"International Emergency Medicine"

[AmoryBlaine]

Coming off the interview trail I was reflecting on how many of my M4 colleagues had expressed an interest in "IEM." Correspondingly, at each program I visited we had varying degrees of discussion about IEM. There is a thread about overseas volunteering going on in another forum and it made me curious what the EM folks would have to say.

I'm not trying to be a flamer here, just to raise some discussion. If you have a real interest in IEM don't get all offended, just debate. Here are my opinions that I'd like to see supported or convincingly rebuffed:

1) Most international medical work involves an excessively large tourism component. Take away the digital cameras, side trips, and evening bar runs and interest would wane quickly.

2) Most (though certainly not all) international medical work is episodic, uncoordinated, and of questionable benefit to the populations served. Temporary clinics treating ambulatory complaints have the potential to cause great harm. An example published in a NEJM op-ed discussed a mother given vitamins for her infant who mistakenly thinks that vitamins are extremely potent medicine and in the future refuses to dose her child with antibiotics because a) vitamins are cheaper and b) she had previously received vitamins from impressive American physicians.

3) Emergency medicine as a specialty is relatively poorly suited for international work.
a) EPs have few special skills that lend themselves to low-resource situations. The practice environment of EPs in the United States involves frequent usage of highly technological imaging and diagnostics. The areas in which EPs are truly "specialists" include resuscitation, airway management, toxicology, and the initial management of trauma are low-yield skills in the international setting.
b) The difficult to define "resourcefulness" of the average emergency physician is unlikey to translate into special skills abroad.
c) Surgical/gynecological fields are far better suited for episodic international excursions. Primary care fields are better suited to longer term, health promotion activities.

4) It is unlikely that a "fellowship" in international emergency medicine conveys many specialized skills beyond the didactics of an integrated MPH. It would be exceedingly difficult to argue that IEM fellowship trained EPs were more effective in delivering international medical care than non-fellows.

5) The term "international emergency medicine" itself is at best problematic and at worst a complete misnomer.
a) The emergency physician overseas has no special role that could not be filled equally well by a family physician, med-peds physician or in the vast majority of cases an internist.
b) An "international emergency" needs a response that is almost completely public health based. Individual physicians in the aftermath of, say, another tsunami would likely contribute more by working with a shovel than with a stethoscope.


Let the games begin. 😀

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[zinjanthropus]

My interest is in IEM (I'm also a PhD candidate in anthropology) so I feel that I need to comment. Ultimately, I would like a joint appointment and would take both MD students/residents, as well as PhD students, into the field to do collaborative work. What I'm getting at is that IEM is probably not for everyone and won't apply to the general EM interests of many. It can be tangential if you want it to be for your career and there is nothing wrong with that at all.

I agree with a lot of what you said (such as the medical tourism aspect) but also feel that the sub-discipline has room for positive growth from this generation. In addition, I very much disagree with some other assumptions you make - which I believe the literature (and those of us who have participated in global work) refutes. For example, it has been argued that much international medicine work has arisen within EM BECAUSE of our skills in a poor resource environment and ability to handle many different types of problems/pathology. In addition, the flexibility of our clinical model gives us the ability to pursue appropriate extra training - such as an MPH, etc.

There is very little formal EM in other locations and we can do a lot to change the structure of education. It is intuitive to many that the world is global and the borders are less defined by modern sociopolitical lines. The challenge is funding and integration of international work into clinical responsibilities.

Anyway, I really think this discussion could be stronger, less flaming, and more formalized if we started by reading the 2005 special issue of Emergency Medicine Clinics of North America volume 23 - it's dedicated to IEM. There are some great articles in there that can get us started in a more meaningful direction with a stronger knowledge base. Also, Annals and AEM each put out a reference list of the best International articles once a year. Annals did it in the Dec 2007 issue.

 

[southerndoc]

You are correct that most internists, pediatrons, med-peds physicians, and family practitioners would be ideal for international work. In fact, I would argue that they are better suited for it because of their training in continuity of care. Although diabetes, MI's, cancer, etc. are less of a concern in a third-world country, they do still exist.

I think emergency medicine has taken over international medicine because of our schedules. It's much easier for an EP to take a month off to volunteer overseas than it is for a family practitioner to close his or her clinic for a month.

You raise a valid point of fragmented care. This is where organizations such as MSF help by maintaining an ongoing presence in areas where it's needed. The Yale/J&J program also does this by ensuring that physicians are in particular sites the majority of times. Although some other organizations might offer fragmented care, one shouldn't abandon all hope just because they feel like it's not going to make a difference.

Finally, I agree with you. I hate the term international emergency medicine. Personally I think it should be just international medicine. International medicine seems to have fallen under the auspices of emergency physicians, and it is likely that emergency medicine will remain the dominant specialty involved in international medicine.

 

[bartleby]

I suppose that you can take issue with the entire issue of US doctors going overseas to share some of their expertise when the US is a major source of brain drain on developing countries.

That said, what does any specialty offer a place that has crushing poverty and no safety net? What does an IM doc's expertise on diabetes or hypertension management offer when there is no availability of meds for either of the above or even basic childhood vaccinations. The entire concept of medicine in a developing world without basic hygiene, etc. seems futile in a sense.

But you can make the argument that any help is good help in an underserved area, and if EP's are interested in going, so be it.

 

[jbar]

To me there are two kinds of international EM. One is where you go over seas to work for awhlie in an area as a pair of hands on the ground. The other is helping organize and structure a medical system. In places that are only starting to develop emergency medicine, EM docs have a lot of training that can help mold these programs. From teaching ATLS, to helping choice equipment, to meeting with local officals about resources need EM docs can help build these programs.

Also it should be noted that there is a difference between being a medical tourist where you work for a month, and specializing in international EM where it is your full time job.

 

[roja]

1. There is a valid point about 'medical tourism'. It is not that this is invalid, or worthless (a huge debate in and of itself) but one should be clear about one wants to do. Medical tourism is fine. If you want to occasionally venture internationally and help others out, within well structured NGO programs, you really don't need a fellowship for this.

2. No field of medicine is really well suited for International medicine. Even peds, IM, etc are not going to provide long term care. They are also not trained for the myriad of issues that surround global health. EM is just as qualified (and in some sinces more so in terms of working in hospitals/clinics because we are well trained in rapid assessment, triage and resuscitation.) Each field brings something of value. One of our fellowship directors is peds em, one is triple boarded: IM/ID/EM (done so because he felt ID was not enough training to be of use in the international medical world).

3. I have worked quite a bit in the development of our own Global Health Fellowship. (so named because it does not encompass much of the medical tourism). It involves exposure to different ID specialty clinics (important in the global health world) such as HIV, TB, etc. it also involves extensive work with NGO's to learn the administrative aspects of global health.

What is often failed to be recognized by many residents, etc is the amount of planning that must go into global health programs. A fellowship can offer you just an MPH with a few trips, or it can offer you alot more. It depends on the program.

 

[BKN]

My thoughts:
1. Third world countries don't need training in how to use a defibrillator, they need to understand sewage.
2. Second world countries need EM and EMS systems, thus could use our expertise.
3. "If you plan for a year plant grass, if you plan for ten years plant trees, if you plan for a hundred years train men". I got this quote from Henry McIntosh, who was chairman of medicine at Baylor while I was a student. He attributed it to Osler. Apparently in other versions, it is an ancient proverb from India, Asia and Hawaii. Anyway, I think the meaning is clear. It doesn't do any good to go spend a week or a month in wherever and then leave. Rather, help the country/medical school establish their own programs, and then get out of the way.

