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: July 3, 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.

Intern Survival Guide – ER Edition

Intern Survival Guide - ER Edition
In some parts of the world, Internships consist of rotating in different departments of a hospital over a period of one or two years depending on the location. In others, interns are first-year Emergency Medicine residents. Whichever country you practice in, an emergency rotation may be mandatory to get the most exposure, and often the most hands-on. Often, junior doctors (including myself)  find ourselves confused and lost as to what is expected of us, and how we can learn and work efficiently in a fast-paced environment such as the ER. It can be overwhelming as you may be expected to know and do a lot of things such as taking a short yet precise history, doing a quick but essential physical exam and performing practical procedures. I’ve gathered some tips from fellow interns and myself, from what we experienced, what we did right, what we could’ve done better and what we wish we knew before starting. These tips may have some points specific to your Emergency Medicine Rotation, but overall can be applied in any department you work in.
  • First things first – Always try to be on time. Try to reach your work a couple of minutes before your shift starts, so you have enough time to wear your PPE and feel comfortable before starting your shift.
  • Know your patients! Unlike other departments, ER does not always have rounds, and you do not know any of the patients beforehand, but it always helps to get a handover from the previous shift, and know if any of the patients have any results, treatment plans or discharges pending, to prevent chaos later on!
  • Always be around, inform your supervising doctor when you want to go for a break, and always volunteer to do more than what you’re asked for. The best way to learn is to make yourself known, ask the nurses to allow you to practice IV Cannulation, Intramuscular injections, anything and everything that goes around the department, remember the ER is the best place to learn.
  • Admit when you feel uncomfortable doing something, or if you’ve done a mistake. This makes you appear trustworthy and everyone respects someone who can own up to their mistake and keeps their patients first.
  • Breath sounds and pulses need to be checked in every patient!
  • Address pain before anything else, if their pain is in control, the patient will be able to answer your questions better.
  • Never think any work is below you, and this is one thing which I admired about ED physicians, you do not need someone to bring the Ultrasound machine to you, you do not need someone to plug in the machine, you do not need someone to place the blood pressure cuff if you can do it yourself. Time is essential, and if you’re the first person seeing the patient, do all that you can to make their care as efficient as possible.
  • Care for patients because you want to, and not for show. Often junior doctors get caught up in the fact that they are being evaluated and try to “look” like the best version of themselves. While it may be true, remember this is the year where you are shaping yourself for the future, and starting off by placing your patients first, doing things for their benefit will not only make it a habit, the right people will always notice and will know when you do things to provide patient-focused care, or when you do them to show that you are providing patient-focused care.
  • Teamwork will help you grow. Not everything in life has to be a competition, try to work with your colleagues, share knowledge, take chances on doing things, learn together, trying to win against everyone else only makes an easier task even more stressful and can endanger lives.
  • Learn the names of the people you work with! In the ER, you may across different people on each and every shift and it may be difficult to remember everyone’s names, but it’s always nice to try, and addressing people by their names instantly makes you more likable and pleasant to work with!
  • Keep track of your patients and make a logbook of all the cases you see and all the procedures you observe/assist in/perform. This not only helps in building your portfolio, but also in going back and reading about the vast variety of cases you must have seen.
  • Always ask yourself what could the differential diagnosis be? How would you treat the patient?
  • Ask questions! No question is worth not asking, clear your doubts. Remember to not ask too much just for the sake of looking interested, but never shy away from asking, you’d be surprised to see how many doctors would be willing to answer your queries.
  • Don’t make up facts and information. If you forgot to ask something in history, admit the mistake, and it’s never too late, you can almost always go back and ask. It’s quite normal to forget when you’re trying to gather a lot of information in a short span of time.
  • Check up on the patients from time to time. The first consultation till the time you hand them the discharge papers or refer them to a specialty shouldn’t be the only time you see the patient. Go in between whenever you get a chance, ask them if they feel better, if they need something. Sometimes just by having someone asking their health and mental wellbeing is just what they need.
  • Take breaks, drink water and know your limits. Do not overwork yourself. Stretching yourself till you break is not a sign of strength.
  • Sleep! Sleep well before every shift. Your sleep cycles will be affected, but sleeping when you can is the best advice you can get.
  • Read! Pick your favorite resource and hold onto it. A page of reading every day can go a long way. The IEM book can be a perfect resource that you can refer to even during your shifts! (https://iem-student.org/2019/04/17/download-now-iem-book-ibook-and-pdf/)
  • Practice as many practical skills as you can. The ER teaches you more than a book can, and instead of looking at pictures, you can actually learn on the job. Practice ultrasound techniques, suturing, ECG interpretation, see as many radiology images as you can, learn to distinguish between what’s normal and what’s not.
  • Last but most important, Enjoy! The ER rotation is usually amongst the best rotations an intern goes through, one where you actually feel like you are a doctor and have an impact on someone’s life! So make the best of it.
If you are a medical student starting your emergency medicine rotation, make sure to read this post for your emergency medicine clerkship, and be a step ahead! https://iem-student.org/2019/10/04/how-to-make-the-most-of-your-em-clerkship/  
Cite this article as: Sumaiya Hafiz, UAE, "Intern Survival Guide – ER Edition," in International Emergency Medicine Education Project, May 26, 2021, https://iem-student.org/2021/05/26/intern-survival-guide-er-edition/, date accessed: July 3, 2022

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