The State of Emergency Medicine in Ecuador

Ecuador is fast approaching its 30th anniversary of recognizing emergency medicine as a specialty. Within these three short decades, the country has achieved significant milestones in advancing the field of emergency medicine, including the development of a national EM society and implementation of post-graduate training programs. However, there is still much work to be done.  I was lucky enough to have a conversation with the ACEP Liaison to Ecuador, Augusto Maldonado, to learn of recent advancements of emergency medicine in the country. 

“Igual que todos los países del mundo, el rol los que responden inicialmente y la organización de los servicios de emergencia frente a esta emergencia de salud ha sido muy especial.”

The COVID-19 pandemic certainly affected the specialty in the scope of medical practice, as well as highlighted some of the limitations of the medical system that were already present. Following the global trend, emergency care providers came to the forefront of medical attention with the manifestation of the pandemic. Dr. AM says that many emergency departments were forced to adapt in the face of the pandemic, as some hospitals became designated ‘COVID hospitals’ requiring emergency departments to coordinate care for the remaining patients. For example, some emergency physicians suddenly found themselves providing postoperative care when patients would be transferred directly from surgery back to the emergency department. In other places, emergency departments were transformed into intensive care units, staffed by emergency physicians. Dr. AM explains that the COVID-19 pandemic has given the specialty the push it needs, stating “ . . regarding the issue of the pandemic, it really has given us a very big boost as a specialty and I believe that to the authorities it is now very clear the importance of emergency medicine as a specialty to face this type of complex situation”. 
This increased visibility of the specialty is mirrored by the substantial popularity of the country’s national emergency medicine society, Sociedad Ecuatoriana de Medicina de Emergencias, which has increased in number by over 500%! 
The country has also seen an increase in the number of residency training programs over the last year.  In addition to the two already running in Quito, a third and fourth have been established in the city of Cuenca, and a fifth is set to open in Guayaquil. Furthermore, a critical care fellowship is in the works at Universidad San Francisco de Quito. This project stems from a recent study which identified a high demand for a critical care fellowship in Ecuador. 
A distribution of the five emergency medicine residency programs found in Ecuador
The impact of COVID on trainees’ education has, thankfully, not been substantial. Unfortunately, the pandemic did result in residents not being recruited to the Quito programs for 2020, but the programs in Cuenca did start a new class of trainees last year. As with many training institutions across the world, the residents were initially barred by the health authorities from treating COVID patients. However, the creation of ‘COVID’ and ‘mixed’ hospitals has resulted in an increased workload for residents serving the non-COVID population – “I believe that the residents have more work than before . . . and have more procedures because of the overhang generated by the creation of ‘mixed’ hospitals. There’s a lot to do.” He states that residents are on-track for completion of their programs, with ample procedures logged to graduate.
Another aspect of residency training is the required completion of a scholarly project. Research has been slowed across the country as a result of the pandemic. Interest in COVID investigations sparked the Ministry of Health to establish an ADHOC committee explicitly tasked with expediting the review of research proposals. The committee was mandated to review proposals within five days of submission, but in reality, approvals are taking upwards of three to four months. La Universidad San Francisco de Quito explored this roadblock and revealed that some twenty studies had been published through alternative review processes due to the lengthy process of gaining official approval. Dr. AM views COVID as a potential kick-start for encouraging providers to do research, saying “I see it as a great opportunity to better focus [on] research, which is one of the things that we have been looking to do for a long time . . . with the pandemic, [we see] the importance of doing clinical research [in being] able to give adequate treatment to our patients.” 

Looking forward, Dr. AM says that there are many remaining opportunities for growth in the field of emergency medicine, much of which he hopes can be better addressed once the economic situation in Ecuador recovers. He says there is much desire for innovation within the field, but many EM providers are having to work two to three jobs to have a sufficient income to live, leaving little time for research, teaching, or collaboration. There are many lessons to be learned world-wide from the pandemic, but Dr. AM says that in order to address future issues international cooperation is key.