Or that's just my opinion, I could be wrong . . . I was interviewing an applicant from a second/third world country who had run a health care system and an ED there. She disagreed with all I said and wanted ED docs, not sanitation engineers.

 

[southerndoc]

Or that's just my opinion, I could be wrong . . . I was interviewing an applicant from a second/third world country who had run a health care system and an ED there. She disagreed with all I said and wanted ED docs, not sanitation engineers.

Most of the advances in our longevity can be attributed to better public health measures instead of medical treatment.

Prevention is key to long-term survival.

 

[AmoryBlaine]

My interest is in IEM (I'm also a PhD candidate in anthropology) so I feel that I need to comment. Ultimately, I would like a joint appointment and would take both MD students/residents, as well as PhD students, into the field to do collaborative work. What I'm getting at is that IEM is probably not for everyone and won't apply to the general EM interests of many. It can be tangential if you want it to be for your career and there is nothing wrong with that at all.

I agree with a lot of what you said (such as the medical tourism aspect) but also feel that the sub-discipline has room for positive growth from this generation. In addition, I very much disagree with some other assumptions you make - which I believe the literature (and those of us who have participated in global work) refutes. For example, it has been argued that much international medicine work has arisen within EM BECAUSE of our skills in a poor resource environment and ability to handle many different types of problems/pathology. In addition, the flexibility of our clinical model gives us the ability to pursue appropriate extra training - such as an MPH, etc.

There is very little formal EM in other locations and we can do a lot to change the structure of education. It is intuitive to many that the world is global and the borders are less defined by modern sociopolitical lines. The challenge is funding and integration of international work into clinical responsibilities.

Anyway, I really think this discussion could be stronger, less flaming, and more formalized if we started by reading the 2005 special issue of Emergency Medicine Clinics of North America volume 23 - it's dedicated to IEM. There are some great articles in there that can get us started in a more meaningful direction with a stronger knowledge base. Also, Annals and AEM each put out a reference list of the best International articles once a year. Annals did it in the Dec 2007 issue.

Re: journals.

Thanks for the considered response. I couldn't access EMCNA and the Dec 07 issue of Annals has nothing about IEM except a discussion of Tuscany.

I'd actually like to see some of these articles if anyone could post PDFs. Similary I would to see the literature described in your passage which I bolded.

 

[AmoryBlaine]

My thoughts:
1. Third world countries don't need training in how to use a defibrillator, they need to understand sewage.
2. Second world countries need EM and EMS systems, thus could use our expertise.
3. "If you plan for a year plant grass, if you plan for ten years plant trees, if you plan for a hundred years train men". I got this quote from Henry McIntosh, who was chairman of medicine at Baylor while I was a student. He attributed it to Osler. Apparently in other versions, it is an ancient proverb from India, Asia and Hawaii. Anyway, I think the meaning is clear. It doesn't do any good to go spend a week or a month in wherever and then leave. Rather, help the country/medical school establish their own programs, and then get out of the way.

Or that's just my opinion, I could be wrong . . . I was interviewing an applicant from a second/third world country who had run a health care system and an ED there. She disagreed with all I said and wanted ED docs, not sanitation engineers.

Wow. Well clearly she has a certain expertise that none of us can claim but even so that seems like a very counter-intuitive statement. Did she elaborate on her reasons for this desire of emergency physicians?

 

[nymbarra]

Wow. Well clearly she has a certain expertise that none of us can claim but even so that seems like a very counter-intuitive statement. Did she elaborate on her reasons for this desire of emergency physicians?

I worked in the health sector in a developing country for three years, two in the community and one in a national organization. I can understand why this person would say this:

Usually there is a health system in place, although it is usually modeled after the Primary Health Care system proposed by the WHO/UN a few decades ago (see Bamako Initiative and Alma-Ata). This usually horribly underfunded and inefficient government-run system is supplemented by the sporadic but well-funded (and arguably still inefficient) projects by NGOs and int'l aid agencies. (As an aside, I've often wondered why the NGO system doesn't integrate better with the govt-run system, but that is a whole other discussion...)

There usually is a black market for healthcare, but most people needless to say, do not have regular access to care.

Factor in the demographic transition (eg, urbanization and switching to imported foods) that these populations are experiencing and they are getting more and more chronic diseases and trauma, on top of the usual infectious diseases--what some call the 'double burden' of disease.

http://www.nih.gov/about/researchresultsforthepublic/GlobalHealth.pdf

So more people who don't have access to regular care are presenting with acute presentations from their chronic disease or with trauma, and those healthcare systems need strategies to improve stabilization, evaluation, treatment or referral to the very limited centers for definitive treatment. Ultimately, strengthening these services will bolster the PHC system already in place, and lead to more efficient care.

On top of the great fit of EM clinically, think of how EM could contribute on a population-based perspective: EMS, Ultrasound, Injury Prevention, etc...holy cow, I'm there! 😛

 

[pseudoknot]

On top of the great fit of EM clinically, think of how EM could contribute on a population-based perspective: EMS, Ultrasound, Injury Prevention, etc...holy cow, I'm there! 😛

How does "population-based" ultrasound work? I'm picturing some sort of giant transducer hovering in the sky like in a bad scifi movie.

 

[AmoryBlaine]

I worked in the health sector in a developing country for three years, two in the community and one in a national organization. I can understand why this person would say this:

Usually there is a health system in place, although it is usually modeled after the Primary Health Care system proposed by the WHO/UN a few decades ago (see Bamako Initiative and Alma-Ata). This usually horribly underfunded and inefficient government-run system is supplemented by the sporadic but well-funded (and arguably still inefficient) projects by NGOs and int'l aid agencies. (As an aside, I've often wondered why the NGO system doesn't integrate better with the govt-run system, but that is a whole other discussion...)

There usually is a black market for healthcare, but most people needless to say, do not have regular access to care.

Factor in the demographic transition (eg, urbanization and switching to imported foods) that these populations are experiencing and they are getting more and more chronic diseases and trauma, on top of the usual infectious diseases--what some call the 'double burden' of disease.

http://www.nih.gov/about/researchresultsforthepublic/GlobalHealth.pdf

So more people who don't have access to regular care are presenting with acute presentations from their chronic disease or with trauma, and those healthcare systems need strategies to improve stabilization, evaluation, treatment or referral to the very limited centers for definitive treatment. Ultimately, strengthening these services will bolster the PHC system already in place, and lead to more efficient care.

On top of the great fit of EM clinically, think of how EM could contribute on a population-based perspective: EMS, Ultrasound, Injury Prevention, etc...holy cow, I'm there! 😛

Respectfully, I don't think you are "there."

The issue (as I saw it) raised by BKN's applicant was whether systems people or practitioners were more "useful." I know that the term "useful" is difficult here but I can't think of anything better.

You raised some good points about "double burden" of disease - something I've never heard of and if you have an article or two I'd be interested in reading them. However I think you just restated that problem of medicine in the developing world and then declared that EM was a good solution.

The point I had tried to raise for discussion was whether or not EM was a particularly good "answer" to population-based "problems." If you read my initial post I tried to make a case that it really was not.

