EPI Issue #21 by Logan Plaster

Dr. Roberta Petrino casts a vision for EuSEM Dr. Lee Wallis on IFEMâ&#x20AC;&#x2122;s latest moves Field reports: Kenya, Mexico, France and more Design your ED for the threats of tomorrow EMERGENCY PHYSICIANS INTERNATIONAL

Syrian school children at a makeshift school at the camp for displaced Syrians in Atmeh, Syria. Read our report on ongoing refugee healthcare efforts on page 16.

ISSUE 21

. FALL 2017 . WWW.EPIJOURNAL.COM

HOPE v HYPE Bringing Healing After the Headlines Cease

AN 54 1.0 07/2016/A-E

The New C-MAC®: One Step Ahead The Premium Class in Video Laryngoscopy

KARL STORZ GmbH & Co. KG, Mittelstraße 8, 78532 Tuttlingen/Germany, www.karlstorz.com

This June Mexico City will host the International Conference on Emergency Medicine (ICEM)

EVENT CALENDAR 10/17–10/18

IN THIS ISSUE www.epijournal.com

YOUR GUIDE TO GLOBAL EM CONFERENCES

Departments 14 | Med Tech

OCTOBER 2017

JUNE 2018

6th EMSSA International Conference // Sun City Resort, Gauteng, South Africa

17th International Conference on Emergency Medicine (ICEM2018) // Mexico City, Mexico

October 2-5, 2017 www.emssa2017.co.za

9th Asian Conference on Emergency Medicine // Istanbul, Turkey October 12-15, 2017 www.acem2017.org

Central European Emergency Medicine Conference (CEEM 2017) // Lublin, Poland October 18-21, 2017 www.ceem2017.pl/en/index.html

American College of Emergency Physicians Scientific Assembly // Washington DC, USA October 29-November 1, 2017 www.acep.org/sa

DECEMBER 2017

Welcome to Google Glass Enterprise Edition

16 | In The Field Flying Doctors in Syria – Care Amidst Human Devastation

18 | In The Field

June 5-9, 2018 www.icem2018.org/

What Does it Take to Make a Change?

SEPTEMBER 2018

Healthcare Drone Use Cases Take Flight

XII European Congress of Emergency Medicine // Glasgow, Scotland Date TBD http://www.eusemcongress.org

OCTOBER 2018 American College of Emergency Physicians Scientific Assembly // San Diego, California, USA October 1-4, 2018 www.acep.org/sa

4th Emirates Society of Emergency Medicine (ESEM) Scientific Congress // Dubai, United Arab Emirates December 6-9, 2017 www.esemconference.ae

LIST YOUR NEXT INTERNATIONAL EVENT FOR FREE ON THE EPI NETWORK – EMAIL LOGAN@EPIJOURNAL.COM

20 | Innovation

21 | IFEM Update Lee Wallis: Balancing IFEM Objectives with a Dedication to African EM Development

23 | EuSEM Update Dr. Roberta Petrino Casts a Vision for European EM

Reports 25 | Design Thinking Redesigning Your ED for the Threats of Tomorrow

28 | Communication Lost in Translation? Here’s a Map

30 | Cyber Security CyberMed Summit Addresses Fears of Hospitals Getting Hacked

32 | Telemedicine Canadian Telemedicine Program Brings Critical Care To the North

34 | Grand Rounds Peter Cameron: Working for the Machine

www.epijournal.com

EDITOR’S DESK

Headlines End, Our Job Remains

first learned of Emergency Physicians International at the 2015 New York Symposium on International Emergency Medicine. Dr. Craig Spencer, who is unfortunately best known for contracting Ebola during his work with Doctors Without Borders, provided the opening remarks. He lamented what he saw as misplacement of funds and efforts during the course of the Ebola epidemic. Furthermore, he expressed his concern that the rest of the world assumed the epidemic was over, since the media seemed to have lost interest. “Ebola is stronger and more committed than our indifference,” he said. “The crisis continues to unfold, and I think it would be worse if we were to look away now.” Concern over media attention was a theme repeated again and again as this issue of EPI came together. Dr. Aaron Tabor, one of our writers, explained a goal of his organization, Make a Change, in an email: “[I want] to help people realize that disaster management doesn’t stop once the interest in the disaster dies down, which too often happens.” He has seen this firsthand during his work in Haiti, which is still recovering from the 2010 earthquake long after it has ceased to be “news.” While we cannot control where the mainstream media chooses to pay its attention, we have recourse. Social media offers providers more power than ever to refocus the discussion on disaster relief and international emergency medicine development. Dr. Jessica Willet, another of our contributors, praised the power of social media to share the stories of those the world has forgotten, such as Syrian refugees still struggling for survival. Furthermore, it offers providers a chance to collaborate, share ideas, and communicate globally. For a young specialty that is still defining itself, this is vital. EuSEM president Dr. Roberta Petrino expressed her desire to use technology to create new opportunities for collaboration and sharing knowledge during this year’s EuSEM Congress in Athens. All over the world, educators are providing free online content for new and aspiring emergency physicians. We need to respect this platform and create quality work, to avoid adding noise to the onslaught of information we receive on a daily basis. But as a specialty we pride ourselves on versatility and adaptability. I have confidence in our ability to face this challenge.

Dr. Emily Thompson guest editor

editorial director C. JAMES HOLLIMAN, MD guest editor EMILY THOMPSON, MD editorial assistant REBECCA CORDER executive editors PETER CAMERON, MD TERRY MULLIGAN, DO, MPH LEE WALLIS, MD PROF. V. ANANTHARAMAN regional corespondents CONRAD BUCKLE, MD MARCIO RODRIGUES, MD CARLOS RISSA, MD KATRIN HRUSKA, MD SUBROTO DAS, MD MOHAMED AL-ASFOOR, MD JIRAPORN SRI-ON, MD editorial advisors ARIF ALPER CEVIK, MD ANITA BHAVNANI, MD KATE DOUGLASS, MD HAYWOOD HALL, MD CHAK-WAH KAM, MD GREG LARKIN, MD PROF. DONGPILL LEE SAM-BEOM LEE, MD ALBERTO MACHADO, MD JORGE OTERO, MD publisher LOGAN PLASTER

Logan@EPIJournal.com twitter.com/epijournal

Dear Dr. Cameron: Here’s why FOAM matters As Olympics approach, Zika looms large Burned out? Take a gap year to work abroad How an app could improve bystander CPR EMERGENCY PHYSICIANS INTERNATIONAL

ISSUE 19

. SPRING 2016 . WWW.EPIJOURNAL.COM

IFEM’S NEXT STEPS Incoming IFEM president Lee Wallis sets his sights on greater W.H.O. collaboration and on seeing the Federation become more inclusive of non physicians. page 16

HERNANDEZ: ‘POST LEAN’ AND THE FUTURE OF ED DESIGN

+ FIELD REPORTS FROM BRAZIL, CAMEROON & IRAQ

“We have a great opportunity to refocus and to expand from specialists in emergency medicine to providers of emergency care.” prof. lee wallis

ABOUT EPI With a quarterly print and digital distribution and an online network of more than 2,000 members, EPI is the essential hub connecting global emergency care, sparking dialogue and creating a space for new collaborations. Find copies of the print magazine at international EM conferences around the world, or read it online at www.epijournal.com

Issue 21 // Emergency Physicians International

www.epijournal.com

THE INTERNATIONAL CONFERENCE FOR EMERGENCY MEDICINE

FIELD REPORT

q Sri Lanka’s modern Colombo Harbor is a symbol of old meets new in a nation known to have one of the oldest known healthcare systems.

FALL 2017

SRI LANKA The island nation struggles to adequately staff emergency departments, but got a boost in 2016 when it hosted its first international EM conference. by dr. nilanka wickramaratne,

& dr. harendra cooray

ith emergency medicine being a brand new specialty in Sri Lanka, the most significant challenge we are facing is the shortage of emergency medicine trained specialists to staff the emergency departments around the country. The first group of EM registrars finished their initial EM training in 2016 and will soon become the first EM trained consultants in the history of Sri Lanka, but many more graduates will be necessary to address this shortage. Other challenges we are facing are the modernization of emergency departments across the country as well as developing a prehospital care and retrieval system.

But we have also experienced successes. Establishing emergency medicine as a unique specialty and training program required overcoming numerous obstacles across a decade of effort and we celebrated our biggest success in 2013: the initiation of a post graduate training program in emergency medicine. The first graduates of this program successfully completed their EM training in 2016 and hosted the Developing EM Conference in Sri Lanka in 2016 as well, which was Sri Lanka’s largest ever gathering of emergency medicine experts from all over of the world. Overwhelming enthusiasm and support for emergency medicine development in Sri Lanka has been extended from many experts all across the world including Australia, USA, Singapore, India, and the UK among many others. We also see the Ministry of Health taking a keen interest in developing a comprehensive emergency health system throughout our country. Soon, we will achieve another

Sri Lanka By the Numbers

~50%

More than half of Sri Lanka’s power is generated by hydropower

92%

Literacy rate (highest in South Asia)

21 Million Total population

555

Number of government hospitals

3000

Number of human eyes donated by the Sri Lanka Eye Donation Society (one of the biggest eye donors in the world)

milestone by hosting our first homegrown international conference in Emergency Medicine, SLEMCON, in November 2017. Most of the specialists in training of the first group emergency medicine registrars are currently working in leading tertiary care emergency departments in Australia and UK for one year prior to returning to Sri Lanka to finish as consultants. The current MD program has nearly 80 post graduate trainees training in emergency medicine and each year over 15 trainees will be completing their MD in emergency medicine. We see a bright and prosperous future for the speciality in Sri Lanka over the next decade. About the authors We are among the first MD qualified trainees in emergency medicine and belong to the first class of EM trainees. Personally we have worked tirelessly for the Sri Lankan Society of Critical Care & Emergency Medicine since 2009 to promote and establish both critical care and emergency medicine in Sri Lanka. We have been involved in organizing, instructing and promoting standard courses such as Emergency Life Care (ELC), Basic Assessment and Support in Intensive care (BASIC), Point of Care Ultrasonography (WINFOCUS), and numerous other scientific sessions on both Emergency Medicine and Critical Care Medicine throughout the island. Dr. Wickramaratne is completing overseas training in Emergency Medicine as a registrar in the emergency department of Canberra Hospital, but is enthusiastic about returning to Sri Lanka at the end of training to ensure that Sri Lanka’s critically ill patients will receive the best standard of care in emergency departments. www.epijournal.com

FIELD REPORT

q The French “stay and play” model is no longer an antagonist to the American “scoop-and run” model. The evolution of the management of severe injuries encourages a “stay load and go”.