Cite this article as: Global EM Student Leadership Program, "The State of Emergency Medicine in Ecuador," in International Emergency Medicine Education Project, September 18, 2021, https://iem-student.org/2021/09/18/the-state-of-emergency-medicine-in-ecuador/, date accessed: December 7, 2022
Halley J. Alberts, MD
Halley J. Alberts, MD

Halley is a first year resident training in Emergency Medicine at Prisma Health - Midlands at the University of South Carolina. She was a GEMS LP mentee for the class of 20-21 and has now joined the leadership team by managing the new GEMS LP blog page and assisting with journal club.

Welcome from GEMS LP!

Hello and welcome to the first blog post from ACEP’s International Section’s Global Emergency Medicine Student Leadership Program. We are thrilled to partner with iEM in the hosting of this blog, and we thank them for their collaboration and enthusiasm.

Global EM is a young, quickly growing field in the world of health care, but there remains much work to be done. The GEMS LP program was designed to involve students in this exciting and fulfilling specialty. The program itself falls under ACEP’s International Section in conjunction with the International Ambassador Program. All of these entities share a common goal: the advancement of the emergency medicine specialty worldwide.

Through this blog, we hope to educate, inspire, update, and collaborate on all things global EM.  Every couple of weeks, you can expect to read the ‘key points’  from our journal clubs. In each meeting, we review fundamental global health topics through a book chapter and a research paper, followed by a dynamic discussion with a diverse group ranging from medical students to attendings, working both in the US and abroad. Additionally, you can look forward to interviews with some of ACEP’s International Ambassador team members, interesting case discussions, GEMS LP project highlights and other fun commentaries from our mentees and team! 

We look forward to providing you relevant content that will encourage discussion, contemplation, and promotion of the field of global emergency medicine. Thank you for joining us on this new adventure! Please visit our page (https://iem-student.org/gems-lp/) for more information about our leadership team, awesome mentors, and upcoming events and meetings. 

Comments, suggestions, additions? Please reach out to us!

Cite this article as: Global EM Student Leadership Program, "Welcome from GEMS LP!," in International Emergency Medicine Education Project, September 16, 2021, https://iem-student.org/2021/09/16/welcome-from-gems-lp/, date accessed: December 7, 2022

Trauma and Public Health

Trauma is a leading cause of preventable morbidity and mortality. Each reader will have a different context regarding what causes traumatic injuries locally, from different types of motor vehicles, various weapons or security concerns, unique household and workplace injuries, among others. There are several generalizable public health level considerations that we can all benefit from.

Traumatic injuries occur “at the organic level, resulting from acute exposure to energy (mechanical, thermal, electrical, etc.) in amounts that exceed the threshold of physiologic tolerance” [1]. Historically, humans have viewed traumatic injuries as “accidents”; it’s even what we often call them. This view has made trauma a neglected subset of public health focus and funding, though more recently, there has been an increased recognition from public health entities that traumatic injuries are often preventable and treatable [1].

Every year, more than 5 million people die from injury, which is a mortality rate of more than 1.5 times that of HIV, tuberculosis, and malaria combined [2]. Beyond deaths, nearly one billion people sustain injuries that require health care each year from around the globe [3]. Notably, for every death from injury, there are 20–50 nonfatal injuries that result in some disability [4]. Further, the morbidity from trauma is often long-lasting and impacts the quality of life, productivity, and the financial security of individuals, families, and entire communities [5].

Of the 5 million annual trauma deaths, an estimated 1.3 million people are killed in road traffic crashes each year, and projections indicate these will likely increase by another 65% over the coming two decades [6]. Common throughout the world, pedestrians and two-wheel vehicle users are at greater risk of injury and death than vehicle occupants [7]. As vehicles like cars and trucks are owned and operated by more individuals around the world, such projections make logical sense.

After a traumatic injury occurs, the aim is the progress of a patient through a continuum of trauma care, as represented in the below figure:

Yet, such systems and continuums of care lack around the world. In one 2017 review of trauma systems from around the globe, Dijkink et al. found only 9 of 23 high incomes countries had well-defined and documented national trauma systems. Very few low and middle income (LMIC) countries had a formal trauma system or trauma registry [9]. Of note, most injuries occur in low-income and middle-income countries, and most trauma care research comes from high-income countries [10].

