EM in a Globalized World

Terry Mulligan, in the Netherlands with daughter Louisa, is one of many American EPs dedicated to promoting the specialty around the globe.  

For Kris Arnold, an emergency physician in Boston, it started in 1976 in Guatemala.

 

He was an intern at the time, on vacation with his wife near Lake Atitlan. One night in Panajachel, Arnold and his wife were awakened by a dogs barking and cocks crowing. Moments later, the walls began to shake and their bed danced into the middle of the room. They rushed out of the guesthouse and spent the rest of the night huddled under a blanket, riding out the aftershocks. In the morning they learned that they’d survived a 7.5 earthquake, an historic disaster that eventually claimed the lives of 23,000 people.

The next day, Arnold found that the only health care resource in the town, a health aid station, was unmanned and securely locked. He broke into the building and, together with a few bomberos—the equivalent of local volunteer firemen—went from house to house caring for the wounded. When they were finished in the town, the local men told Arnold about the many outcroppings of huts in the region, the homes of coffee plantation workers. So he and five men took what supplies they could carry and hiked up mountains and down ravines, from one tangle of huts to the next.

But it wasn’t the experience of tropical medicine that set the stage for the decades Arnold would dedicate to international emergency medicine. During those days backpacking through the jungle he mostly treated cuts and bruises or reassured people that they would live. No, he would pursue international emergency medicine because of the bomberos, five men so hungry for medical knowledge, so desperate to remember enough to continue care once he was gone. It was good to care for the wounded, but Arnold knew he would come back to teach.

 

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This month, the International Federation of Emergency Medicine (IFEM) holds the 12th biennial International Conference on Emergency Medicine (ICEM) in San Francisco. This landmark international gathering will not take place in the United States again for at least 14 years. The conference will celebrate a year of unprecedented progress in the advancement of emergency medicine around the globe, thanks to a core group of dedicated emergency physicians who will do much of their service without pay, often even footing the travel bill themselves.

A global paradigm

Forget what you knew about international emergency medicine (IEM); it’s a new paradigm for a globalized world. Gone are the days when IEM simply meant the global fight against infectious disease, when American physicians would swoop into an underserved region, give a round of shots and then leave. Gone too is the sense that primary care education, like a maternal health seminar in a refugee camp, is the best that we can offer. For decades it’s been this “bottom up,” mentality, but that’s all changing. The new word is “development,” and it reflects a fresh, integrative focus that starts with the establishment of emergency medicine systems and infrastructures.

“In most of the world, emergency medicine does not yet exist as a specialty,” says Dr. Terry Mulligan, chair-elect of ACEP’s international section. “Development of a specialty . . . has multiple layers that have to be developed at the same time.” This means simultaneous, integrated academic, administrative and support personnel training. Right now Mulligan is working alongside emergency physicians in the Netherlands, helping develop these core EM systems. Meanwhile, George Molzen, MD, former president of ACEP, is in Qatar, helping evaluate and modernize emergency medical care. In India, Kumar Alagappan, an EP from New York, has spent the last decade campaigning for the recognition of an emergency medicine specialty. And these are just three of thousands dedicated to bringing EM systems to the four corners. Ambitious? Yes. Realistic? Just try and stop the momentum.

“We’ve reached critical mass where all of a sudden, in various countries, EM is being recognized,” says Indrani Sheridan, MD, an IEM conference coordinator and recipient of AAEM’s International Emergency Medicine award.

To be fair, there are a myriad reasons to get involved in international emergency medicine that are much more practical than, say, altering the course of medicine in India. Want experience? Get involved with IEM and you’ll not only experience a new culture, you might also get to practice procedures not often performed in the States, such as thoracotomies or emergency amputations. Want to become a better diagnostician? Work in a region where excessive tests are an impossible luxury. And then there are the people. According to Dr. Jim Holliman, frequent IEM lecturer and ACEP’s lead ambassador to Afghanistan, one of the greatest benefits of getting involved in IEM are the “deeply appreciative patients and foreign colleagues,” many of whom hunger for knowledge and desire to form long-term bonds.

The key to getting involved in international emergency medicine is to simply step forward. If you are traveling abroad, says Sheridan, “that might mean simply walking into the local equivalent of an ER and saying, ‘Hi, I’m an ER doc. Can you show me around?’” By the end of the day, “you will have made a life-long friend.”

Another good way to get started is to attend one of the growing number of IEM conferences held around the globe.

“If you go to one of these conferences,” says Mulligan, “you get to meet one or two thousand doctors from 20 or 30 different countries who are all struggling with the same problems you are.” The core group of leaders who actively pursue IEM around the globe – a cohort Sheridan numbers at about 75 – is particularly supportive of one another’s efforts.

“[It’s] almost like a family get-together,” says Sheridan. “We all do a little bit of the teaching, we all do some of the conferences, we all go to various places to do clinical practice.” If you show up at an IEM conference with an interest in getting involved, chances are, one of these 75 will recruit you to help.

An added benefit of  IEM events is the unity it tends to bring between EM organizations.

“When you go to an AAEM international meeting vs. an ACEP international meeting, It’s exactly the same people,” says Sheridan. “ACEP and AAEM have had their little squabbles . . . the one place where they are absolutely united is on the international front. We’re sharing information, we are collaborating on many of the conferences. When AAEM puts on a conference, many of the speakers are hand-picked from ACEP, and vice versa.”