 

[deleted65604]

I whole-heartedly agree with the original post. We train for 3 years in an emergency department and learn to work with the most amazing, skilled and versatile nurses in the world and have the largest array of medical tools and specialists in the history of mankind. Take us out of that environment, and we might as well be a paramedic. I agree that we can help other countries build their EMS and hospital systems, giving them advice from our experience, but thinking that I am going to go to Africa and help the native doctors there treat malaria, dengue fever, and schistosomiasis is ludicrous. Setting up temporary clinics to treat diseases is a farce. People come from far and wide, with largely inconsequential complaints in hopes that they can score some free medicine of some kind. I think that a clinic that was permanent, and involved the expertise of the local physicians could yield a useful experience. It would be useful purely to appreciate the essentially unlimited resources we have here and the blank checks that hospitals give us.

I feel similarly about wilderness medicine. It is just a way to not have to work for a month or 2 during med school or residency. Take away the cameras and the sense of adventure that city-slickers get when they think they are "going into the wilderness," there is little knowledge that is applicable to Emergency medicine. I got into this argument yesterday with some of my fellow residents. One of them defended wilderness medicine and challenged me what I would do with a wound in the wilderness. I said that I would bandage it the best I could, clean it with water if available, and get them the heck out of there. With condescension, he explained to me that he would go kill an animal, boil its fat down, add lye and make soap. He had learned that tip from some demented instructor in a wilderness medicine conference. Where are you going to get lye from? Where are you going to get a pot big enough to render the fat off an animal? Wouldn't you be better off packing a bar of soap than a pot big enough to render fat? If you want a useless merit badge, you should have participated in Boy Scouts, because that is about all you are going to get out of a wilderness medicine rotation.

I saw the same trend when I was a medical student. Everybody thought that if they talked about international medicine or wilderness medicine enough that they would seem cool and that it would help them get into residency. Programs stroke their egos, encouraging their dreams in interviews and then perform the bait and switch. The US needs more doctors working in ERs, not more lazy pseudophysicians running around foreign countries and wilderness areas.

I concede a great point made further up that ER docs are the only people whose schedules allow them to go off on adventures to foreign lands. That would make them we suited to work in international medicine, but nothing else in our training would make us better suited than say an FP.

 

[RxnMan]

...Where are you going to get lye from?...

From the ashes of your fire.

Just a former chemist and Boy Scout poking fun. Carry on.

 

[BlondeDocteur]

Take this with a grain of salt... I'm not heading into EM.

I think international EM sprung up as a field for a couple of reasons. One is certainly schedule. But the stronger is temperament: I strongly believe that different medical specialties attract different personalities, and I think EM is a field to which the cowboys flock. The average EP salivates at the thought of crashing out into the jungle, on his own. That, coupled with the wide array of pathology most EPs encounter and feel comfortable treating, makes the field seem like a natural fit.

Except... not really. Some IEM people actually teach emergency medicine abroad. MVAs are extraordinarily common, for example, in most developing countries... so running an emergency department, reviewing triage procedures, and teaching trauma resuscitations are all quite useful. But most actually try to run non-hospital based clinics abroad, treating chronic disease entities with which they have less than zero experience, all of which is ludicrous. And then, in my experience, they go ziplining through the treetops or climb the nearest volcano on the weekend.

Unless they truly intend to move there, American physicians clinically volunteering abroad is a bit ethically troubling from a continuity of care/expectations perspective. If docs get interested in a systems-based approach to health addressing the context of disease, that's awesome. But I believe the only short-term work that has *any* utility is 1) surgical missions, especially for complicated cases that simply cannot be handled by local personnel, and 2) teaching local practitioners a technique, a management philosophy or the like. There are exceptions, such as times of extraordinary need (i.e. forced migration camps, which are truly the most dreadful places on earth, or natural disasters on the scale of the tsunami) but those are rare.

 

[pseudoknot]

I got into this argument yesterday with some of my fellow residents. ... With condescension, he explained to me that he would go kill an animal, boil its fat down, add lye and make soap.

Was this your co-resident by any chance?

 

[notdeadyet]

Was this your co-resident by any chance?

Nice one... Excellent...

 

[AmoryBlaine]

Except... not really. Some IEM people actually teach emergency medicine abroad. MVAs are extraordinarily common, for example, in most developing countries... so running an emergency department, reviewing triage procedures, and teaching trauma resuscitations are all quite useful. But most actually try to run non-hospital based clinics abroad, treating chronic disease entities with which they have less than zero experience, all of which is ludicrous. And then, in my experience, they go ziplining through the treetops or climb the nearest volcano on the weekend.

Exactly, one point that I thought about putting in my OP was that I think that an interest in IEM is often nothing more than an interest in travel (which is completely acceptable) combined with a vague sense of moral obligation towards the third world (which is not at all objectionable) combined with a deep desire to be photographed in a ramshackle clinic surrounded by natives (which is at best supremely egotistical).

 

[AmoryBlaine]

I feel similarly about wilderness medicine. It is just a way to not have to work for a month or 2 during med school or residency. Take away the cameras and the sense of adventure that city-slickers get when they think they are “going into the wilderness,” there is little knowledge that is applicable to Emergency medicine. I got into this argument yesterday with some of my fellow residents. One of them defended wilderness medicine and challenged me what I would do with a wound in the wilderness. I said that I would bandage it the best I could, clean it with water if available, and get them the heck out of there. With condescension, he explained to me that he would go kill an animal, boil its fat down, add lye and make soap. He had learned that tip from some demented instructor in a wilderness medicine conference. Where are you going to get lye from? Where are you going to get a pot big enough to render the fat off an animal? Wouldn’t you be better off packing a bar of soap than a pot big enough to render fat? If you want a useless merit badge, you should have participated in Boy Scouts, because that is about all you are going to get out of a wilderness medicine rotation.

I saw the same trend when I was a medical student. Everybody thought that if they talked about international medicine or wilderness medicine enough that they would seem cool and that it would help them get into residency. Programs stroke their egos, encouraging their dreams in interviews and then perform the bait and switch. The US needs more doctors working in ERs, not more lazy pseudophysicians running around foreign countries and wilderness areas. I know, I know, that is just my opinion.

1. Your wilderness medicine friend is an idiot and I supremely hope you made this story up. I think both wilderness medicine and "tactical medicine" (a term I have yet to hear convincingly defined) should both be relabeled as "expeditious evacuation."

2. As per the bait-and-switch, I completely agree with you. I think one could argue that it does a huge disservice to medical students to delude them in any way from the reality that most of them will have careers that are almost exclusively composed of pulling shifts in US EDs. In my mind it's sort of like the "join the military, see the world" stunt.

 

[deleted65604]

1. Your wilderness medicine friend is an idiot and I supremely hope you made this story up. I think both wilderness medicine and "tactical medicine" (a term I have yet to hear convincingly defined) should both be relabeled as "expeditious evacuation."

2. As per the bait-and-switch, I completely agree with you. I think one could argue that it does a huge disservice to medical students to delude them in any way from the reality that most of them will have careers that are almost exclusively composed of pulling shifts in US EDs. In my mind it's sort of like the "join the military, see the world" stunt.

He's not an idiot, he's my good friend. He is a great guy who has been brain-washed by people who make money off teaching wilderness medicine courses. Him and other people like him want to be like their wilderness medicine instructors and teach wilderness medicine courses one day. Wilderness medicine doctors never really accomplish much other than providing courses on wilderness medicine. When you actually need a wilderness doctor, you are in the wilderness, and they can't help you.