FALL 2017

FRANCE France’s emergency care system has been put to the test in the wake of recent terrorist attacks, but this ever-evolving system is up to the task. by eric revue, md

e need to enhance the number of emergency physicians. Many emergency departments and prehospital EMS (SAMU) are struggling to recruit young emergency physicians, despite the fact that emergency medicine was successfully established as a specialty in November 2015. The fact is, the number of young physicians entering the specialty is still insufficient. The majority of emergency physicians working in the emergency department and prehospital EMS are over 50 years old and most of them wish to 8

change their specialty to another. Working conditions are another big challenge in French emergency medicine. The 48-hour (now 39hour) per week law is supposed to be attractive for young emergency physicians, but is not sufficient for the emergency department. It results in overcrowding, which has become a nationwide problem. The French Ministry of Health has given some recommendations to prevent patients for visiting the ED and to fix the boarding patients problem, but the number of general practitioners is decreasing every year, so the problems are multifaceted. The Ministry of Health has suggested enhancing hospital capacities, developing ambulatory care, involvement of administrators in bed management, and using bed managers among other tactics. A third challenge is France’s aging population, which is still grow-

Issue 21 // Emergency Physicians International

France By the Numbers

64.3 million Population (2015)

79/85

Life expectancy at birth M/F

11.5%

Total expenditure on health as % of GDP (2014) Source: WHO

ing. The number of ED visits within the elderly population is difficult to manage for many reasons, from multiple disorders to mental health issues to social problems. Implementation of the Lean process in hospitals is still rare in France and organization of ED process is still a challenge. For instance, Point of Care and Dedicated Imaging for Emergencies are not well developed. In France there is a dual culture. Pessimistic emergency teams are daily unhappy with their conditions and not ready to change, yet they can surpass themselves when a disaster strikes, like a terrorist attack. This is the “French Revolution“ mentality. The fact that emergency medicine was recognized as a full specialty in 2015 is still worth celebrating. The recognition of EM as a specialty in France is the outcome of a 40-year story since the creation of the first ambulances in the 70s for management of car injuries. The French “stay and play” model is no longer an antagonist to the American “scoop-and run” model. The evolution of the management

of severe injuries encourages a “stay load and go” model where the objective is to keep the patient alive and drive MICU to the OR. Second, while recent terrorist attacks have been devastating, they have shown that France’s management and preparedness programs against terrorist attacks are strong. All the French regions are now implementing a nationwide plan for disaster and terrorist attacks. Annual preparedness scenarios for massive attacks are updated with simulation training programs for EMT and hospitals to “be prepared to be surprised.” Equipment of MICU ambulances (SMUR) for damage control are part of the National Emergency Plans. We also celebrate that French emergency medicine is working with EMS to train their personnel for a unique and specific way to practice emergency care. Specifically, ED and EMS Leaders are working to develop new concepts of emergency medicine, like the prehospital ECMO program, initiated for out-of-the hospital cardiac arrest. This program has excellent results on survival rates. We’ve also worked to develop telehealth, telemedicine and IT solutions (Google Glass for EMS, drones for casualties events). Simulation centers are still in progress and France is trying to develop them in University Hospital Centers. Dr. Revue has more than 25 years of experience in emergency medicine. He was involved in responding to recent terrorist attacks in Paris, and is the head of a French emergency department.

We’ve also worked to develop telehealth, telemedicine and IT solutions (Google Glass for EMS, drones for casualties events). Simulation centers are still in progress and France is trying to develop them in University Hospital Centers. -Dr. Revue

PHILIPPINES Emergency medicine advocates make gains in developing localized training programs as well as national EMS legislation. by loreen cadiz-kern, md

mergency medicine in the Philippines faces several challenges such as ED overcrowding, lack of coordination for inter-hospital transfers, and EMS. There is also a lack of recognition of EM as a specialty as only 11% of hospitals in the Philippines have their own emergency department. Subsequently, there are few EM residencies, and fewer trainees. There is a ratio of 1 certified emergency physician per 157,886 population. A majority of these EM-trained doctors are also practicing in the capital, Metro Manila, while a significant number are practicing abroad. Only a handful are manning EDs in the provinces. A recent positive development in emergency medicine has been the creation of training programs in the provinces within the past five years. This has attracted local doctors with the intent of encouraging them to

practice in their regions. Local government support, especially in the renovation of emergency departments and EMS/Ambulance systems, have accompanied these training programs. Currently there are several bills for a Filipino EMS Law being considered in both the Congress and Senate. The Senate bill would create a national Emergency Medical Services System that contains provisions for an EMS system and it would institutionalize EMS as a profession. We have also been seeing a strengthening of EM linkages with Asian neighbors. The Philippines will be hosting the EMS Asia Congress in a southern city in 2018. Dr. CADIZ-KERN is a third-year resident in the department of emergency medicine at the Philippine General Hospital-University of the Philippines. The PGH is the largest hospital in the country and is designated as the National University Hospital. Follow Dr. Cadiz on twitter @lore_ckern.

www.epijournal.com

FIELD REPORT FALL 2017

Doctors march in Nairobi in February 2017.

KENYA Last year’s physician strike highlighted desperate working conditions in the African nation. by kathryn paul, ms4, sarah

leeper, md, justin myers, do, mph

rom December 2016 to March 2017, more than 5,000 doctors in Kenya’s public sector went on strike in an attempt to improve conditions for doctors and patients. 100 difficult days without public medical services followed. Outside of Kenyatta National Hospital in Nairobi, public hospitals were either closed or staffed only by nurses and clinical officers who have a limited scope of practice. This February, an attending, global health fellow, and fourth year medical student from UNC had planned to travel to Nairobi to complete ongoing research in pediatric emergency care. After years of groundwork, funding, and 10

connections had been made, they decided not to cancel the trip, despite the strike. Rather, they felt it would be an excellent opportunity to continue to further understand and appreciate the complexities of the Kenyan medical system. The following is their report on the situation, examining the factors that led to this impasse and the effect the strike had on patients. Most Kenyans are highly dependent on public sector health services. In 2013, 58% of all outpatient visits and 56% of all inpatient visits were within the public sector. However, only 6% of the GDP goes to health care expenditures, leaving public sector physicians struggling to provide effective services. Doctors in the public sector used social media to share stories (Figure 1) of working in dangerous conditions with poorly stocked facilities. Dr. Oroko, Chairman of Kenyan Medical Practitioners, Pharmacists, and Dentists

Issue 21 // Emergency Physicians International

Kenya By the Numbers

46 million Population (2015)

61/66

Life expectancy at birth M/F

5.7%

Total expenditure on health as % of GDP (2014) Source: WHO

Union (KMPDU), said physicians had come to feel that they “needed to go to school to be trained on how to supervise deaths,” due to how illequipped some hospitals are. These conditions, combined with low salaries (the lowest paid received Ksh.35,910 per month - less than $400 USD), have led many physicians to move to the private sector. 74% of Kenyan doctors work in private healthcare facilities, whose fees place them out of reach for the majority of the population. Others leave Kenya; a 2005 study shows a physician emigration rate of 51%. The physician union points to poorly funded public facilities and low physician salaries as the impetus for the current strike. At issue was a 2013 collective bargaining agreement that was signed by members of KMPDU and the Kenyan government, but never implemented, which included provisions for improvement of the public sector, as well as a salary increase for public sector physicians. The available literature addressing the effects of physician strikes on indicators of health has not sufficiently addressed developing countries in which most emergency services are withdrawn. However, one prior study in South Africa demonstrated a possible increase in mortality. The strike in Kenya was unique in that Emergency services were nearly completely withdrawn from the public sector. A series of interviews with staff at Kenyatta National Hospital in Nairobi, Kijabe Mission Hospital outside of Nairobi, and Tabitha Medical Clinic in Kibera provided

in their own words

KENYANS TAKE TO TWITTER TO CHRONICLE HARSH CONDITIONS BEFORE & DURING THE STRIKE --Kawira @joykawira7 She came in with very severe anemia. No blood in hospital, she was gasping and oxygen was unavailable. I lost her. Wambui Munjua @wambuimunjua Watching the nutritionists mix cow milk and water as hospitals could not afford formulae for the babies at the nursery. Beldina Gikundi @Naito1 Donating my own blood for a bleeding mother in maternity because there is no blood in the blood bank. Wambui Munjua @wambuimunjua Sending home a sexually assaulted child without PEP, pharmacy reports PEP out of stock. Health Transformer @bin_abeid I had to use my bare hands to stop bleeding in an HIV positive mama due to lack of gloves; instead I had to take ARVs. Jessie Shera @jessherry My senile patient set his bed on fire. There are no fire extinguishers in the hospital.

some initial on-the-ground impressions. Kenyatta National Hospital Because Kenyatta National Hospital is a national referral center, the Kenyan military employees, nonparticipants in the strike, were sent to staff the emergency department

there. Even with their presence, the impact was severe. The Accident and Emergency (A&E) department went from seeing up to 200 patients per day to around 50 patients per day. Only the most emergent of patients were seen. If admitted, patients could not be guaranteed that physicians would be available to provide inpatient care. One nurse described calling five to ten physicians before someone said they would come. Once they received a commitment, “He would take his time to come or not come at all,” the nurse said. In the week prior to our interview, KNH had admitted a twoand-a-half month old with gastric outlet obstruction, who came in with abdominal distention from a peripheral hospital. “She was seen, investigations done, ultrasound confirming gastric outlet obstruction. The surgeon…he could not come. They called the next one, he could not come. Until the last one, he said he will come, but he did not come throughout the night, so the child succumbed at 5 a.m. Yeah, it’s very hard.” Kijabe Hospital Faith-based organizations, which typically charge lower fees than private hospitals but higher fees than public hospitals, were busier than ever attempting to meet the increased demands on their services and had been forced to limit their care to the most emergent patients. Dr. Berg of Kijabe Hospital reported anecdotal evidence that their patients were of a higher acuity than usual, suggesting that they had waited longer to present for care, and mortality rates were higher for the months of the strike than of the

months preceding. Tabitha Medical Clinic The neighborhood of Kibera in Nairobi, considered the largest shantytown in all of Africa, is home to 250,000 people. A nurse at Tabitha Medical Clinic in this community explained that they had previously relied on referrals to Mbagathi District Hospital when patients required hospital level care. With district hospitals closed during the strike, they referred instead to nearby St. Mary’s, a mission hospital, where patients are often required to make a deposit prior to admission. The lowest paid inhabitants of Kibera live on $2 a day, and many patients struggle or are simply unable to come up with the necessary funds. Patients recently referred (but not guaranteed admission) included a child in sickle cell crisis, an infant in the throes of malaria, and a pregnant woman requiring a caesarian section due to a large fibroid burden. Now that the strike has ended after a promise from the government to increase salary and to develop a new collective bargaining agreement within 60 days, coordinated research efforts will be vital in an effort to quantify the impact of this conflict. Doctors should continue to deliberate the ethical and societal implications of “industrial action” in our profession. Hopefully, the aftermath of this strike will be a step forward for public healthcare and medical funding in Kenya.

www.epijournal.com

FIELD REPORT

Field Note: A blog describing the work of Sergio Castro can be found at sergiocastrosc.blogspot.mx

FALL 2017

MEXICO A medical aid trip to Chiapas leads to a deep appreciation for the work of local humanitarian Don Sergio Castro. by ken iserson, md

ayans speaking their indigenous languages and wearing their colorful traditional dress. Zapatistas intermittently blocking roads and occupying the zocalo (central city square). Abandoned 8th century cities and pyramids, great food and an escape from Tucson heat to awesome mist-covered mountains. This was my recent experience working in an indigent indigenous community of Chiapas, Mexico. I spent two weeks caring for severe wounds and burns, and other medical problems, under the auspices of humanitarian Don Sergio Castro. Our five-person team was 12

mostly volunteer clinicians from Clínica Amistad, a facility for primarily Spanish-speaking medically indigent patients in Tucson. Each day felt like two full workdays. We started early, performing home calls in the city and outlying Mayan communities. We cared for patients in subsistence communities who were too ill or injured to get into the clinic, including paralyzed accident victims and those suffering from severe diabetic or vascular wounds. Working in both Spanish and one of the two regional Mayan languages, Tzeltal and Tzotzil, we treated patients using only the supplies we could carry on our backs, sometimes hiking to get to the patient’s home. In the afternoon and evening we helped staff the makeshift clinic outside the Museo de Trajes Regionales, a small museum used to help support the operation. Patients were seen in the order they arrived.