Another suggestion from Dr. Sheridan is to start small. “It’s nice to take equipment to these developing countries, but it’s not always the best way. If they don’t have the equipment in their country, there is no point in teaching them how to use it.” Instead, when Sheridan is heading to a country that is need of supplies, she looks around the ED. “Two months before I go somewhere, I tell my people in the ER that I’m collecting, say, leftover things from the suture kit that haven’t been used, needle drivers and forceps and those kinds of things.” By the time she leaves, she usually has “buckets and buckets and buckets” of these supplies.

Many physicians connect with international projects through one of the growing number of IEM fellowships in the country. Dr. Terry Mulligan was one such physician. After completing his residency at George Washington University, Mulligan enrolled in one of the country’s first IEM fellowships. The program taught him how to set up emergency systems – from prehospital care to physician training to administration – in places that don’t have them. At the moment there are about 16 IEM fellowships currently available in the United States, and new programs are continually being created.

Dr. Mulligan summed up the issue, declaring that the time for international emergency medicine is now.

“Twenty years ago it would have been almost impossible to do international development for emergency (medicine) because it was just happening in the US, and 20 years from now it’ll be done,” says Mulligan. “This is a great window of opportunity.” 

 

Continue Next for profiles of EPs around the globe 

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Kathryn Challoner: In the war zone

It wasn’t until Dr. Kathryn Challoner’s third trip to Liberia that war broke out. She was helping to set up an emergency medicine training program when civil war boiled into the streets. It had been simmering on the outskirts for years, but all of a sudden, it was knocking at the gates and Dr. Challoner received a phone call from the U.S. Embassy.

They told the emergency physician from California that they would provide safe haven for her, but that she had to get to the Embassy on her own. And that meant driving through a war zone.

She jumped in the car with the Liberian student she’d been teaching and headed into the thick of the conflict. Along the road they talked their way through three barricades, some guarded by children with machine guns. But then, at the fourth barricade, a well-armed man motioned that they turn their vehicle and drive down an nearby alley.

The student looked at Dr. Challoner and they both new: if they drove down this road, they would be killed. So the student feigned the turn and then slammed his foot onto the gas pedal, heading straight for the wooden barricade. They crashed through, but found that the other side was no less harrowing than the alley they’d avoided. Between the car and the embassy lay an active war zone. Bullets whizzed overhead and pinged the side of the car, but they kept moving. They rolled up to the embassy doors and the student, knowing he would not be given shelter inside, pushed Dr. Challoner out of the car and into the arms of a U.S. Marine.

Dr. Challoner stayed in the embassy three days before she was evacuated to Sierra Leone in a Black Hawk helicopter. As they lifted into the air, shots still ringing below, the Ethiopian woman crammed in the seat next to her spoke for many. “I’m getting tired of this,” she said.

And yet, Dr. Challoner has gone back more than once, and she’s planning another trip next September. When asked why she continues to go, often funding the trips herself, she doesn’t hesitate. “One falls in love with the people of Liberia. They’ve had years of civil war, yet they are wonderful, warm and resilient.”

Indrani Sheridan: The network natural

For Indrani Sheridan, the path towards international emergency medicine began at birth. Born in Trinidad, Sheridan went to college in Canada, attended medical school in Ireland, and completed her residency in the United States. At the age when most physicians were hearing their first lecture about international emergency medicine, Sheridan was firmly planted in the subspecialty, traveling from India to the United Kingdom to Argentina and everywhere in between.

Along the way Sheridan helped establish the American Academy for Emergency Medicine in India (AAEMI), a group of emergency physicians of Indian descent, based in the United States, who have dedicated themselves to the promotion of the specialty in India. In 2006, she even served as the organizations president. But Sheridan’s interest in international emergency medicine goes far beyond developing the specialty in India. For years Sheridan has traveled the world attending just about every major IEM gathering, many of which she helped orchestrate. In the last few years, these meetings have grown from a few hundred attendees to over 1,000 apiece. This body of work earned Sheridan AAEM’s 2007 award for International Emergency Medicine.

George Molzen: The mid-life adventurer

George Molzen had it all planned out. The former president of ACEP had put in 20 faithful years as an emergency physician in Albuquerque, New Mexico. He’d put his daughter through college and decided it was time to try something new, perhaps transfer to a nice, sunny hospital in Florida. However, while acting as immediate past president of ACEP and the ACEP officer responsible for international emergency liaisons, he had also caught the bug of international emergency medicine. During this year, Molzen traveled to speak at conferences from Argentina to Mexico to India and everywhere inbetween. 

“It was fun,” says Molzen. “My wife likes to travel and I’ve always loved to travel.” And then, at the 2007 ACEP Scientific Assembly, this penchant for globe-hopping turned into a career move. After hearing Molzen speak to the international section a physician approached him. The physician, Alan Hodgdon, who works for the Pittsburg-based UPMC, invited Molzen to join a team that had been contracted to try and improve emergency medicine services in Qatar, in the Middle East.

“It was just at a time when my wife and I had been saying, ‘well maybe it’s time to move’.” They gave it some thought, and finally decided to try it for a year.

He’s six weeks into the stint and Molzen already knows he made the right decision. On his first shift alone he treated patients from ten different countries.

“Initially it’s overwhelming, but now it’s really fun . . . I’m having a ball.” But even better than a diverse patient mix, says Molzen, is the unique experience of working with a staff hailing from 23 different countries.

“They are gracious people,” says Molzen. “One doctor was going back to Egypt and she said, ‘Can I bring you anything from Egypt?’ I didn’t know what to ask for.”

Sure, it’s an Islamic state, but Qatar lies on the more liberal end of that spectrum. Men and women do have separate waiting rooms in the ED, recalls Molzen, but male doctors still see and treat female patients.