Now it is my turn to look stupid. Maybe I will mix animal fat and ashes next time I'm camping and need a bath. 😳

 

[nymbarra]

Respectfully, I don't think you are "there."

You raised some good points about "double burden" of disease - something I've never heard of and if you have an article or two I'd be interested in reading them. However I think you just restated that problem of medicine in the developing world and then declared that EM was a good solution.

The point I had tried to raise for discussion was whether or not EM was a particularly good "answer" to population-based "problems." If you read my initial post I tried to make a case that it really was not.

Whoa dude, you're killing my buzz! 😀

Going back to your OP, I agree with points 1 and 2, as well as 4.

With point 3, I think I have laid out a pretty good argument about how EM is well-suited for work in the health systems of such countries. It is similar to the need in this country for acute care stemming from a lack of access to primary care. It may not address the root causes, but there definitely is a need, eg the trauma care for MVAs as BlondeDoc pointed out.

Specifically within the context of physician-depleted and resource-poor environments, it will save money if local health providers--already in place as part of the Primary Health Care system I mentioned--are trained with some appropriate EM skills, such as use of ultrasound. There are collaborations between institutions and health ministries already in place that already do that, in places like India and China. I remember that the NY Hosp Queens program has a dedicated program w/ Brazil and China.

With the article requests, just google...but oh alright, here are some:

ultrasound:

Mindel. Role of imager in developing world. The Lancet, vol 350, issue 9075, pp426-9.
​

double burden and excellent article from the aforementioned EM Clinics issue devoted to IEM:

Smith and Haile-Mariam. Priorities in global emergency medicine development. Emergency Medicine Clinics of North America - Volume 23, Issue 1 (February 2005)
​

Obviously EM is not a panacea for global health, but that is not the point. The question should be: can EM contribute to the health of populations in developing countries? The answer is an overwhelming YES. And everyone has their own vision! Some will pass with time, others will be borne out by good research.

And regarding your point 5, I think that is the whole point to naming this interest in EM, "International Emergency Medicine." Not that it encompasses all of Int'l Medicine, but that the specialty of EM has a vital role in global health.

Just another thought...there was a switch a few years back from "International health" to "global health"...

I propose we rename 'IEM' to the flashier 'GEM.' Remember, I called it first here. 😎

 

[AmoryBlaine]

He's not an idiot, he's my good friend. He is a great guy who has been brain-washed by people who make money off teaching wilderness medicine courses. Him and other people like him want to be like their wilderness medicine instructors and teach wilderness medicine courses one day. Wilderness medicine doctors never really accomplish much other than providing courses on wilderness medicine. When you actually need a wilderness doctor, you are in the wilderness, and they can't help you.

Now it is my turn to look stupid. Maybe I will mix animal fat and ashes next time I'm camping and need a bath. 😳

My apologies. To clarify I meant, "he is thinking idiotically about a particular medical problem."

 

[anonymousEM]

As an IEM fellow just noticing this thread, I'd say that you have hit many of the points to the arguement both ways. For those asking about an IEM fellowship, each program has it's own set of priorities...there's not a board exam for IEM nor a unified curriculum, so if you're considering one, be sure it's covering what you want. Many focus on what I humbly believe is the role of an EP internationally....development of EM as a specialty in a realistic manner in that place. This means policy development, advocacy, physician/nurse/non-physician provider/community education. Rarely does it mean primarily caring for patients. It is important also for us to realize that we cannot import the US system, but learn from our own mistakes and achievements in order to improve the system (or begin to develop one) in a reasonable manner locally.

At the other end of the spectrum are programs which focus on public health, humanitarian medicine, refugee medicine etc. To be excellent at this, I think the public health training and special expertise of the fellowship in a department with a track record of these things is essential.

Road traffic will be the number 3 killer worldwide by 2020...our role needs to be not only in treatment but prevention.

 

[deleted65604]

Like most of the Fellowships in EM, except for toxicology, IEM should be viewed as more of a hobby. Like most fellowships in EM, there is a big disconnect between what the job is portrayed as and perceived, and what you actually do on a daily basis. The international medicine program at my institution (available to medical students) was a bit of a farce. They pitched it as a wilderness medicine/ international medicine rotation in Belize. You think, cool, I'll go down, see how their healthcare system works, learn some Spanish, get some culture, and also learn some tropical medicine and wilderness medicine. What happened was that you flew to Belize and walked out in the jungle and took turns acting like your limbs were broken and making your fellow students fashion gurneys out of banana leaves and sticks. After a few mock scenarios, you spent the rest of the time getting drunk (why do you spend a fortune traveling to a foreign country and then waste most of your time drinking and causing most of the vacation to be somewhat of a blur, and when it is not a blur, you are vomiting). Everybody spoke English and you didn't learn anything about their culture or their healthcare. In previous years, they had put on free clinics but found it to be of little use. People showed up not because they needed medical help, but just so they could score some free medicine from the naive americans. I suspect that if medical school faculty actually knew what little applicable knowledge was imparted, that they wouldn't have given credit for a month long rotation. Students would have got more out of the rotation had they sat on their back porch at home and read a wilderness medicine textbook.

 

[pseudoknot]

Like most of the Fellowships in EM, except for toxicology, IEM should be viewed as more of a hobby.

I think both wilderness medicine and "tactical medicine" (a term I have yet to hear convincingly defined) should both be relabeled as "expeditious evacuation."

Although I wouldn't extend it to most EM fellowships, I do think that wilderness and tactical medicine are typically things people do in their spare time and on a volunteer basis. As such, they are like hobbies. That doesn't make them illegitimate or worthless. Besides, how many internal medicine or ophthalmology-related hobbies do you know of?

As far as tactical medicine, I'm not sure what you mean about the definition. I think that it is a real field but most people who hear about it think it's something it's not (i.e., MDs running around with an MP-5 in one hand and a scalpel in the other, doing surgical airways while shooting at bad guys). Most of the time the role of the MD in tactical medicine is training and supervision, just like an EMS medical director. There are exceptions, but hopefully no one matches into EM thinking that they will get a full time job as Dr. Rambo.

2. As per the bait-and-switch, I completely agree with you. I think one could argue that it does a huge disservice to medical students to delude them in any way from the reality that most of them will have careers that are almost exclusively composed of pulling shifts in US EDs. In my mind it's sort of like the "join the military, see the world" stunt.

Do you really think there are that many people who have gotten so far in the process and are so misinformed? I'm not being argumentative here, I'm really asking.

 

[deleted109597]

There are exceptions, but hopefully no one matches into EM thinking that they will get a full time job as Dr. Rambo.

😱

You've ruined my dreams!!!!!one!!!1!!!

 

[AmoryBlaine]

As far as tactical medicine, I'm not sure what you mean about the definition. I think that it is a real field but most people who hear about it think it's something it's not (i.e., MDs running around with an MP-5 in one hand and a scalpel in the other, doing surgical airways while shooting at bad guys). Most of the time the role of the MD in tactical medicine is training and supervision, just like an EMS medical director. There are exceptions, but hopefully no one matches into EM thinking that they will get a full time job as Dr. Rambo.

Do you really think there are that many people who have gotten so far in the process and are so misinformed? I'm not being argumentative here, I'm really asking.