Issue 21 // Emergency Physicians International

Our team included Vivian Shi, a University of Arizona wound care expert (L).

They ranged in age from infants – frequently suffering from boiling water burns – to the very elderly. Some injuries were minor; others required weeks of daily care. Our medical supplies were an amalgam of donated and improvised materials; there were usually barely enough to care for our patients. Don Sergio Castro has been serving the Mayan population of Chiapas for 50 years. He started as an agronomist with some veterinary training, but he quickly abandoned his government job to help build schools and sanitation systems, and to care for wounds in the Mayan communities. While he came from a wealthy background, he lives frugally, spending most of his funds on his work. Over the years, many clinicians and groups have had the opportunity to work with Don Sergio. Pat Ferrer has helped him financially and on-site for many years. On this trip, I had the privilege to learn a great deal about wound care from experts and assist in an ongoing, sustainable effort for an indigent population.

DOPLR

EPI

Watch This

Four French physicians with a passion for fine watches put their heads together to form Doplr, a Swiss-made watch with old school medical functionality. Doplr founder Vincent Azzola shares the story. For doctors, by doctors We wanted a watch which was useful in terms of our job, symbolically innovative with regard to the history of medicine, while at the same time being timeless and unique. Almost all pilots own a Breitling, which at one time allowed them to navigate the air. Why don’t doctors have their own watch brand? A storied history There exists an historical link between medicine and watchmaking. This watch existed 310 years ago! It was the first pulsometer watch invented by Dr. John Floyer, an English physician, to measure the pulse of patients. It was designed with London watchmaker Samuel Watson. Fascinated by this invention, we decided to create our own version for 2017: Doplr (pronounced “doppler”). It took 15 months of development to create the watch, in collaboration with Swiss watchmakers and French designers. An idea among friends During a vacation together, I told three friends about my idea: a watch, inspired by John Floyer’s pulsometer watch, timeless, of real quality and useful on a daily basis in our jobs as physicians. My friends were immediately enthusiastic, and we launched the project in March 2016. After 15 months of work, the first prototypes were on

our wrists. We then created a website, sent invitations to our friends and over social media. In 24-hours, we’d received 200 registrations. That encouraged us to carry on. Old school medical functionality Just like John Floyer’s first pulsometer watch, our watch is equipped with a pulsometer on the dial which can be used to measure a patient’s pulse. While not revolutionary, this accessory is as useful for a doctor as a Breitling is for a pilot. To take the pulse of the patient all that is needed is to wait for the second hand to pass the 12 o’clock hour mark, and then you count 15 pulsations. At the 15th beat, simply read the number on the scale and you get the heart rate. We have also added an asthmometer, which allows for the measurement of the respiratory rate (you can avoid having to use the stopwatch on your smartphone). As soon as the end of the second hand passes 6 o’clock, you count five breaths. On the movement of the patients fifth breath, simply read the number on the scale and you will have the respiratory rate. The watch is disinfectable and waterproof up to 100m, and tested in a sauna. You can wash your hands without fear. The watch movement is mechanical and winds automatically, so no need for a battery. Used by

<< Vincent Azzola, a French emergency physician, came up with the idea for the Doplr watch while on vacation with three friends –his future partners.

our longevity, this is not what motivates us.

the leading Swiss brands, this watch is designed to last a lifetime. And each watch is unique. As part of this limited edition the name of the owner is engraved on the inside. There will only be 300 Pulse-Watches for the first collection. Balancing life as a physician entrepreneur Finding this balance was very difficult at first. All four of us are young doctors with very full medical timetables. We had to work very hard nonstop, often late into the night and on weekends to create Doplr, but it has all been worth it. Funding challenges For the moment, we have financed the project with our own money, as we wanted to be 100% independent. We will not make any profits for several years, but even if this is vital for

A larger mission For every Doplr we sell, we donate 25 euros, the equivalent of a medical consultation or 15 anti-cholera vaccinations, to Médecins Sans Frontières. We would like to do more in the future and create partnerships with other associations. That’s our vision for the company. Advice for physician entrepreneurs It takes a lot of time and energy, and you have to expect many setbacks and surprises. But at the end of the day, the simple fact of holding in your hands a beautiful object that has come from your imagination is worth all the sacrifices. If something fires your imagination, do it! Read the full interview with Vincent Azzola at www.epmonthly.com

order your unique Doplr watch at

D O P L R - W AT C H . C O M www.epijournal.com 13

Med Tech

Welcome to Google Glass Enterprise Edition Google’s reboot of its much-hyped augmented reality headset takes the device in an important new direction. Through targeted projects with “Glass Partners,” Glass EE is poised to find important applications in healthcare.

by Scott Jung

Issue 21 // Emergency Physicians International

oogle Glass Explorer was announced to the public with much hype in April 2012 by Google co-founder Sergey Brin. Many speculated that Glass and the new class of devices it would subsequently create would be the next evolution in personal computing. In the original product announcement video, Google presented a vision of the future in which Glass would merge the physical world around you with your smartphone, placing navigation, emails, and social media literally within eyeshot through the use of augmented reality. Google Glass Explorer was initially received with much excitement, however, the device was buggy and with a price tag of $1,500, too expensive for widespread adoption. Price and technology issues aside, Glass also entered a market that was not yet ready for such a novel technology. Privacy and security concerns were foremost, as many were uncomfortable with the notion of Glass recording them without permission. Lawmakers were never able to reach a consensus regarding whether Glass should be considered a recording device that would be banned from certain public establishments or a potentially obstructive monitor that would be prohibited from use while driving. Google officially discontinued Google Glass Explorer in 2015. While Glass’ departure came with a somewhat generic “We’ll be back soon!” statement, it still took many by surprise in July 2017 when Google announced a new version of its wearable known as “Google Glass Enterprise Edition” (Glass EE). So what’s different about Google Glass EE, and has Google learned from the mistakes of its past? On the technology side of things, Glass EE is still an optical, head-mounted computer with a transparent display that brings information into your line of sight. However, the form factor has been completely redesigned to optimize the way it folds, charges, and even resists sweat. Most notably, Glass EE can be clipped onto a pair of glasses or any type of industry frames, such as safety goggles. Glass EE also incorporates upgraded electronics that make it faster

A new training program at Loyola in Chicago will teach medical students how to incorporate Glass EE into a homecare visit.

and more reliable, as well as more secure. Moreover, battery life has been increased and the camera has been upgraded. And for those with privacy concerns, Glass EE has a green light that turns on when a video is being recorded. Technology upgrades aside, Google has taken a more restrained marketing approach this time, launching Glass EE in a market that

is a little more primed for change: the workplace. At the time of writing, Glass EE is only available through a dozen companies that Google calls “Glass Partners.” Consisting primarily of manufacturing, logistics, and healthcare companies, these Glass Partners have already been using Glass EE for a couple years, all with statistical evidence to support how Glass EE has helped them work faster and more efficiently. And there are no smartphone notifications and no tweeting; Glass EE can only run the single application that its Glass Partner has developed. Only time will tell whether or not Google Glass will find its way back into the consumer space. But until then, enterprise users should be excited that they’ll be at the forefront of technology this time around with a device specifically designed to make their jobs easier.

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In the Field

A Syrian woman in a camp for displaced persons in Atmeh, Syria.

Flying Doctors in Syria – Care Amidst Human Devastation For one physician, an opportunity to provide humanitarian aid to Syrian refugees created a burden almost too heavy to bear. Yet in the end, even having a small impact on health proved a worthy effort.

by jessica willett, md

child is born in a refugee camp. Without access to any food besides breast milk, he grows slowly. He does not receive enough Vitamin D and develops rickets. An eight-year old child watches his family die in an explosion. From that point on he is mute, too psychologically traumatized to speak. A ten-year-old girl, trapped in a fire, suffers burns to more than 50% of her body. She survives but is horrifically scarred, both 16

Issue 21 // Emergency Physicians International

physically and mentally. A pre-teen boy loses his father to bombing and becomes his family’s sole provider. He is then injured in a farming accident and, without medical care, is forced to heal on his own. The permanent deformity to his leg now affects his ability to work. A teenager finds a dead body while playing with his friends. The image haunts him in his dreams – nightmares that mirror his reality. A father raises his children alone after his wife dies from a preventable disease. He feels helpless when he can’t provide them with a home or an education. A mother falls into a deep depression after her family has to leave everything behind overnight. She now lives without running water or electricity in the stifling heat of the Jordanian desert. For those living in Syrian refugee camps, these situations are the norm. These and many other stories were passed on to me by those who lived them, and who are still living them. While the rest of the world has moved on, the effects of the Middle Eastern conflict continue to ripple. My personal goals in international work have evolved through the years, impacted by my education and experiences. I currently work with a handful of small organizations, as well as a larger group, the Flying Doctors of America. The Flying Doctors were created in the 1990s as a non-profit, non-sectarian organization. Their mission statement aligns with my own, with the goal of pro-

viding “hope & healing” to marginalized populations around the world. While many medical missions provide a similar function, they are often religiously based. In certain locations, religion can have an impact on how medical care is received. The neutrality of Flying Doctors lends itself to trust and reliability. This is important not only to medical care, but also to volunteer safety in politically charged areas. My prior experience in international settings touched the surface of humanitarian work, but I could not have predicted how my time with the Syrian refugees would change my perspective. In the midst of such devastation, how do we as outsiders make a difference and leave these lives better than we found them? As a physician, I am trained to look at a big picture and identify systemic problems within a community. With displaced populations, this becomes more complex. Limiting communicable diseases takes priority over diabetes education. Water sanitation trumps hypertension. The epidemiology within refugee camps completely shifts the typical goals of healthcare. Our organization works to make small changes that will be cumulative over time, but it often feels like bandaging a wound that will quickly bleed through. In Syria, as in most settings of displaced persons, communicable diseases spread rapidly due to close proximity and unsanitary living conditions. Patients with skin infections and parasitic diseases were numerous in my small mobile clinic near the Syrian border. All of these illnesses are medically treatable. More concerning was the mental health of those who walked through my door. “How long have you been in the camps? Who lives with you? What are your living conditions like? Are you having nightmares?” I asked them, steeling myself. There was no way to prepare for their answers. Often, I had to take a moment in between patients to wipe tears from my eyes. The extent of physical and emotional trauma witnessed in the chaos extends beyond post-traumatic stress disorder. The Syrian conflict has given birth to a new term: human devastation syndrome. It is not uncommon for entire families to be wiped out, leaving one or two survivors with an unimaginable burden to shoulder for the rest of their lives. The Adverse Childhood Events study on childhood stresses emphasizes that traumatic incidents early in life significantly impact mental and physical health into adulthood. Children who bear witness to tragedy and loss face an uphill battle, and healthcare is only a fragment of this. The power of the Syrian conflict to transform an entire generation is unthinkable. Before they fled their home country, many refugee families were working middle-class, with an income, education, and lives they were proud of. They now live in tents in random camps¬, finding work from day to day. They struggle to raise children without access to healthcare, schools, and in many cases, food. Infants, born in the camps daily, often die because of harsh living conditions. With no birth certificate or documentation of their existence, it is as if they simply vanish. As the eyes of the media have turned away, many Syrians fear they will vanish as well. They asked me to