In their review of LMICs developing trauma care system, Reynolds et al. identified several common strengths, including training, prehospital systems, and organization, but also found weaknesses in LMICs’ lack of focus on performing quality-improvement, costing, rehabilitation, and policy around trauma care [10].

Each context, even within countries, has a unique set of advantages and barriers, ranging from well-developed to non-existent: EMS systems, in-hospital diagnosis and treatment, and rehabilitation care. Estimates derived from the Global Burden of Disease data suggest that nearly 2 million lives could be saved every year if case fatality rates among seriously injured persons in low- and middle-income countries were similar to those achieved in high-income countries [10,11].

Moving towards such improvements is a monumental task that requires stepwise action. One tool that can help is something I have written about previously: the World Health Organization’s Basic Emergency Care course. The multi-day course curriculum has been developed to teach a high-yield approach to emergent health problems systematically. The course focuses on triage interventions for treating trauma, breathing, shock, and altered mental status. This framework for knowledge and skills can help to improve the acute care of a traumatic injury in almost any location.

I strongly encourage every reader to take a few minutes to consider what are the local causes of traumatic injury, to think about how your current trauma care system is both doing well and where it needs help. I would ask that you think about what ways you could focus on this crucial public health issue and find ways either through education, advocacy, or otherwise, to improve the health of your local and global community.

References

  1. Krug et al. The global burden of injuries. Am J Public Health. 2000 Apr;90(4):523-6. DOI: 10.2105/ajph.90.4.523.
  2. World Health Organization, 2014. Injuries and Violence: The Facts. Geneva: WHO
  3. Haagsma et al. 2016. The global burden of injury: incidence, mortality, disability-adjusted life years and time trends from the Global Burden of Disease study 2013. Inj. Prev. 22(1): 3–18
  4. Debas HT, Donkor P, Gawande A, Jamison DT, Kruk ME, Mock CN, eds. 2015. Essential Surgery: Disease Control Priorities, Vol. 1. Washington, DC: Int. Bank Reconstr. Dev./World Bank. 3rd ed.
  5. Wesson HKH, Boikhutso N, Bachani AM, Hofman KJ, Hyder AA. 2014. The cost of injury and trauma care in low- and middle-income countries: a review of economic evidence. Health Policy Plan. 29(6): 795–808.
  6. Global Road Safety Facility (2014) Transport for health: the global burden of disease from motorized road transport. Washington, DC, The World Bank.
  7. Jayanth Paniker, et al. Global trauma: the great divide. SICOT J. 2015; 1: 19. Published online 2015 Jul 21. doi: 10.1051/sicotj/2015019.
  8. National Academy of Sciences, Committee on Military Trauma Care’s Learning Health System; Health and Medicine Division. Berwick D, Downey A, Cornett E, editors. Washington (DC): National Academies Press (US); 2016 Sep. https://doi.org/10.17226/23511
  9. Dijkink S et al. Trauma systems around the world: A systematic overview. J Trauma Acute Care Surg. 2017 Nov;83(5):917-925. doi: 10.1097/TA.0000000000001633
  10. Reynolds TA et al. The Impact of Trauma Care Systems in Low- and Middle-Income Countries. Annu Rev Public Health. 2017 Mar 20;38:507-532. doi: 10.1146/annurev-publhealth-032315-021412. Epub 2017 Jan 11.
  11. Mock C, Joshipura M, Arreola-Risa C, Quansah R. 2012. An estimate of the number of lives that could be saved through improvements in trauma care globally. World J. Surg. 36(5): 959–63.

 

Cite this article as: J. Austin Lee, USA, "Trauma and Public Health," in International Emergency Medicine Education Project, May 11, 2020, https://iem-student.org/2020/05/11/trauma-and-public-health/, date accessed: December 7, 2022