1. I think that the tactical medicine aficianados would sincerely hope (and say) that there was something more to it than medical direction. I have seen presentations describing weapons training, tactics, and the like.

2. As to your final point: I appreciate that you are not being wantonly argumentative and in that same spirit I respond to your question, "absolutely." I feel that there are many, many applicants to EM who sincerely think that they are going to be able to find jobs that allow them to fufil their fantasies. You need not be too long either on SDN or on the EM interview trail to hear multiple people talking about their plan to "work half the year in academic EM, lecture medical students, do clinical research, and spend half the year in [insert favorite strife-ridden nation here] doing relief work." Similarly I have heard multiple people talk about their plans to "practice" WM, whatever the hell that means.

 

[pseudoknot]

1. I do know that there are some physicians who are reserve police officers and participate in SWAT operations, but they don't get paid and do it in their spare time because they think it's fun. By the same token, the cops appreciate having a physician around, but most police agencies are not going to pay more than a paramedic's salary to do what is generally a paramedic's job.

2. That's unfortunate. I definitely agree with the spirit of your other thread on EM misconceptions. I've noticed that there are a ton of M1s and M2s who like the idea of EM but seem to have no clue of what it actually entails.

3. Your numbered paragraphs make it very convenient to respond to your posts. 🙂

1. I think that the tactical medicine aficianados would sincerely hope (and say) that there was something more to it than medical direction. I have seen presentations describing weapons training, tactics, and the like.

2. As to your final point: I appreciate that you are not being wantonly argumentative and in that same spirit I respond to your question, "absolutely." I feel that there are many, many applicants to EM who sincerely think that they are going to be able to find jobs that allow them to fufil their fantasies. You need not be too long either on SDN or on the EM interview trail to hear multiple people talking about their plan to "work half the year in academic EM, lecture medical students, do clinical research, and spend half the year in [insert favorite strife-ridden nation here] doing relief work." Similarly I have heard multiple people talk about their plans to "practice" WM, whatever the hell that means.

 

[a_ditchdoc]

As someone who has trained internationally at a school dedicated to international health, and actually worked in third world countries, I have conflicting views. I feel some of you are, without a doubt, misguided in your perspectives.

Is EM "geared" for international medicine? It's a question I wrangled with. I have a desire for international medicine as well as a love for EM. From my experiences, I think it is uniquely valuable for international work, but it depends on the work that you do and where you do it. I haven't written an article to "prove it".

EM is the most broad of the medicial specialties, if not particularly deep in most areas. Certainly in a well functioning health care system where long term care delivery is possible, FP is a great fit, along with pediatrics and many other specialties. Of course, the countries I worked in worried very little about cholesterol or hypertension. I can't say I can recall a single person being treated for either of these two while I was in Ethiopia. I think knowing a little about a lot goes very far in the international setting. Knowing brain surgery does little good without the extraordinarily expensive equipment and operating theatre. What are the people dying from in the third world anyway? They are dying from poverty.

I recall working in a small village, screening kids for illness and malnutrition. At one point I remember telling a friend "Usually you look for disease, I have found myself looking for a healthy one. Out of 120 kids, I think I found one that was free of any illness, and I am sure it was because I didn't look hard enough. Surely he had some parasite that was going to get him in a few months. Ten percent of the kids I saw will never make it to five years of age, fewer still will make it to adulthood. They didn't need a neurosurgeon. They needed someone skilled in the basics of medicine, along with a healthy dose of tropical medicine.

We can all spout off about the need for preventive care, sewage systems, better nutrition, clean water, and hygiene. All of these things would reduce the burden of disease drastically. They haven't been implemented in most places.

What I finally came to was this: People are dying now. Yep, right now, of simple diseases that we could treat easily with a few cheap meds and a broad range of medical knowledge. You can tell me hundreds of times "But, you can't really make a difference." In the end, I know you are right. I certainly cannot be the one to implement all of these things that need to be done for the sake of the people in third world countries. But, I can save some. Even if I am a "Tourist", hiking on the weekends, drinking my fill at night, I can save some of them. If it was your child I saved, is this "No difference"?

I gave a young couple the money to take their infant daughter with pneumonia 50 km to another town so that they could get IV antibiotics that were not available where I was. All they could manage to scrounge from friends and family, in 24 hours, was $3. Not enough. I chipped in the the rest, less than the cost of a few beers in NY. I'll never miss it, but perhaps they will remember the gesture, and more importantly, perhaps the little girl lived. Some with me argued that I should not give the money, as I "cant' save everyone". I weighed the pleasure of those three beers against the grunting baby. How could they even think it.

In the big scheme of things that child, or the young Mursi woman I treated for malaria will probably never impact the world, nor will the homless people whose wounds I scrubbed and treated with antibiotics. But at least I was not here, armchair quarterbacking in my comfortable air conditioned home telling everyone how futile it is. Academic argument is best left in academia. I learned more in a couple of months there than any book I ever read.

I did feel overwhelmed and impotent, in ways you cannot imagine. But I know there has to be a better way. Try this. Send part of he money you have planned for your 4k square foot home to a small village for water, sanitation and a small clinic. Give a few hundred bucks of your salary to third world physicians so they can afford a house of their own and a cheap used car. Maybe then they won't leave for more prosperous countries. You see, they aren't ignorant. They are some of the most talented physicians I have ever worked with. They simply want a better life. They want to open the medicine cabinets at the hospital and find more than empty shelves and a half used bottle of antiseptic. Refusing care to dying patients every day because they cannot afford treatment weighs on the soul.

I Know, my point of view does little to ad to the EM versus <insert here> in international medicine, but I think the broad range of knowledge and versatilty we have can go far. Plus, I think we, as a group, are more open to less pristine environents and working with shovels...

Sorry for the rant. Ask me later about prehospital care there and my thoughts...

ditch

 

[nymbarra]

Is EM "geared" for international medicine? It's a question I wrangled with. I have a desire for international medicine as well as a love for EM. From my experiences, I think it is uniquely valuable for international work, but it depends on the work that you do and where you do it.

EM is the most broad of the medicial specialties, if not particularly deep in most areas. Certainly in a well functioning health care system where long term care delivery is possible, FP is a great fit, along with pediatrics and many other specialties.

Thank you for your eloquent post.

I did not decide on EM until rather late, but I based it on my experiences living and working in West Africa for three years before medical school. I also have public health training from an excellent global health program. During my third year clerkships, I saw that while each specialty of medicine is relevant to improving healthcare in developing countries, EM provided the greatest fit and had the most potential for what I wanted to do. Btw, friends of mine who served with me in W Africa and who also went to med school are doing surgery, EM, and FP.

We can all spout off about the need for preventive care, sewage systems, better nutrition, clean water, and hygiene. All of these things would reduce the burden of disease drastically. They haven't been implemented in most places.

I disagree somewhat with this, I prefer to think that it is underutilized. Most people would say, "well, they need more health education." Maybe so, but I don't think that it is the exposure to health education that is at issue. Rather, it's the type of health education project, most of which are narrow one-day workshop affairs with very little integration with nutritional programs or follow-up to show the benefits of optimal hygiene. And there is the cultural element (along w/ environmental and economic factors), chiefly the philosophy of fatalism among the poor that renders the 'locus of control' external, and makes self-efficacy a joke.