return home and share their story – to help them overcome this feeling of invisibility to the rest of the world. For the past five years, conflict in this area of the world has had a devastating impact on humanity. For a time, it was at the forefront of the news: photos of Aleppo before the war were contrasted with the vast expanses of rubble and heartbreak that exist today. The mainstream media exploited suffering for viewership. While ethically questionable, attention paid by the media influences the public’s desire to participate in ongoing relief efforts. However, the sheer availability of global media coverage today contributes to information overload. The scale of suffering in crises like the Syrian conflict can lead to compassion fatigue in viewers, influencing those who create the news to focus elsewhere. But the crisis is not over because the cameras are off. Social media allows us to swing the focus back to the refugees, honoring them by sharing their stories. Social media also allows healthcare professionals to make connections and work together remotely. Perhaps more importantly, it can serve as a bridge from burnout back to functionality. While incredibly rewarding, working against the intractable problems of the Syrian refugees also led to feelings of despair and inadequacy. I was able to share their stories as well as my own experience on my blog. I could also connect with like-minded individuals via other forms of social media, which helped me to rekindle my passion for humanitarian work. Now that I have returned to the United States, I can stay connected with Jordanian medical students and organization leaders. Maintaining lines of communication lends itself to continued discussions, and planning of future projects. Although my time working directly with the Syrian refugees was limited, it impacted my approach to humanitarian work drastically. I don’t have the answers when it comes to fixing these big problems. I do know, though, that the human spirit is resilient beyond measure. In times of conflict such as the Syrian crisis, this resilience keeps entire populations moving forward, while also motivating us as healthcare workers to continue our work for them. When I returned to the US after working in Jordan, I continued to ask myself if I had truly made a difference. Successful international interventions depend on sustainability, but I found that with displaced populations, this is much more difficult. Healthcare is complex, and the most successful measures require a sustained, multi-disciplinary approach. It is difficult then, to imagine a powerful impact from a small team of healthcare workers in less than a month. But is a small difference better than no difference? When it comes to health, absolutely.

In the Field

What Does it Take to Make a Change? A medical aid trip to Haiti during medical schools sparked a desire to have a lasting impact on global health, long after the disaster relief teams have gone home.

by aaron tabor, md, mph

stood in a small emergency room in Fond-des-Nègres, Haiti, during my third year of medical school. The chaos of injuries from multiple vehicle accidents unfolded in front of me. Someone handed me a bag of supplies, indicating that I should start placing IVs, stitching lacerations, and setting broken bones. This was my first real exposure to emergency medicine. Fear gripped me—but so did excitement. I observed for few minutes, watching the only other doctor perform her duties. Then I took a deep breath and started to work. Over the next week, both day and night, I was there for every accident. Even though I was a student, I was often responsible for managing the care of patients in their emergency room. This launched my career into emergency medicine and solidified my niche in global health. The earthquake that struck Haiti in 2010 left an already devastated country even more broken. Initially, relief poured in, millions of dollars were donated, and health care providers flocked to help. Then, one day, it all stopped. Newly-built clinics were left empty. Projects were started and left unfinished. Patients who managed to see a doctor were abandoned. This happens all too often with global disaster relief: once the dust settles from the immediate catastrophe, there is a perception that emergency services are no longer needed. Emergency physicians are some of the most well-equipped first responders to disasters as they can be thrust into the unknown and thrive. However, I would argue that when the disaster dies down, emergency physicians are still needed. As I prepared to leave Haiti, the hospital staff told me that they hoped I would return. I could tell by the look in their eyes that they really meant it. It wasn’t a polite “hope to see you again,” but a plea: “We need help. Please come back.” During my final year of medical school, I spent a month with a fellow medical student in the Republic of Congo. We left the day after match day, so our futures were secure—he was starting in general surgery and I was going to be an emergency physician. We flew for over 30 hours to the jungles of Impfondo, and took a jeep down rugged roads to arrive at the hospital campus. Originally designed as a communist camp to indoctrinate youth, it was reclaimed to provide emergency, surgical, medical and obstetric care. I was thrilled to find out that the doctor I would be 18

Issue 21 // Emergency Physicians International

working with was emergency trained, and I was stunned by the vast skillset of the local doctors. The hospital’s isolation made it nearly impossible to reach any outside surgical facilities, so the family and emergency physicians had learned to perform surgeries. They operated every day, doing whatever was necessary: bowel resections and anastomoses, cesarean sections, hernia repairs, and hysterectomies. Beyond that, daily activities consisted of rounding in adult and pediatric wards, addressing acute problems in the ER, managing clinic patients, and delivering babies. They were on call 24/7. They were the most well-rounded physicians I had ever encountered. I wanted to be like them. One morning, the midwife interrupted rounds to ask for help with a breech baby. They had tried on their own, but once the body was delivered, the head became stuck. We sprinted across the outdoor campus to the OB ward, delivered the baby and attempted resuscitation. We were unsuccessful. Maybe with more resources, I told myself as we returned to rounds. Maybe next time. Soon we were interrupted again. A 4-year-old girl arrived with a fever of 105 and intractable seizures. Her parents had overdosed her anti-malarial medications to try to cure her faster. I ran into the room and started the resuscitation with only one nurse. The patient’s glucose levels were undetectable, so we scrambled to mix dextrose and draw up Ativan. We were out of Tylenol, so we attempted to cool her with water and cloths—there is no ice in the 110-degree jungle. The Ativan didn’t work, and the parasites and the medication ate up the sugar as fast as we gave it. I knew we

...though the needs fade from the public eye, the disasters continue. These are not problems that can be fixed or solutions that can be finished so easily. However, as emergency physicians we have a vast arsenal at our disposal: broad medical knowledge, procedural skills, ultrasound, disaster response training, and public health. We are uniquely suited to make ripples.

had phenobarbital somewhere, but in the heat of the moment we couldn’t find it. After twelve hours, I was too exhausted to continue the resuscitation. The little girl passed away. I found the phenobarbital in the storage closet a couple of days later. This was not an abnormal day in the Congo and there was no time to stop. Another child came in with shortness of breath. With our bedside ultrasound, we found that his pneumonia had turned into a pleural empyema, so we placed a chest tube. Our HIV patient was decompensating, and we were concerned he had toxoplasmosis of the brain. With limited resources, we struggled to do our best for each patient. Prior to medical school I earned my master’s in public health with a focus in community nutrition. The more I learned about medicine, the more I wanted to tie in public health practices. Experiences abroad quickly opened my eyes to the need for sustainability. I wanted to answer the plea of the Haitian doctors, but I wanted my efforts to be long-lasting, reproducible, and selfsustaining. I couldn’t do it alone. The change needed to be bigger than me. In my final year of medical school, with incredible support from close friends and family, Make A Change International was born. We hoped to bridge some of the gaps between what other groups were already doing around the world and provide solutions to the lack of sustainability in global health. Mother Teresa said, “I alone cannot change the world, but I can cast a stone across the waters to create many ripples.” We wanted to create ripples. Since starting Make A Change International, we have partnered with multi-disciplinary groups including internal and emergency medicine, otolaryngology, and orthopedic, gynecologic, and

general surgery. We have supported projects in the Dominican Republic, Haiti, India, the Philippines, the Republic of Congo, Rwanda, Honduras, and South Korea. Our focus is on establishing partnerships with global organizations and health providers, to empower the local communities in sustainable development. One of our partners has focused on public health projects, such as a water treatment facility. This led to drastic health improvements, initiated local collaboration, and built trust. In addition, it created a business opportunity for the town to sell clean water, providing a source of income to hire local physicians and nurses to staff clinics. Coupling budding infrastructure with developing primary care services is leading to further advancement, including the ability to offer surgical services and development of ultrasound training. Now I’m a third-year emergency medicine resident in Detroit, Michigan. I have had excellent training, and learned to work in a resource-limited setting in my own country, as well as abroad. I’ve recently returned to Haiti, where I had the great privilege of taking a multi-disciplinary team of pediatric, emergency, and internal medicine physicians, emergency nursing, and pharmacy staff. I partnered with the same group I worked closely with in medical school. They allowed me to use their clinic in Jerusalem, a mountainside community that was built after the earthquake. We planned for 60 patients a day, but that number soon rose over 100 as adults and children lined up to be seen. I had the consulting power of medicine and pediatrics on my side, and I am gaining the skills of the physicians I admired in the Congo. I felt ready. A patient arrived in hypertensive emergency, so I placed an IV and started medications. An elderly woman had dislocated her shoulder a week prior; we rigged up some cloth and some rocks and let the weight slowly pull the joint back into place. I had etomidate if I needed it for sedation. A young man with necrotizing fasciitis of his finger refused amputation. He received antibiotics and left. Sadly, I never heard back from him and I expect the worst. A woman who was 26 weeks pregnant arrived hypotensive, febrile, and had started bleeding. I didn’t have an ultrasound machine with me, so we gave IV fluids and antibiotics and sent her to a hospital. She couldn’t pay and wasn’t seen. A man came in with a knee effusion, which a local practitioner had attempted to treat with leeches. We drained the fluid so he could walk and work again. A man had an angiosarcoma growing out of his eye for so long that it covered half of his face. We removed it so that he could eat. This is the reality of global health in this community and many others around the world. Though we have small victories, though the needs fade from the public eye, the disasters continue. These are not problems that can be fixed or solutions that can be finished so easily. However, as emergency physicians we have a vast arsenal at our disposal: broad medical knowledge, procedural skills, ultrasound, disaster response training, and public health. We are uniquely suited to make ripples.

www.epijournal.com

Innovation

Healthcare Drone Use Cases Take Flight In a few short years, the use of drones in healthcare has gone from a speculative side show to a firm reality. Since drone technology is available to the masses and the FAA instituted drone regulations in 2016, it’s now simply a matter of inventing new use cases and applying these tools to deliver time critical and lifesaving resources.

by jeremy tucker, do

hile there are a myriad of uses for drones in rescue scenarios (think drones dropping life preservers to drowning surfers), their applications in actual healthcare delivery have so far been more limited. Some of the limitations have been due to the technology. Although improvements continue to be made, payload and battery life remain limiting factors to many situations. While FAA regulations have been established, they are fairly restrictive and most—if not all—applications would require a waiver of one or more of these restrictions such as the ability to fly beyond the line of sight, fly over people, or fly at night. Here are three current use cases that have been developed for drones in healthcare. 20

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Zipline's fixed wing drones got their start dropping blood products in Rwanda, but they're coming to the USA soon.

1. The Telemedicine Pack

2. Rapid AED Deployment

3. Medical Supply Delivery

Dr. Italo Subbarao and Dr. Guy Paul Cooper from Carey University Medical School have developed a telemedicine pack that can be delivered by drone to provide medical services to remote populations. This drone is an octo-copter and can carry about 20 lbs and fly up to 40 mph. It would be summoned to fly to a GPS point near the victim. It can carry a medical “suitcase” that has variable equipment depending on need, such as medical supplies for trauma including inflatable splints, dressings, clotting sponges, tourniquets, etc. The pack contains a video connection to a medical provider who can direct the bystander to render first aid to the victim. Before actual clinical use can occur, a number of FAA regulations will need to be waived or modified when it becomes clear that drones can safely share airspace even in our busiest cities.

Defibrillators are in malls, airports, and wherever large crowds of people gather. But what about more remote locations such as golf courses, parks, and rural America? AED delivery to a victim of cardiac arrest is possible with an AED drone developed at Delft University of Technology in the Netherlands in 2014. With the touch of an app or a text, an AED could be summoned and on the scene very quickly. They claim that they can reach a victim within 7.4 square miles within 1 minute. A research letter published in the Journal of the American Medical Association in June, demonstrated a median response time reduction of 16 minutes over standard EMS response times in simulated cardiac arrest around Stockholm, Sweden. While this has been developed, it’s practical use will also require FAA waivers in the United States.

