, date accessed: February 1, 2023

Triads in Medicine – Rapid Review for Medical Students

triads in medicine

One of the most convenient ways of learning and remembering the main components of disease and identifying a medical condition on an exam are Triads, and medical students/interns/residents swear by them.

Be it a question during rounds, a multiple-choice exam question to be solved, or even in medical practice, the famous triads help physicians recall important characteristics and clinical features of a disease or treatment in an instant.

Since exam season is here, this could serve as a rapid review to recall the most common medical conditions.

While there are a vast number of triads/pentads available online, I have listed the most important (high-yy) ones that every student would be asked about at least once in the duration of their course.

1) Lethal Triad also known as The Trauma Triad of Death
Hypothermia + Coagulopathy + Metabolic Acidosis

2) Beck’s Triad of Cardiac Tamponade
Muffled heart sounds + Distended neck veins + Hypotension

3) Virchow’s Triad – Venous Thrombosis
Hypercoagulability + stasis + endothelial damage

4) Charcot’s Triad – Ascending Cholangitis
Fever with rigors + Right upper quadrant pain + Jaundice

5) Cushing’s Triad – Raised Intracranial Pressure
Bradycardia + Irregular respiration + Hypertension

6) Triad of Ruptured Abdominal Aortic Aneurysm
Severe Abdominal/Back Pain + Hypotension + Pulsatile Abdominal mass

7) Reactive Arthritis
Can’t See (Conjunctivitis) + Can’t Pee (Urethritis) + Can’t Climb a Tree (Arthritis)

8) Triad of Opioid Overdose
Pinpoint pupils + Respiratory Depression + CNS Depression

9) Hakims Triad – Normal Pressure Hydrocephalus
Gait Disturbance + Dementia + Urinary Incontinence

10) Horner’s Syndrome Triad
Ptosis + Miosis + Anydrosis

11) Mackler’s Triad – Oesophageal Perforation (Boerhaave Syndrome)
Vomiting + Lower Thoracic Pain + Subcutaneous Emphysema

12) Pheochromocytoma
Palpitations + Headache + Perspiration (Diaphoresis)

13) Leriche Syndrome
Buttock claudication + Impotence + Symmetrical Atrophy of bilateral lower extremities

14) Rigler’s Triad – Gallstone ileus
Gallstones + Pneumobilia + Small bowel obstruction

15) Whipple’s Triad – Insulinoma
Hypoglycemic attack + Low glucose + Resolving of the attack on glucose administration

16) Meniere’s Disease
Tinnitus + Vertigo + Hearing loss

17) Wernicke’s Encephalopathy- Thiamine Deficiency
Confusion + Ophthalmoplegia + Ataxia

18) Unhappy Triad – Knee Injury
Injury to Anterior Cruciate Ligament + Medial collateral ligament + Medial or Lateral Meniscus

19) Henoch Schonlein Purpura
Purpura + Abdominal pain + Joint pain

20) Meigs Syndrome
Benign ovarian tumor + pleural effusion + ascites

21) Felty’s Syndrome
Rheumatoid Arthritis + Splenomegaly + Neutropenia

22) Cauda Equina Syndrome
Low back pain + Bowel/Bladder Dysfunction + Saddle Anesthesia

23) Meningitis
Fever + Headache + Neck Stiffness

24) Wolf Parkinson White Syndrome
Delta Waves + Short PR Interval + Wide QRS Complex

25) Neurogenic Shock
Bradycardia + Hypotension + Hypothermia

Further Reading

Cite this article as: Sumaiya Hafiz, UAE, "Triads in Medicine – Rapid Review for Medical Students," in International Emergency Medicine Education Project, June 12, 2020, https://iem-student.org/2020/06/12/triads-in-medicine/, date accessed: February 1, 2023