For example, Islam is a prevalent religion in West Africa, and Muslims perform absolutions (vigorously washing feet, face, mouth, and hands) five times a day before their prayers. They also--along with the Jewish tradition--have a very codified system of preparing foods. Obviously handwashing is not new to West Africans, nor undercooking foods. However, things like poor birth spacing, no toys for kids so they're playing in the dirt, no access to pediatricians or pediatric medicine (nor the expectation of proper medical care), along with malnutrition, heat, and humidity, certainly play roles in the increased susceptibility to (and acceptance of) infectious diseases.

Also, if they knew that 20-30% of Americans don't wash their hands properly after using public restrooms, they would wonder who is better positioned to teach that topic. 😱

http://www.cleaning101.com/newsroom/2005_survey/handhygiene/keyfindings.cfm

Pittet et al. Hand hygiene among physicians: performance, beliefs, and perceptions. Ann Intern Med. 2004 Jul 6;141(1):1-8.

The point is that knowledge and awareness contribute very little to the adoption and maintenance of sanitation practices. There are other factors involved that are not adequately addressed by the prevention projects in many of the places in the developing world.
But that was a huge digression...😴

You can tell me hundreds of times "But, you can't really make a difference." In the end, I know you are right. I certainly cannot be the one to implement all of these things that need to be done for the sake of the people in third world countries. But, I can save some. Even if I am a "Tourist", hiking on the weekends, drinking my fill at night, I can save some of them. If it was your child I saved, is this "No difference"?

Again, each has their own vision of EM in developing countries. There is benefit in terms of clinical EM practice as well as the fusion of EM and public health in the 'systems' or population-based approach.

I mean, two or three decades ago, our EM forefathers (sorry, I know you guys aren't that old) fought hard to make it into a respected specialty in medicine. Can't the detractors today see similarities in that and our potential in global health?

Give a few hundred bucks of your salary to third world physicians so they can afford a house of their own and a cheap used car. Maybe then they won't leave for more prosperous countries. You see, they aren't ignorant. They are some of the most talented physicians I have ever worked with. They simply want a better life.

This is bleeding into the field of int'l development, but what you are alluding to is the Brain Drain Syndrome. In short, professionals will go wherever they can go to make the most money and then send back to their families and/or communities. The second part of this equation is the health care systems of developed countries that are recruiting these providers, such as the US and the UK. The 'first world' doesn't have to spend the money to train nurses or physicians from developing countries, so it makes sense that there is this economically-driven exodus. Ask the developing country providers, "why not stay in a chronically under-funded, politically-driven, and suboptimally-managed health system," and you're asking yourself a rhetorical question.

Mullan. The Metrics of the Physician Brain Drain. New England J Med, 2005.
http://content.nejm.org/cgi/content/full/353/17/1810

Sorry for the rant. Ask me later about prehospital care there and my thoughts...

ditch

What are your thoughts on EMS/prehospital care?

 

[iridesingltrack]

...hear multiple people talking about their plan to "work half the year in academic EM, lecture medical students, do clinical research, and spend half the year in [insert favorite strife-ridden nation here] doing relief work." Similarly I have heard multiple people talk about their plans to "practice" WM, whatever the hell that means.

I know two attendings at my institution that do exactly what the students you are describing are dreaming of doing. One of them works in the traditional sense more than 6 mo a year, going abroad when he can (medical tourism?), the other however, works far less and is mostly in a "strife ridden nation" but teaches, gives lectures when at "home." They have been expedition physicians spending time at base camps for climbing expeditions (Wilderness Med applied, IMO); serving scientific crews on ships exploring the ice caps; in the poorest countries in the world caring for patients one at a time; assisting other countries build EM/trauma/public health infrastructure; provide disaster relief, etc. One of them just joined Doctors without Borders and is leaving academics. From what I see, these opportunities are available if one wants them. I doubt they pay well...if at all. But, they sure seem to have been valuable experiences to these two attendings, and are likely priceless to those who have benefited from their service.

I have to wonder if these opportunities are rare or if those that are actually willing to sacrifice 6 months of income and absence from family/friends are rare? I tend to think that it is likely the latter.

These are just my mid-night ramblings and .02 cents.

 

[IronMed10]

I know two attendings at my institution that do exactly what the students you are describing are dreaming of doing. One of them works in the traditional sense more than 6 mo a year, going abroad when he can (medical tourism?), the other however, works far less and is mostly in a "strife ridden nation" but teaches, gives lectures when at "home." They have been expedition physicians spending time at base camps for climbing expeditions (Wilderness Med applied, IMO); serving scientific crews on ships exploring the ice caps; in the poorest countries in the world caring for patients one at a time; assisting other countries build EM/trauma/public health infrastructure; provide disaster relief, etc. One of them just joined Doctors without Borders and is leaving academics. From what I see, these opportunities are available if one wants them. I doubt they pay well...if at all. But, they sure seem to have been valuable experiences to these two attendings, and are likely priceless to those who have benefited from their service.

I have to wonder if these opportunities are rare or if those that are actually willing to sacrifice 6 months of income and absence from family/friends are rare? I tend to think that it is likely the latter.

These are just my mid-night ramblings and .02 cents.

for those who are doing IEM/GEM fellowships, how many have families (spouse + children)? same question applies to teaching attendings. thanks, great thread.

 

[excheerleader]

Wow, I never post (just read), and I rarely go into the EM forum, but this was an incredible thread. Thanks for the amazing insight into the intricacies of international medicine, and how much we, as American physicians, may benefit or actually harm the third world countries we seek to help. Thank you!

 

[EvoDevo]

Great thread!

One of the things that I've been thinking of for a while is working for the State Dept as a Regional Medical Officer. The pay's lousy but they *do* pay for you to live wherever you're stationed....seems like there would rarely be a boring day.

 

[Baditude]

Would some experience in disaster medicine be beneficial when working in 3rd wold countries as opposed to just EM experience? I am not sure what all disaster medicine entails but it seems like it would be more focused to mass need of basic health care.
Just curious because I would like to be involved with some sort of international medicine as a volunteer since my kids will be grown and gone by the time I am done with residency and I will have some time. 🙂

 

[el_chavo]

Would some experience in disaster medicine be beneficial when working in 3rd wold countries as opposed to just EM experience? I am not sure what all disaster medicine entails but it seems like it would be more focused to mass need of basic health care.
Just curious because I would like to be involved with some sort of international medicine as a volunteer since my kids will be grown and gone by the time I am done with residency and I will have some time. 🙂

I'll echo what others have said, great thread and very along the lines of what I am thinking. I've seen elements of many of the comments made as of done time living abroad and done a couple medical tourism trips as a med student. Finally I decided to take a year off between third and fourth year to see for myself and will work with an established rural clinic in South America.
But, like others have said, I have a kid on the way and hope to have a somewhat stable family life. So with all these natural disasters that have happened in the last month it got me thinking about DMAT teams and training to organize a team to help during disasters both here in the US and abroad. It seems that this could be an intersection of international healthcare and emergency medicine. Any other thoughts?
In the end, I wanted to see for myself and so I'll take the time to do so.

 

[BlondeDocteur]

for those who are doing IEM/GEM fellowships, how many have families (spouse + children)? same question applies to teaching attendings. thanks, great thread.

In my experience, people who spend more than half the year on relief work postings almost never have children and rarely have a romantic relationship. If they do it is, by mutual agreement, extremely unconventional. Long-term overseas work is a vocation, like the priesthood. Expect to sacrifice almost everything else to it.