Delivery of medical supplies, including vaccines, medications, and blood products, are another compelling drone use case. Zipline currently delivers blood products and medical supplies in Rwanda. Initiated by a SMS text and using a fixed wing drone, their delivery network allows them to rapidly deliver supplies to hard-to-reach areas. Their drone allows delivery up to 75 km away and in most weather conditions, including high winds and rain. Their drones are limited to 1.5 kg of payload, but their network has an average fulfillment time of 30 minutes and the capacity to do 500 deliveries daily, according to their website. Zipline is also trialing delivery in the US to remote island populations in Washington State and the Chesapeake Bay.

IFEM

The bulk of IFEM work and activity lies in committees and interest groups, but there is a frenzy of behind to scenes work. The IFEM Foundation is a US-based charity that receives donations in support of IFEM’s work. Now 18-months in the making, and still in its very early stages, is the IFEM Institute, which will be an organization attached to IFEM that does educational and system development work with in-country partners. We already have a couple potential projects lined up which are ready to get off the ground when the Institute is up and running. IFEM is a volunteer organization and it’s a priority to continue to make it more sustainable. One pressing reason for this is that we’ve been collaborating with the WHO on projects related to emergency care systems development, and to continue to have that opportunity we need to be a sustainable organization.

Wallis: Balancing IFEM Objectives with a Dedication to African EM Development Dr. Lee Wallis has nine more months as president of the International Federation of Emergency Medicine (IFEM) and he’s going out with a bang.

interview by rebecca corder

EPI: What’s going on in IFEM’s world? Dr. Lee Wallis: These are very exciting times for IFEM, as always, which is both invigorating and exhausting in equal measure. The spectrum of things going on amongst the membership is really inspiring. Some recent highlights. There is a position paper coming out on crowding in emergency departments, stemming from the Netherlands Society’s June symposium. Crowding in emergency departments is a major problem worldwide. There are talks with the Ministries of Health in Guatemala, Spain, and Tonga, lobbying for support of emergency medicine development. There are new special interest groups for critical care, behavioral emergencies, and trauma.

EPI: What’s the latest with the African Federation for Emergency Medicine (AFEM)? Wallis: I’ve returned to some within-Africa travel this year, which has been nice. Kenya just had their first emergency care conference. EM is now a recognized specialty in Kenya, and they’re working to launch an EM residency. Uganda is about to launch their first EM residency, too, and AFEM has been involved in its development. The Emergency Care Outcomes Project in Uganda and Tanzania pushes on; we’ve completed a year of pre-intervention data collection, implemented the intervention package, and are now a few months into the year of post-intervention data collection. We are limited by the resource envelope and sample size, but the central goal is to add robustness to the literature supporting the value of low-cost interventions – like triage and clinical checklists. With ECOP we’re directly measuring mortality as an outcome. We have teams on the ground in Uganda, Tanzania, and Cape Town. A challenge for both IFEM and AFEM is that our new members, inevitably, are almost always countries without established emergency care systems, and often are looking for longitudinal partnership that necessitates more than trainings that last two or three days around a conference. Longitudinal engagement is challenging for both AFEM and IFEM considering the limited resources; it’s a question of how thin you can spread our resources and still make meaningful impact. I find it a source of personal frustration; I feel like I’m always letting people down. Part of my job as IFEM President is managing member societies’ expectations on what IFEM can and can’t bring to a problem. EPI: How do you prioritize all the different projects and partnerships in IFEM’s pipeline? Wallis: for my personal involvement or travel, it mostly has to be on a first-come, first-serve basis, depending on what else is going on that year and what level of resources exist and are needed. I’m very poor at saying no. This is a problem of my own. And I’m very good at telling people who I’m mentoring that you have to learn to say www.epijournal.com

I’m very poor at saying no. This is a problem of my own. And I’m very good at telling people who I’m mentoring that you have to learn to say no, and I’m very pleased when people start saying no, unless they start saying no to me, in which case it gets very awkward. no, and I’m very pleased when people start saying no, unless they start saying no to me, in which case it gets very awkward! I try to limit project travel to three places per month, because after all I have a day job and a family. This year has been crazy for travel. I’ve been all over, some places I’ve been before, and some places I hadn’t been. EPI: I imagine it’d be hard to find a place you haven’t traveled to at this point. Wallis: Ha… I went to Singapore for the first time. And Bethesda [Maryland, USA]. And everywhere in between. Because everywhere is so difficult to get to from Cape Town there’s never really enough time on the ground to appreciate the culture, the people, and the place that I’d want. You go to Seoul for 2 days and you’ve seen the inside of a conference room. Thankfully, Abbi [wife] will be joining me in Mexico City for ICEM 2018 in June. We’ll stay after for a week. And for the EMSSA Conference in October the family will join, and the kids will enjoy Sun City.

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WHO Welcomes Emergency Medicine Representation

mergency care finally has a seat at the table at WHO. Since 2015, Teri Reynolds, EM veteran, has been working within the WHO Department for Management of Noncommunicable Diseases, Disability, Violence and Injury Prevention (NVI). Reynolds has long been involved with AFEM work, and in AFEM and IFEM has found sound implementation partners for certain projects regarding emergency care system development and assessment. “The fact that we’re invited to be at the table helping to influence thinking on global emergency care system development… we’re contributing formal and constructive input” reflects Lee Wallis, IFEM President. Specific projects IFEM and AFEM have collaborated with WHO on include the Emergency Care Systems Assessment (ECSA) implementation, the Emergency Care Outcomes Project (ECOP) and the Basic Emergency Care Course (BEC). These initiatives help to define and measure the emergency care system, assess its clinical impact, and train front-line clinical providers. The ECSA tool was developed by Reynolds and her team at WHO, and has so far been implemented in over 25 countries. AFEM has collaborated on ECSA implementation in several African countries including South Africa in September 2016 (see photo). “Ministries of Health have great interest in the ECSA because it allows them to produce a strategic roadmap for systems improvement,” says Lee Wallis, who played a big role in the South African ECSA process. The ECSA process takes place on the national level and consists of a comprehensive survey taken by a range of emergency care system stakeholders, followed by a 2-day working group discussion on survey results. The outcome of the working group discussion is a list of concrete action priorities, ranked by working group participants according to chosen factors such as political will and resource burden. The final deliverable is a written report directed at Ministers of Health that outlines strengths and gaps in a country’s emergency care system ,and provides actionable items to address system gaps. The pilot BEC course has been widely piloted and the final version will be released this year, and is co-branded as a product delivered by WHO, IFEM, and ICRC.

EuSEM

Dr. Roberta Petrino Casts a Vision for European EM The president of the European Society for Emergency Medicine (EuSEM) is looking forward to an innovative, interactive conference in Athens, and to a bright future for emergency medicine in Europe.

interview by emily thompson, md EPI: Tell us about your own journey into emergency medicine. Dr. Roberta Petrino: When I started many years ago, emergency medicine [did not exist] in Italy…I started as a gastroenterologist…I found out very soon after one or two years that what mostly excited me was the emergency care, critical patients in an emergency. I remember when I first started, decided to do this job I said I had to learn what to do. And so I asked my general manager and my chief to send me to the United States, because I knew that the US had a system that was already developed. So I went for a few months in New York at Mt Sinai and stayed there to learn and to see what to do. It was really very exciting. EPI: How did you develop as an emergency practitioner in Italy? Petrino: In Italy there was a group of people who were feeling that that the emergency department needed to be better organized with better professionalism and proficiency. We were kind of pioneers. We were the first to build up a training program, a short training program, one year. The Italian Society of Emergency Medicine was created, and started to work with the government, the Ministry of Education, to set up the specialty. It took about 15 years, and in 2009 we had the first training program in Italy. Another very important point was the development of the European Curriculum of Emergency Medicine. Again I had the fortune to be the chair of the group that wrote the European Curriculum of Emergency Medicine. It came out in 2008/2009. It was a job that was done by a multinational group. We had representatives from each national society that was part of EuSEM. It was again a very important move because many countries adopted it. Even Italy

that was developing its training program for the specialty, adopted the European curriculum as a guideline for developing ours. EPI: So you became involved with EuSEM organically, in that you were interested in emergency medicine and then deeply involved in its creation? Petrino: I worked for European emergency medicine from the very beginning…more than 15 years. I had the opportunity to write the first edition of the curriculum, which was very short and very basic, in 2002. Then the second and more comprehensive one was in 2009. And then I promoted the development of the European Board Examination in Emergency Medicine (EBEEM). EPI: You have worked with emergency practitioners from all over the world. Why is global collaboration important in emergency medicine? Is it more or less important than in other specialties? Petrino: We think that global collaboration is important in general in medicine because patients are patients everywhere in the world, so the advancement of knowledge is important everywhere. But in particular for emergency medicine, because you may find when you are travelling that you may not get a good treatment everywhere. From a cultural point of view [we need] to make very clear that the right to be cured in an emergency is a universal right. Anywhere, in any place, all people have the right to be cured in an emergency. Even in the poorest place in the world…It is important that the quality of emergency care is the same everywhere...So to do that it is important to have a global collaboration, to have an exchange with colleagues from all over the world. And the places that are more developed [should] give a hand to the places that are still developing. EPI: What are some of the challenges with developing emergency medicine across a continent with as many diverse cultures, languages, and lifestyles as Europe? Petrino: It is very challenging because emergency medicine is coming from different traditions and origins in different countries. In some [it originates] from pre-hospital [care], in some others from the hospital….The different languages are a barrier, but not too [serious] because the young generations of doctors and nurses are widely English-speaking, in particular in all northern and central Europe… There is a great tendency [toward] “cooperation” in the process of developing EM. This means that some doctors are traveling and exchanging experience in other countries, and then go back to their country of origin and build up the experience. I have been in several countries, like Serbia, Croatia, Slovenia, Romania, Hungary, Slovakia, and others, and I have found a lot of commitment in the

“

Anywhere, in any place, all people have the right to be cured in an emergency. Even in the poorest place in the world…It is important that the quality of emergency care is the same everywhere...So to do that it is important to have a global collaboration, to have an exchange with colleagues from all over the world. And the places that are more developed [should] give a hand to the places that are still developing. -Dr. Roberta Petrino, President of EuSEM development of Emergency Medicine according to the European Curriculum and the European rules. EPI: Do you think there is an EM practice structure or system that will work across all countries in Europe? What would that system look like? Petrino: I think there is a common structure that is based on competence. The [European] Curriculum, which is now being revised, [presents] all the competencies for the emergency physician. These are not only clinical, but for communication, organization and management, ethics, research, and education. There are [recommendations] on the structure of training, and on the standards for an emergency department as a training center. Following these [recommendations], the emergency medical systems must be organized in a common way, and the standard of care should be similar. We know that at the moment this is not yet so, but the process is on this way. The development of the European Board Examination in Emergency Medicine is a way for certifying this process and these competencies. In any case, a system should have a strong hospitalbased emergency department. EPI: EuSEM lists a commitment to public health as one of its tenets. What is the emergency physician’s responsibility to public health? Do you have any examples? Petrino: Our commitments are not only clinical, but also aimed at prevention, and the education of patients and population. One important example is the development of safety equipment on cars, which was [pushed] by the campaigns made [about] damage and death due to car accidents. The same could be [done] for prevention in disasters, or even during the response to disasters…Another very recent example [of a problem that needs to be addressed] is the wave of mood against vaccines that is circulating in these last months. So basically [we promote] a commitment…based on personal communication to the patient, on more comprehensive action on public health promotion. 24

Issue 21 // Emergency Physicians International

EPI: What are your goals for this EuSEM conference in Athens? Are there particular overarching themes or topics you hope to address? Petrino: We are presenting a new format for the conference…We will have of course the updates and keynote lectures, but we will have many sessions that will be much more interactive with pros and cons, with question and answer to the audience, with interactive items like voting systems with cell phones…so we are trying to be a bit more social and more modern, and to involve the audience in the discussion. We will have the Sim Wars, simulation sessions…There will be two teams that will be playing together with two mannequins and two identical scenarios at the exact same moment. There will be a big networking lunch where the young doctors will meet the older people like me (laughs), and we hope to bring inspiration. Any person that may want something from us can propose a collaboration. We have a nice social program for networking…Of course we have developed the not very “hot” topics like geriatrics, pediatrics etc... but also disasters, refugees, the problem of [both] natural disasters and [man-made] disasters, so the terrorist attacks and so on that are so important at this moment in Europe right now. So, of course, we need to be present in this problem. EPI: How would you like to see emergency medicine training evolve over the next decade? Petrino: It is now very well established that emergency medicine is best trained by simulation exercises and real-scale exercises. For this reason we are promoting courses that encompass such for training, and [supporting] that the EBEEM is based on clinical scenarios on high fidelity manikins and human role players. The implementation of simulation environments that [reproduce] the ED [environment], for example the shock room, will increase the experience of learning, and should reduce drastically the rate of errors, with the possibility to review and criticize the simulation session. Continued on page 35

R report

// design thinking

While secured by key card access, the reception, triage, and entry points to ED treatment areas still provide lines of sight through glass and interior windows. (Project: Centre hospitalier de l’Université de Montréal (CHUM), Montreal, QC) © Christopher Barrett Photography

Redesigning Your ED for the Threats of Tomorrow Every day it seems that emergency departments become more hazardous places to work. But there are proven design strategies that can help create a safer zone for patients and providers.

by manuel hernandez, md

t’s a typical Thursday evening in the emergency department. Treatment stations are fully occupied. Physicians and nurses are busily tending to patients. Families come and go from the department and the waiting room is full

of patients waiting for their turn to receive care. Suddenly, chaos ensues. Maybe a patient under law enforcement custody overpowers an officer, gains access to a firearm and opens fire. Or a psychiatric patient not properly supervised stabs a nurse with a sharp object from her treatment area. Perhaps an individual, seduced by the opportunity for martyrdom, detonates an explosive vest, sending shrapnel and other projectiles in every direction. In another part of the world, a gang member with a gunshot wound is in the trauma resuscitation bay when a rival gang member enters to finish what

he started on the street. Or a lone criminal holds the emergency department staff at gunpoint in an effort to steal narcotics from the department’s medication dispensaries. Different emergency departments, different challenges, but the same unfortunate outcome. Every day in emergency departments around the globe, safety and security play front and center in the minds of hospital staff. With the increasing frequency of terrorism and mass acts of violence, most hospitals are focused on developing systems and plans to respond to the massive influx of patients associated with external disasters, yet few have exerted the same effort to design their emergency department to withstand such an incident with a minimal impact to life, limb and property. Many hospitals focus on preparing for pandemics of influenza, ebola, SARS and the like, yet few consider how to protect their emergency departments from violence. A review of the literature on planning hospitals for safety and security shows that information in this area is limited, with most research www.epijournal.com

R report

// design thinking

focusing on preparedness, not solutions focused on withstanding a direct assault on the emergency department itself. Planning for Safety and Security Begins at the Beginning The time to plan for safety and security in a new emergency department is at the inception of a design project. Identifying the types of risks that need to be mitigated, the size and scope of the events and the likelihood of such an event are all important aspects of conducting and initial risk-benefit analysis of what types of safety and security events should be designed into a new emergency department. Once potential risks have been identified, emergency department staff, hospital leaders, and design professionals should identify safety and security performance expectations. These metrics should then inform the types of solutions that will be required. Some performance and success expectations may require a built environment solution, while others may be best handled through modifications to operations, policies, staffing or technology. A final, but essential predesign consideration is understanding the budget for an ED design project. While there are a number of beneficial design and technological solutions that will enhance safety and security, each comes at a price that is often a premium over traditional design methods, construction materials and overall equipment. Understanding budgetary constraints will enable emergency department and hospital leadership to make informed decisions regarding the value of each investment made. It is also important to consider how each of the safety and security measures planned for inclusion in a new emergency department design will impact future flexibility and adaptability of the spaces. For example, blast-resistant safe rooms are much harder to move or expand than spaces separated by aluminum framing and sheet rock. Specific Design Components to Enhance Safety and Security There are a wide variety of design options and building materials that can assist with 26

mitigating the impact of safety and security issues. Each department should consult with their design and security professionals to consider which materials are right for the new emergency department based on local building code requirements, the design and construction budget, and the desired performance specifications. However, some of the most important design solutions that support safety and security are ones that costs very little. Every emergency department should be designed with the specific intention of ensuring proper lines of sight from staff work zones and security monitoring posts to all areas of the emergency department. This focus on sight lines will ensure that emergency department staff can maintain situational awareness, which can provide early and life-saving detection of a threat within the department, along with easy notification of others to the situation. Another simple and low-cost solution to ensuring the safety and security is designing the department with a limited number of access points from the clinical, or sterile zone, to the non-clinical areas (reception, administration, etc.) and the hospital complex. Limiting the number of access points will reduce the number of doors that need to be monitored and, when necessary, secured to facilitate a departmental lock

Issue 21 // Emergency Physicians International

Treatment zones for high-risk patient populations allow staff to restrict access to medical gasses and safely observe the patient through a window and via video surveillance. (Project: Centre hospitalier de l’Université de Montréal (CHUM), Montreal, QC) © Patsy McEnroe Photography

down to ensure the safety and security of those inside the sterile area. A third and equally important design consideration is considering how emergency department staff are positioned in the department relative to patients, visitors, corridors, areas of refuge and the like. In many parts of the world, emergency departments and other areas of the hospital are being designed using patient-centric, or customer service approaches. These considerations have led to solutions that include decentralized staff workstations -- including use of conference tables instead of traditional nursing stations -- where the staff may be seated with their backs to the corridors when performing work functions. Going back to the concept of situational awareness and understanding that the emergency department is a chaotic and often somewhat uncontrolled environment, design solutions that limit the ability of

the exterior environments. While it is not suggested to design an emergency department to resemble a “prison ward,” there are critical lessons to be learned about access strategies, situational awareness, creating safe spaces, and the speed at which environments can be secured if conditions warrant.

Security starts from outside of the facility by ensuring that entrances are secure and can block oncoming vehicles, as shown here. (Project: Kaleida Health, Buffalo General Medical Center Emergency Department at Gates Vascular Institute, Buffalo, NY) © Tim Wilkes Photography

the emergency department staff to “duck and cover” or those that position them with backs to corridors or patients, should be considered carefully before implementing. Learning From GeographicallySpecific Design Approaches and Building Codes Each part of the world is subject to a different set of natural and man-made disasters that, over time, have informed how buildings can be designed to withstand a disaster. While disaster studies may not be the exact safety and security issues an emergency department is attempting to mitigate, the learning principles may be applicable. When considering how to design environments that can endure the impact of the blast from an explosive event, much can be learned from parts of the world where buildings are designed to withstand a volcanic eruption or the force of a category five tropical cyclone. In the case of the solutions

tied to volcanic eruptions, building solutions have been designed to mitigate and absorb the initial blast and the aftermath, including fire which can spread rapidly, as well as falling ash which can add thousands of tons of weight to a roof. Buildings designed to survive hurricanes are intended to withstand massive winds, epic flooding and shrapnel flying at a building in excess of 300 kilometers per hour. Hospitals and emergency departments designed in some of the most rural areas of the world can teach us about how to design spaces to function “off of the grid” for hours, days or even weeks. Thinking about adequate storage space to function without replenishment for extended periods of time, as well as access to clean or filterable water and even energy reserves to power emergency generators for extended periods of time, can be an important consideration in areas where a safety or security event can mean functioning for extended periods before help arrives. Medical units designed inside high security prisons can provide vital lessons in how to ensure patient and staff security in the event of a safety or security issue within the hospital or emergency department where it becomes necessary to completely secure and isolate the emergency department from the rest of the hospital complex and

Leveraging the New Emergency Department for Mass Casualty Training Exercises In addition to designing the new or expanded emergency department with safety and security in mind, another valuable opportunity is to leverage the newly designed space to engage in preoccupancy training exercises relevant to the types of safety and security incidents that could potentially occur in the new ED. Training exercises that are of value prior to opening a new or expanded emergency department to the community should focus on potential safety and security issues relevant to the local environment. Around the globe, the focus may be different, and can range widely from active shooter, use of improvised explosive device, to use of high velocity vehicle or hostage condition. In each situation, the use of the vacant emergency department allows leadership to assess the ability of the emergency department to respond to a number of different “what if ” scenarios, advancing learning to the next training exercises. The design of hospitals and emergency departments has continued to evolve as clinical technologies and patient expectations have advanced. The unfortunate reality is that design must also adapt to reflect the dangers of a world where violence is a common occurrence and, in some cases, the emergency department is ground zero for the violence. However, with proper planning and smart operational, technological and physical design solutions, the emergency department can be better prepared with withstand the threat.

www.epijournal.com

report // communication

Canopy Innovations, a NYC digital health startup, was awarded a Pilot Health Tech award to work in Mount Sinai Hospital’s Emergency Medicine (EM) residency program. Their goal was to better understand providers’ perception of available language assistance tools and systems. Canopy also sought to gauge an emergency physician’s reception to mobile technology solutions. The need for communication aid is especially amplified in EM due to the high caseload of patients in a context characterized by urgency. The Sinai EM residents, specifically, rotate between hospitals in Manhattan and Queens, environments of extreme diversity, providing an ideal location to examine the landscape of LAS. Some linguistic experts believe as many as 800 languages can be found in New York City. In fact, Queens has been claimed to be the most diverse urban area in the world.

Lost in Translation? Here’s a Map A critical look at current interpretation tools and new approaches on the horizon.

by Olivia Norrmén-Smith & Raviraj Patel, MD

t will come as no surprise to the emergency medicine (EM) physician that the linguistic and cultural barrier in healthcare is a monumental obstacle to providing competent care. The last two censuses reveal that from 1990 to 2010, the limited-English-proficient (LEP) population has increased by 80%; currently, there are over 26 million people who are LEP in the US. The Pew Research Center reports that if current trends continue, immigration will account for a full 82% of US population growth through 2050. In comparison to the English-speaking 28

patient, the LEP patient experiences more testing, longer stays, higher rates of readmission, lower adherence to treatment, and subsequently higher costs. The provision of language assistance services (LAS) to bridge the communicative impasse remains a significant challenge for health facilities, posing an extreme threat to the safety and health outcomes of the patient as well as an enormous financial and operational burden. Beyond the increased cost of care for each of the millions of LEP patients, medical misunderstandings present liability and have lead to millions of dollars of settlements and legal fees.