If they eventually did settle down, most people in my acquaintance did not marry until their mid to late 40s, and only after deciding to take developed-country jobs (like managing the New York / London / Geneva office of an NGO). A few of the men who married young enough women have children, but again they were born when the guys were in their 50s.

 

[MCAT guy]

Bump because interesting...

 

[Felzor]

Bump because interesting... I'm a non-trad pre-med who has worked for years in international politics and development (i.e. United Nations) and I'm looking to transition into medicine and ultimately combine my interests in medicine with international affairs. I'm searching for concrete examples of how to apply medicine internationally (whether IEM, FP, ID, a policy role at WHO, any of the above). Several of the responses in this thread were fairly down on the idea of international medicine. I certainly don't want to enter med school with romanticized ideas of international medicine or a false sense of what options are available to me, so would love to get more recent thoughts on this. Thanks in advance, grateful for your time and insights.

 

[Birdstrike]

Bump because interesting... I'm a non-trad pre-med who has worked for years in international politics and development (i.e. United Nations) and I'm looking to transition into medicine and ultimately combine my interests in medicine with international affairs. I'm searching for concrete examples of how to apply medicine internationally (whether IEM, FP, ID, a policy role at WHO, any of the above). Several of the responses in this thread were fairly down on the idea of international medicine. I certainly don't want to enter med school with romanticized ideas of international medicine or a false sense of what options are available to me, so would love to get more recent thoughts on this. Thanks in advance, grateful for your time and insights.

Wasn't the EM doc that went to Africa to fight Ebola, and came back with it, an EM International Medicine fellow?

 

[deuist]

Off the top of my head, you can do an international emergency medicine fellowship, work for Doctors Without Borders, volunteer with Samaritans Purse, go on short mission trips with several medical schools, or go on one of the many Honduras trips.

 

[alpinism]

Bump because interesting... I'm a non-trad pre-med who has worked for years in international politics and development (i.e. United Nations) and I'm looking to transition into medicine and ultimately combine my interests in medicine with international affairs. I'm searching for concrete examples of how to apply medicine internationally (whether IEM, FP, ID, a policy role at WHO, any of the above). Several of the responses in this thread were fairly down on the idea of international medicine. I certainly don't want to enter med school with romanticized ideas of international medicine or a false sense of what options are available to me, so would love to get more recent thoughts on this. Thanks in advance, grateful for your time and insights.

Well, what are you interested in specifically? There's a huge variety of options out there.

International medicine can mean a lot of different things to a lot of different people.

Unfortunately for most med students and residents, their only experience revolves around short term "medical mission trips" which are usually half primary care clinic and half expensive vacation. As others have mentioned, they may or may not be of any real benefit to patients.

Some realistic examples of international emergency medicine:

1) working with local hospitals and EMS systems to teach courses and train providers
2) actually helping to set up and organize EM departments and EMS systems
3) humanitarian work with NGOs such as MSF, IRC, IMC, etc
4) exchange programs to share experiences and broaden knowledge
5) public health work related to trauma and injury prevention
6) remote expedition medicine

We have EM faculty at my school who some of the above on a fairly regular basis. I also have a few close friends who do humanitarian work overseas every one or two years.

Full disclosure: I'm still a clinical med student with a diploma in tropical medicine and experience working overseas for the military and NGOs. Planning on doing international EMS and humanitarian work after residency.

As someone who has trained internationally at a school dedicated to international health, and actually worked in third world countries, I have conflicting views. I feel some of you are, without a doubt, misguided in your perspectives.

Is EM "geared" for international medicine? It's a question I wrangled with. I have a desire for international medicine as well as a love for EM. From my experiences, I think it is uniquely valuable for international work, but it depends on the work that you do and where you do it. I haven't written an article to "prove it".

EM is the most broad of the medicial specialties, if not particularly deep in most areas. Certainly in a well functioning health care system where long term care delivery is possible, FP is a great fit, along with pediatrics and many other specialties. Of course, the countries I worked in worried very little about cholesterol or hypertension. I can't say I can recall a single person being treated for either of these two while I was in Ethiopia. I think knowing a little about a lot goes very far in the international setting. Knowing brain surgery does little good without the extraordinarily expensive equipment and operating theatre. What are the people dying from in the third world anyway? They are dying from poverty.

I recall working in a small village, screening kids for illness and malnutrition. At one point I remember telling a friend "Usually you look for disease, I have found myself looking for a healthy one. Out of 120 kids, I think I found one that was free of any illness, and I am sure it was because I didn't look hard enough. Surely he had some parasite that was going to get him in a few months. Ten percent of the kids I saw will never make it to five years of age, fewer still will make it to adulthood. They didn't need a neurosurgeon. They needed someone skilled in the basics of medicine, along with a healthy dose of tropical medicine.

We can all spout off about the need for preventive care, sewage systems, better nutrition, clean water, and hygiene. All of these things would reduce the burden of disease drastically. They haven't been implemented in most places.

What I finally came to was this: People are dying now. Yep, right now, of simple diseases that we could treat easily with a few cheap meds and a broad range of medical knowledge. You can tell me hundreds of times "But, you can't really make a difference." In the end, I know you are right. I certainly cannot be the one to implement all of these things that need to be done for the sake of the people in third world countries. But, I can save some. Even if I am a "Tourist", hiking on the weekends, drinking my fill at night, I can save some of them. If it was your child I saved, is this "No difference"?

I gave a young couple the money to take their infant daughter with pneumonia 50 km to another town so that they could get IV antibiotics that were not available where I was. All they could manage to scrounge from friends and family, in 24 hours, was $3. Not enough. I chipped in the the rest, less than the cost of a few beers in NY. I'll never miss it, but perhaps they will remember the gesture, and more importantly, perhaps the little girl lived. Some with me argued that I should not give the money, as I "cant' save everyone". I weighed the pleasure of those three beers against the grunting baby. How could they even think it.

In the big scheme of things that child, or the young Mursi woman I treated for malaria will probably never impact the world, nor will the homless people whose wounds I scrubbed and treated with antibiotics. But at least I was not here, armchair quarterbacking in my comfortable air conditioned home telling everyone how futile it is. Academic argument is best left in academia. I learned more in a couple of months there than any book I ever read.

I did feel overwhelmed and impotent, in ways you cannot imagine. But I know there has to be a better way. Try this. Send part of he money you have planned for your 4k square foot home to a small village for water, sanitation and a small clinic. Give a few hundred bucks of your salary to third world physicians so they can afford a house of their own and a cheap used car. Maybe then they won't leave for more prosperous countries. You see, they aren't ignorant. They are some of the most talented physicians I have ever worked with. They simply want a better life. They want to open the medicine cabinets at the hospital and find more than empty shelves and a half used bottle of antiseptic. Refusing care to dying patients every day because they cannot afford treatment weighs on the soul.

I Know, my point of view does little to ad to the EM versus <insert here> in international medicine, but I think the broad range of knowledge and versatilty we have can go far. Plus, I think we, as a group, are more open to less pristine environents and working with shovels...

Sorry for the rant. Ask me later about prehospital care there and my thoughts...

ditch

Even though its been over 5 years...

Completely agree with the above.

Great post.

 

[EMIM2011]

As someone who has trained internationally at a school dedicated to international health, and actually worked in third world countries, I have conflicting views. I feel some of you are, without a doubt, misguided in your perspectives.