Issue 21 // Emergency Physicians International

Language Assistance Services, in reality Despite an acutely heterogeneous patient population, the LAS tools and systems at EM residents’ disposal are wanting. Current interpretation options tend to rely on antiquated technology and are scattered and cumbersome to use. Remote over-thephone interpretation (OPI) and video remote interpretation (VRI) offer critical solutions that scale, however, providers consistently report logistical difficulties accessing those solutions, rendering them less efficacious. Some residents described the dual-handset interpreter phone as “grimy,” and its usage did not fit into their workflows: locating it, knowing which access code to use, and connecting to the voice on the line. Remote interpretation can feel abstract—elderly patients get confused, and if they’re hard of hearing, lack of body language cues creates difficulty. Additionally, about a third of residents questioned the qualifications of the remote phone interpreters and perceived the resource to be inaccurate. Aside from OPI and VRI, EM residents can request a trained in-person medical interpreter, the coveted gold star resource.

The approximate ratio of 3,000 nationally certified medical interpreters to an LEP patient population of almost 30 million, equates to about 10,000 patients per interpreter. Facilities may have their own internal qualification and allocation processes for interpreters, but residents nonetheless reported great difficulty in accessing qualified in-person interpretation through approved channels. It’s this inadequate access and availability of approved, appropriate interpretation resources that causes people to turn to ad hoc, unqualified interpreters and family members. These inadequate tools and resources lead to adverse events for the patient. Furthermore, this behavior takes a toll on the provider: when working across the language barrier, residents reported feeling “frustrated” and “powerless” or doing more guesswork, testing, and omitting conversations. One resident expressed that with certain patients that speak a rare language, there seem to be no available resources and, “It’s pretty much a veterinarian visit at that point.” Enter the Smartphone Given its ubiquity and immediacy, there is a palpable opportunity to safely harness the smartphone as a mobile access point to scalable technology platforms. Study shows that 88.6% of healthcare employees report they bring and use their device irrespective of hospital protocol. It is second nature for providers to turn to apps, especially given the high rates of smartphone ownership among staff. However, different apps differ in their approaches to the communication issue. Some promote access to qualified interpreters, while some like Google Translate, avoid people all together. According to a study by the British Medical Journal in 2014, an app like Google Translate is inaccurate 43% of the time in medical contexts—so safety and practicality are wanting when providers turn to this unapproved tool. In late 2016, the new Google Translate morphed from using large scale statistical machine translation to neural machine translation. Though

Google Translate may have experienced improvement, (the magnitude of which has yet to be elucidated for the medical context, specifically) the extreme nuance, frequent necessity of cultural brokerage, and sensitivity of medical conversation should convince the reader that faith and reliance on this refurbished digital tool is unwise. Canopy offers a different way to harness the smartphone, not with real-time translation capability as the beacon but as an access point for other systems and processes that can strategically improve interpreter service delivery. Through qualitative interviews and in-depth discovery, the Canopy team has prioritized a new digital approach that uses the smartphone as an access point to a more complex interpreter services platform. Pilot feedback and exploration influenced the development of Canopy Connect, an interpreter services delivery and analytics tool that is currently going through its own pilot programs with a small handful of facilities. Canopy believes in user-driven innovation to mold its technology development priorities. Relying on smartphones for communication has barriers, though. About half of the participating residents reported using their smartphone in close proximity with patients feels “unhygienic” and “unprofessional.” Although cellphone use while in the hospital is common, it may not feel normalized or accepted yet. This perception, amongst others, is important to understand when developing nuanced, appropriate and adoptable solutions. With the changing landscape of healthcare and a shift from quantity-ofcare delivery to quality-of-care delivery, hospitals will need to optimize the delivery of LAS services to effectively support encounters between providers and LEP patients. Performance-based reimbursement programs offer financial incentives and impose penalties to health facilities based on their ability to meet quality benchmarks such as readmission rates, patient satisfaction, and other metrics that are directly affected by the quality of

clinical communication. Accessible and appropriate LAS tools are key, so providers aren’t tempted by more immediate yet subpar methods, like getting help from the 9-year-old, kind-of-bilingual child at the bedside. Because use of LAS and language barriers are often underreported, LAS coordinators and departments face the challenge of justifying funding of LAS. In this framework, teamwork and awareness are key. However, given the increasing financial implications, facilities are pressured to prioritize proper and efficient LAS. Feedback from providers through each step of implementation is key as well. If providers’ perceptions of tools and systems are not taken into account, there may be another “EHR situation”: a necessary evolution that promised to revolutionize delivery and efficiency but that has added significant frustration and burden to providers’ daily practice. How can hospitals and tech innovators leverage the power of technology to better improve communication across linguistic and cultural barriers? How can one reap the benefits of mobile apps — scalability, immediacy, tracking and automatic data collection, familiarity, and ubiquity—while taking provider perceptions and workflow constraints into account? These questions frame Canopy’s pilot program, in recognition that the success of its digital approaches depend upon insight from different user groups and iterative development. Moving forward, facilities will need to make better use of all of their interpretation modalities: access to over-the-phone interpreters, video remote interpreters, and the efficient deployment and effective use of in-house, in-person interpreters. And now, the smartphone can serve as yet another access point for immediate, accessible and accurate interpretation. This article originally appeared in Emergency Physicians Monthly. Read more at www. epmonthly.com

www.epijournal.com

R report

// cyber security

CyberMed Summit Addresses Fears of Hospitals Getting Hacked Three physicians participate in first-of-its-kind simulation.

by Kevin J. Kohler

ou’re working your usual shift in the ED when you are called upon to take care of a patient with atrial fibrillation and a rapid ventricular rate at 190 bpm. Her blood pressure is a little soft, but she does not require cardioversion yet. As your nurse starts to mix and hang the diltiazem you ordered, you begin your pointof-care ultrasound of the patient’s heart. Suddenly, you notice that the bag of diltiazem has been bolused in its entirety into the patient’s vein over the course of a mere 10 minutes. Your nurse looks at you with shock and horror. “I didn’t do that doc!” she screams as the patient’s blood pressure and heart rate drop to fatal numbers. Just as you begin giving medications in an attempt to reverse the effects of the calcium-channel blocker overdose, your jaw drops. You see several other medication pumps in adjacent resuscitation bays start doling out entire bags of medications as well! This may sound like a sci-fi thriller, but 30

security researchers have shown that pacemakers, insulin pumps, and other medical delivery systems are vulnerable to cyber attack. To play out these nightmare scenarios and learn from them, the University of Arizona hosted the first ever CyberMed event in Phoenix last June. The two-day event brought together 155 clinicians, policymakers, security researchers, and industry insiders to watch dramatic simulations and discuss the grave threat that hacking poses to today’s healthcare delivery. Just weeks after the summit, new ransomeware known by some as “Petya” quickly spread to countries around the world, including the United States, with hackers holding computers hostage for payouts. Last January, Hollywood Presbyterian Hospital in Los Angeles paid out $17,000 after hackers took control of its computers. “We went from being prone and prey with no predators to now a little blood in the water,” cybersecurity expert Josh Corman told ABCNews. “Hospitals and health

Issue 21 // Emergency Physicians International

Laerdal SimMan 3G used during the simulated CyberAttack could blink, sweat, and cry.

Dr. Wu directs the simulation scenario behind the one-way mirror while being filmed by ABCWorld News with Dan Harris.

care went to the No. 1 targeted industry last year, in less than one year—so our relative obscurity is over.” Not scared yet? Last month, a worldwide cyberattack by a ransomware called WannaCry not only hit computers but also storage refrigerators and MRI machines, shutting down 65 hospitals in the United Kingdom. The FDA has been urging manufacturers to update their products’ security measures since at least 2013. However, agency guidelines issued last year are not binding, and the FDA does not review the vast majority of cyber security updates made to devices under its own rules, which are intended to streamline medical device upgrades. In a collaborative effort to increase awareness of such cybersecurity threats in healthcare, doctors Teresa Wu, Jeff Tully, and Christian Dameff worked to create a simulation-based conference focused on creating awareness of the issue and finding solutions. Josh Corman, Director of the Cyber Statecraft Initiative at the Atlantic Council’s Brent Scowcroft Center, and Beau Woods, founder of the grassroots computer security organization “I am the

Cavalry” and Deputy Director of the Cyber Statecraft Initiative, further aided the team. “Simulation is an incredibly powerful learning modality, particularly for the rare or novel situation requiring specialized responses,” says Dameff. “It also allows the translation of theoretical or conceptual problems to ‘real’ patient physiology and care. Designing and executing the first ever simulations of patients affected by compromised medical devices allowed us to take the work performed by security researchers in the laboratory and demonstrate what that may look like to the ER doc and team who will have to care for the patient who rolls in with a hacked AICD or insulin pump.” Three physicians with no foreknowledge of the simulation were selected by Dameff and the team to act as “unwitting physicians,”—one for each scenario. Each physician was called to do damage control post-cyber attack, assessing and caring for critically ill patients targeted by hackers across the globe. Actors portrayed patients and real paramedics served as support staff, responding to the attending doctor’s directions. Each scenario involved a compromised device based on research: a medication infusion pump dosing the full quantity

Directions were provided to actors by Dr. Wu via hidden two-way headsets.

Dr. Jesse Shriki (left), Dr. Teresa Wu and Dr. Tarann Henderson.

in minutes, a wearable insulin pump causing the wearer to go into a coma and crash a car, an a hacked pacemaker eventually causing cardiac arrest. Thirty-five attendees viewed the simulation from behind oneway glass; the rest viewed a live stream from down the hall. As Dameff explained, in each scenario when something grave happened, the lights would be turned off, freezing the simulation, as the human patient would be replaced by a high fidelity simulation mannequin that could blink, sweat, and cry. Outside the room, Dr. Wu was the wizard behind the curtain, using a computer to control the mannequin based on what the physician did, increasing heart rate, stopping breathing, etc. None of the physicians realized that the equipment was hacked, but all of the patients ultimately survived. Doctor AnneMichelle Ruha’s patient was in a rapid atrial fibrillation. “When his heart rate and blood pressure began to drop, I assumed it was related to his primary condition, until I discovered an entire bag of diltiazem had infused in minutes. Despite knowing the theme of the conference, it did not occur to me that hacking of the infusion pump had occurred--I assumed human error,” she said. Of course, her focus was then on treating the calcium channel blocker toxicity. Once her patient was stabilized, she learned about the hacking. “I think in a real-life situation the physician deals with the ‘What went wrong?’ question after the patient is stabilized, and I don't think knowing what happened would have affected my treatment,” said Ruha. “However, I do think it is important to be aware of the possibility because if I had seriously suspected hacking, I would have instructed the nurses to set the infusion pump aside and not use it for anything.” Ruha added hacking really never crossed her mind in the past, and she’s glad to now be aware of the potential problem. “I still don't think I would be likely to consider it if something like this occurred with a single patient, but if several pumps 'malfunctioned' simultane-

ously, hacking would now be the first thing I would think of,” she said. “We had to design and create a clinical environment and patient scenarios that enabled our physicians and audience members to suspend disbelief,” said Wu, who is the Simulation Director at the University of Arizona, College of Medicine-Phoenix and also for the national American College of Emergency Physicians. “Our scenarios were so realistic and engaging that audience members almost jumped right out of their seats to help the physician and team members caring for the affected patients,” she said. “Part of the problem is, as physicians, we are trained to rely on a vast array of technologies to assist us in the care of our patients,” said Tully. “From decision support tools to actual implantable medical devices, we have an implicit trust in such technologies that they will do what they are intended to do without need for additional scrutiny or oversight. We are now entering a world where such trust without vigilance and verification may become negligent. We need to prepare for such a practice environment.” The summit was the first ever simulation of cyberattack in medicine, and attendee feedback was 90% “extremely satisfied” and 10% “satisfied.” The team hopes to expand the conference nationally and even internationally. Wu, who has been creating, designing, and running medical and surgical situations for more than a decade, hopes people will start to understand just how dangerous and unpredictable these types of cyberattacks can be. “We wanted folks to walk out of the sessions amped up and ready to make a difference. I think we achieved our goals and so much more with our CyberMed Summit,” she said. For more information about cyberattacks in medicine and patient care, follow these doctors on Twitter: @TeresaWuMD, @CDameffMD, and @Jeff TullyMD.