Is EM "geared" for international medicine? It's a question I wrangled with. I have a desire for international medicine as well as a love for EM. From my experiences, I think it is uniquely valuable for international work, but it depends on the work that you do and where you do it. I haven't written an article to "prove it".

EM is the most broad of the medicial specialties, if not particularly deep in most areas. Certainly in a well functioning health care system where long term care delivery is possible, FP is a great fit, along with pediatrics and many other specialties. Of course, the countries I worked in worried very little about cholesterol or hypertension. I can't say I can recall a single person being treated for either of these two while I was in Ethiopia. I think knowing a little about a lot goes very far in the international setting. Knowing brain surgery does little good without the extraordinarily expensive equipment and operating theatre. What are the people dying from in the third world anyway? They are dying from poverty.

I recall working in a small village, screening kids for illness and malnutrition. At one point I remember telling a friend "Usually you look for disease, I have found myself looking for a healthy one. Out of 120 kids, I think I found one that was free of any illness, and I am sure it was because I didn't look hard enough. Surely he had some parasite that was going to get him in a few months. Ten percent of the kids I saw will never make it to five years of age, fewer still will make it to adulthood. They didn't need a neurosurgeon. They needed someone skilled in the basics of medicine, along with a healthy dose of tropical medicine.

We can all spout off about the need for preventive care, sewage systems, better nutrition, clean water, and hygiene. All of these things would reduce the burden of disease drastically. They haven't been implemented in most places.

What I finally came to was this: People are dying now. Yep, right now, of simple diseases that we could treat easily with a few cheap meds and a broad range of medical knowledge. You can tell me hundreds of times "But, you can't really make a difference." In the end, I know you are right. I certainly cannot be the one to implement all of these things that need to be done for the sake of the people in third world countries. But, I can save some. Even if I am a "Tourist", hiking on the weekends, drinking my fill at night, I can save some of them. If it was your child I saved, is this "No difference"?

I gave a young couple the money to take their infant daughter with pneumonia 50 km to another town so that they could get IV antibiotics that were not available where I was. All they could manage to scrounge from friends and family, in 24 hours, was $3. Not enough. I chipped in the the rest, less than the cost of a few beers in NY. I'll never miss it, but perhaps they will remember the gesture, and more importantly, perhaps the little girl lived. Some with me argued that I should not give the money, as I "cant' save everyone". I weighed the pleasure of those three beers against the grunting baby. How could they even think it.

In the big scheme of things that child, or the young Mursi woman I treated for malaria will probably never impact the world, nor will the homless people whose wounds I scrubbed and treated with antibiotics. But at least I was not here, armchair quarterbacking in my comfortable air conditioned home telling everyone how futile it is. Academic argument is best left in academia. I learned more in a couple of months there than any book I ever read.

I did feel overwhelmed and impotent, in ways you cannot imagine. But I know there has to be a better way. Try this. Send part of he money you have planned for your 4k square foot home to a small village for water, sanitation and a small clinic. Give a few hundred bucks of your salary to third world physicians so they can afford a house of their own and a cheap used car. Maybe then they won't leave for more prosperous countries. You see, they aren't ignorant. They are some of the most talented physicians I have ever worked with. They simply want a better life. They want to open the medicine cabinets at the hospital and find more than empty shelves and a half used bottle of antiseptic. Refusing care to dying patients every day because they cannot afford treatment weighs on the soul.

I Know, my point of view does little to ad to the EM versus <insert here> in international medicine, but I think the broad range of knowledge and versatilty we have can go far. Plus, I think we, as a group, are more open to less pristine environents and working with shovels...

Sorry for the rant. Ask me later about prehospital care there and my thoughts...

ditch




Even though its been over 5 years...

Completely agree with the above.

Great post.

+1. Same experiences and thoughts here. There ain't any right answers in this field.

 

[EMIM2011]

1) working with local hospitals and EMS systems to teach courses and train providers
2) actually helping to set up and organize EM departments and EMS systems

One of the difficult questions that comes up with this is the "backbone" of the hospital. I've seen places where people started an air ambulance service with fancy tools and well-trained staff. However, when the patient is being dropped off at any hospital, the "ED" is dirty, poorly equipped and staffed by someout without any knowledge of acute care medicine. Or, some US EM dept decides to partner with a hospital overseas, and they build a new ED, start an EM residency....but once the patients hit the floor, they go back to the level of care that existed before the EM folks arrived. This is why you really need a system-wide change in most instances. Doesn't mean you can't do anything but that, but that should be the ultimate goal.

 

[Felzor]

Many thanks for these interesting responses so far -- would love to hear more!

One of the difficult questions that comes up with this is the "backbone" of the hospital. I've seen places where people started an air ambulance service with fancy tools and well-trained staff. However, when the patient is being dropped off at any hospital, the "ED" is dirty, poorly equipped and staffed by someout without any knowledge of acute care medicine. Or, some US EM dept decides to partner with a hospital overseas, and they build a new ED, start an EM residency....but once the patients hit the floor, they go back to the level of care that existed before the EM folks arrived. This is why you really need a system-wide change in most instances. Doesn't mean you can't do anything but that, but that should be the ultimate goal.

EMIM2011, I think you explain so well the dilemma of performing short-term actions like setting up a ED or doing humanitarian work vs. the need for real system-wide change in these countries. I imagine it might become very frustrating no matter what side of the fence you're on, whether the long-term game of implementing system-wide change on the one hand or treating an endless onslaught of patients with curable disease on the other.

Well, what are you interested in specifically? There's a huge variety of options out there.

International medicine can mean a lot of different things to a lot of different people.

Unfortunately for most med students and residents, their only experience revolves around short term "medical mission trips" which are usually half primary care clinic and half expensive vacation. As others have mentioned, they may or may not be of any real benefit to patients.

Some realistic examples of international emergency medicine:

1) working with local hospitals and EMS systems to teach courses and train providers
2) actually helping to set up and organize EM departments and EMS systems
3) humanitarian work with NGOs such as MSF, IRC, IMC, etc
4) exchange programs to share experiences and broaden knowledge
5) public health work related to trauma and injury prevention
6) remote expedition medicine

We have EM faculty at my school who some of the above on a fairly regular basis. I also have a few close friends who do humanitarian work overseas every one or two years.

Full disclosure: I'm still a clinical med student with a diploma in tropical medicine and experience working overseas for the military and NGOs. Planning on doing international EMS and humanitarian work after residency.




Even though its been over 5 years...

Completely agree with the above.

Great post.

Alpinism, thanks for this list. One option I didn't see on your list which I'm interested in is public health at the global level. You might call this global health governance, for lack of a better phrase. As the Ebola outbreak shows, there may be a need for more coordinated and coherent public health response at the global level to respond to disease outbreaks. Do you know of something like this that exists? World Health Organization?

To answer your question, though, I guess if I were to head down the international medicine track, I would want to have my cake and eat it too -- that is, to directly treat patients as well as be involved in public health. My current gig in international development focuses on systemic change and international public policy (for lack of a better word). Change comes at an absolutely glacial pace. You could spend your whole life doing it and not sure you made an impact. I suppose a dream job for me might be working at an organization shaping international health policy and regulations, but then doing humanitarian work or mission trips for a few months out of the year. Is this a pipe dream? Maybe, I don't know, I'd be interested to hear from those who've tried...