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Canadian Telemedicine Program Brings Critical Care To the North Canada is a unique launchpad for virtual healthcare as it combines a modern, nationalized health system with incredibly remote towns and villages. One program in Ontario has had significant success and may serve as a model for other provinces.

by scott pruden

he baby was coming – but much earlier than expected. Karina Beavis was 30-weeks pregnant and in early labor when she rushed to the emergency room at rural Espanola Regional Hospital and Health Centre in Espanola, Ontario. The problem? Espanola had no OB-GYN on staff, and the transfer hospital was an hour away in Sudbury. Dr. Sean Mahoney, the family physician on staff at Espanola, had no obstetric 32

expertise and was desperate to have the laboring woman transported to Health Sciences North, the large regional hospital in Sudbury. “[Mahoney] called the obstetrician on the phone. He said there’s no way the mother’s going to get here on time,” says Dr. Derek Manchuk, Medical Director of the Virtual Critical Care (VCC) Unit at Health Sciences North (HSN), the regional hospital in Sudbury. “They’re going to deliver in

Issue 21 // Emergency Physicians International

Caroline Chum, a Moose Factory local with Type 2 diabetes, looks out from her home at the Elder’s lodge, a live-in retirement home. photo by Christopher Manson

the ambulance, so it’s better to keep them in the hospital emergency room.” Mahoney then asked if he could have the obstetrician help him via telemedicine using VCC. A nurse set up the connection, and by consulting directly with specialists in Sudbury via the dedicated video conferencing system, Mahoney successfully delivered Beavis’ daughter, Leah, who weighed in at four pounds. “We were able to involve the VCC nurse, the obstetrician and the pediatrician, who helped deliver and resuscitate the baby, who was then transferred to HSN and did very well,” Manchuk says. “The mother was very happy with what had happened and the care that she could receive.” Happy, but pleasantly surprised, she said

Health Sciences North in Sudbury, Ontario, serves a number of remote communities throughout Northeastern Ontario via its Virtual Critical Care Unit.

after Leah’s delivery. “It was a little weird having people in another hospital watch me give birth,” Beavis told the local newspaper. “But it made a huge difference for the delivery. We feel very blessed that everything came together and that Virtual Critical Care unit was available.” According to Manchuk, without VCC, Leah’s birth likely would have gone much differently. “One of two things would have happened. They would have tried to muddle through on the phone giving advice without seeing what was going on, or they would have just said, ‘Best of luck to you, get them here when they’re stable,’ and hung up the phone,” he says. “I think it’s a quantum leap in terms of the care that can be provided.” Putting Practitioners and Patients Together Leah’s birth, which took place in September of 2016, is just one dramatic example of how the province is leveraging the power of telemedicine to provide first-class care to patients at remote hospitals throughout northeastern Ontario. The system, launched in 2014, is the first of its kind in Canada. Through the program, HSN maintains a group of doctors, nurses and specialists on call to respond to emergency and critical care situations at remote hospitals throughout the Canadian province.

For Americans, it’s sometimes hard to grasp the geographical challenges facing patients in farther-flung areas of Canada who need help beyond what their local doctors can provide. Within northeastern Ontario, for instance, many communities maintain hospitals like Espanola’s, with a staff of primarily nurses and family physicians. Others are even smaller and more distant, and their lack of healthcare providers is compounded by their geographic inaccessibility. It’s in these circumstances that VCC is invaluable, Manchuk says. Recently, VCC was used to assist a patient in the town of Hearst, which has a population of 5,000 and is an eight-hour drive away from Sudbury and two hours away from its next closest community. “We had a patient that was in their emergency room for well over a day because the air ambulance couldn’t get there because of weather,” Manchuk says. “[Using VCC] we could maintain that patient in Hearst for almost two days, a critically ill patient on life support with the family physician there and a nurse – and they have very little experience in terms of managing critically ill patients. They see maybe a handful a year at most.” And then there are spots such as the remote town of Moose Factory, a native community of 1,700 on the Moose River

near the southern tip of James Bay. Moose Factory is more than 300 miles away from Sudbury and completely inaccessible by car during spring, summer and fall because it depends on ice roads for surface travel. Bridging Geography, Saving Money The foundation of the Canadian health system, known there as Medicare, is ensuring that every Canadian citizen will receive health care, regardless of their ability to pay. What results is a system that would, to Americans, be somewhat familiar in the way services are provided, but is entirely different when it comes to payment. For standard procedures, doctors bill each provincial health care system directly and are compensated accordingly using funds collected through taxation. There are no insurance company middle men, a limited amount of red tape, and zero costs – such as deductibles or copayments – passed along to the patient. However, costs associated with pharmaceuticals, dental and vision are not covered through the national health plan. Canadians pay those out-ofpocket or have them covered through private insurance companies. On the upside, because there are no costs to the patient, there are fewer roadblocks to preventative treatment and early detection, which results in lower per capita spending on health care by Canadian residents. In 2015, the per capita rate of health care spending for a U.S. resident was $9,451 (U.S.), compared to $4,608 (U.S.) for a Canadian. On the downside, Canadian healthcare maintains a documented reputation for long delays – some up to 10 months or a year – in scheduling elective or nonemergency surgeries and procedures compared to those for providers in the U.S. Because of the limitations to healthcare access in areas like north

www.epijournal.com

Grand Rounds PETER CAMERON, MD // PAST PRESIDENT OF IFEM

Working for the Machine Sometimes tech advances in healthcare feel like a step in the wrong direction.

they can get an ECG, but before I can get to the cubicle, the phone rings with a result from yesterday – there is a positive blood culture from a 70-year-old who was sent home with a fever thought to be due to a UTI. I go to log into the computer to check the notes and see if the patient was OK on discharge and to get contact details to undertake an urgent phone review. I ring the patient and add a note to the file to say that they are OK and appropriate antibiotics were given. There are now 13 patients waiting to be seen and I finally get a chance to see the ECG on the chest pain patient. Fortunately there is no STEMI! I say hello to the patient and spend three minutes in the ED, 20 patients waiting to go upstairs and 15 in short stay – asking him about the pain, then log back into the computer to make not too bad for a busy evening. a basic note regarding the history. I quickly review the patients in Go to see one of the waiting patients but the phone rings – anthe queue to make sure no one is dying, but then have to log other patient on the way. Better put on the “expects” list. back into the computer again to order some blood tests Log onto the EDIS, open windows and sign off. Go for the chest pain patient. to see one of the 10 waiting again, but the nurse One of the patients in the queue has severe says that they aren’t triaged (on the screen) yet, After an hour pain, but can’t access a bed. Fortunately she is so not sure which one to take. There is a space on this shift in the clerked on the computer, so I can order anin short stay for one of the patients in the RITZ, I have spent exalgesia. However I can’t actually give narRITZ area with renal colic, however the actly three minutes talking cotic analgesia, because the “Pyxis” pharpatient can’t go because the short stay form to the patients and more than macy system requires an authorised user. hasn’t been done. I go to enter the form on 30 minutes facing a computer. The nurses, who are authorised, are tied the computer for short stay, but someone I remember a time when doing up with moving patients between differelse has logged in and left open patient a clinical shift, meant seeing ent areas of the ED and documenting what notes on the screen. Log into another compatients, talking to patients, they have done on the computer. Hopefully puter and do the paperwork. Check to see if examining patients and she will get some analgesia soon! the chest pain patient has had ECG, but still treating patients. After an hour on this shift in the RITZ, I no cubicle as all the patients in the RITZ area have spent exactly three minutes talking to the paare either waiting documentation to go to the ward tients and more than 30 minutes facing a computer. I or short stay. remember a time when doing a clinical shift, meant seeing paThe lab rings, blood has arrived and the wrong time has been tients, talking to patients, examining patients and treating patients. marked on the tube and they won’t process the blood test. They ask Somehow I seem to have entered a parallel universe where clinical that another blood sample and form be filled out as both form and medicine has become a technical exercise of computerised form fillrequest are inconsistent with time. I kindly ask the nurse to repeat ing with little human contact. the blood and then log into the computer to repeat the request for I wonder what the patients think? blood. The computer identifies that I have double ordered, thereIs this really improving patient safety and improving clinical fore it double checks every request. care? Radiology rings. One of the requests for a painful wrist ordered Would we be better to wait until the computing technology by a junior doctor from the previous shift has the pain documented improved to the extent that enabled, rather than obstructed, good on the opposite side to where it actually is. They want me to reclinical care before widespread implementation? request the form for a wrist Xray. They also state that this is a reMaybe these are the ramblings of an older clinician who rememportable incident and that they will fill out an incident form. The bers the glory days of clinical medicine. You decide. patient won’t be Xrayed until the correct request has been made. I go to see if the patient with chest pain now has a bed so that

Just doing another clinical shift in the “Rapid Initial Assessment Zone” (RITZ). Ten patients waiting to be seen, four in an ambulance queue, three can’t get a bed to lie on despite being in severe pain and one has chest pain needing an ECG. Overall 60 patients

Issue 21 // Emergency Physicians International

The mHealth Toolbox The first hands-on digital health workshop for emergency physicians.

--October 29–31, 2017 ACEP17 innovatED ---

<<Interview with Dr. Roberta Petrino, President of EuSEM Continued from page 24

EPI: How do you see emergency medicine developing as a specialty in the future? What are potential pitfalls?

standards recognized and established, at least inside the EU countries.

Petrino: First of all the objective is the [initiation] of the emergency medicine specialty in the few countries, like Spain, Portugal, Greece, Austria, and Germany, that still don’t have it. We hope that promotion from outside Europe will also help in this aim. The major pitfall for the specialty of emergency medicine is the difficulty in finding specialized emergency doctors…It is [vital] that governments everywhere understand that EM is necessary, and will lead to a reduction in expenses for healthcare and also in reduction in the need for specialists, because of the reduced number of consultations and admissions [in good EM systems]. Some resources should be diverted from other specialties to EM to be able to create wellorganised, well-equipped EDs. This is above all a political issue, for this reason the EuSEM is working in tight collaboration with the UEMS (European Union of Medical Specialists) Section and Board in EM. [We are] dialoging with the EU parliament and government [to make] the rules and

EPI: What advice do you have for trainees and students interested in emergency medicine? Petrino: Be aware that EM is the best possible job only if one is ready to adapt to an “unconventional life.” That means working at night, on Sundays, on Christmas…Do not be surprised on the possibility of a sudden overload of work, of a disaster response, of communicating bad news, of being frustrated by [angry, stressed] people. If this is not a problem, the satisfaction of saving lives, working in a team, multi-tasking, being open-minded…being the first in seeing the patient and solving the problem is difficult to compare.

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cannondesign.com 36 Issue 21 // Emergency Physicians International