Taking it Global: Structuring Global Health Education in Residency Training.

To meet the demand by residents and to provide knowledge and skills important to the developing physician, global health (GH) training opportunities are increasingly being developed by United States (U.S.) residency training programs. However, many residency programs face common challenges of developing GH curricula, offering safe and mentored international rotations, and creating GH experiences that are of service to resource-limiting settings. Academic GH partnerships allow for the opportunity to collaborate on education and research and improve health care and health systems, but must ensure mutual benefit to U.S. and international partners. This article provides guidance for incorporating GH education into U.S. residency programs in an ethically sound and sustainable manner, and gives examples and solutions for common challenges encountered when developing GH education programs.

Operationalising emergency care delivery in sub-Saharan Africa: consensus-based recommendations for healthcare facilities.

A major barrier to successful integration of acute care into health systems is the lack of consensus on the essential components of emergency care within resource-limited environments. The 2013 African Federation of Emergency Medicine Consensus Conference was convened to address the growing need for practical solutions to further implementation of emergency care in sub-Saharan Africa. Over 40 participants from 15 countries participated in the working group that focused on emergency care delivery at health facilities. Using the well-established approach developed in the WHO's Monitoring Emergency Obstetric Care, the workgroup identified the essential services delivered-signal functions-associated with each emergency care sentinel condition. Levels of emergency care were assigned based on the expected capacity of the facility to perform signal functions, and the necessary human, equipment and infrastructure resources identified. These consensus-based recommendations provide the foundation for objective facility capacity assessment in developing emergency health systems that can bolster strategic planning as well as facilitate monitoring and evaluation of service delivery.

Development and implementation of an emergency medicine graduate training program at Addis Ababa University School of Medicine: challenges and successes.

BACKGROUND: Ethiopians experience high rates of acute illness and injury that have been sub-optimally addressed by the existing health care system. High rates of patient morbidity and mortality prompted the Federal Ministry of Health (FMOH) and the Addis Ababa University School of Medicine (AAU-SM) to prioritize the establishment of emergency medicine (EM) as a medical specialty in Ethiopia to meet this acute health system need. OBJECTIVES: To review the EM residency training program developed and implemented at AAU-SM in partnership with the University of Wisconsin (UW), the University of Toronto (UT) and University of Cape Town (UCT) and to evaluate the progress and challenges to date. METHODS: An EM Task Force (EMTF) at AAU-SM developed a context-specific three-year graduate EM curriculum with UW input. This curriculum has been co-implemented by faculty teachers from AAU-SM, UT and UW. The curriculum together with all documents (written, audio, video) are reviewed and used as a resource for this article. RESULTS: Seventeen residents are currently in full-time training. Five residents research projects are finalized and 100% of residents passed their year-end exams. CONCLUSION: A novel graduate EM training program has been successfully developed and implemented at AAU-SM. Interim results suggest that this curriculum and tri-institutional collaboration has been successful in addressing the emergency health needs of Ethiopians and bolstering the expertise of Ethiopian physicians. This program, at the forefront of EM education in Africa, may serve as an effective model for future EM training development throughout Africa.

Emergency medicine and its development in Ethiopia with emphasis on the role of Addis Ababa University, School of Medicine, Emergency Medicine Department.

INTRODUCTION: Globally Emergency Medicine (EM) is young discipline and even in developed countries it is about five decades old. In Ethiopia formal pre-hospital care or hospital based Emergency department (ED) development is a recent phenomenon and this article describes development of Emergency Medicine care in Ethiopia before, around and after Ethiopia millennium. METHODOLOGY: Documents related to emergency medicine development and implementation from different government and nongovernmental data sources are used as a resource for this article. RESULTS: Emergency Medicine task force (EMTF) has been established in Addis Ababa University (AAU) school of Medicine (SOM) in June 2006 and the taskforce has closely worked with Federal Ministry of Health (FMOH) and Addis Ababa city council Health Bureau (AACCHB). In addition to the main actors many partners have contributed significantly to this initiative. Some of the developments were establishment of emergency departments in Tikur Anbessa Specialized Hospital (TASH) and the restructuring of EM service by FMOH. Emergency care has been considered as a crucial service in hospitals' service along with outpatient and inpatient services. Furthermore, Pre-hospital care initiatives have been commenced in Addis Ababa and expanded to the regions with a arrangement of one or two ambulances to small districts having 100,000 population. There have also been key achievement in human resource development, notably the establishment of EM residency and MSC in EM and critical care nursing. Prehospital care givers training programs in order to produce emergency medicine technicians (EMT) have been started in various regional health professionals training centers. Furthermore, EM module has been included in the current undergraduate medical education. The Ethiopian society of emergency professionals (ESEP) has been established with members from different categories of emergency medicine professionals. In all these developments the emergency medicine training center in the emergency department of AAU has played key role in the training of human resources in different categories. DISCUSSION AND CONCLUSION: The recent successes in EM development is due to concerted efforts of the FMOH, AAU SOM and AACCHB along with committed partners. Hence, it is concluded that consistent local efforts and relevant stakeholders support in EM has resulted in successful development of the field in the country.

Small bowel obstruction from potato and broccoli phytobezoar mimicking mesenteric ischemia.

BACKGROUND: Bezoars are concretions of undigested foreign material that form in the gastrointestinal tract. Rare in humans, they are nonetheless a well-documented cause of intraluminal bowel obstruction. OBJECTIVES: The objectives of this case report include describing an unusual presentation of small bowel obstruction due to phytobezoar, which mimicked mesenteric ischemia, and highlighting the risk factors, presentation, and management of bezoars, in addition to covering historical beliefs regarding bezoars. CASE REPORT: Here we report a 64-year-old man who presented to the Emergency Department with chest pain, vomiting, and hypotension. Initial work-up was directed at ruling out cardiac causes and aortic catastrophe such as aortic dissection or ruptured abdominal aortic aneurysm. Computed tomography angiography of the chest and abdomen showed findings suggestive of mesenteric ischemia and small bowel obstruction. However, exploratory laparotomy revealed intraluminal small bowel obstruction from a phytobezoar consisting of undigested chunks of potato, brussels sprouts, and broccoli. CONCLUSIONS: Although rare in humans, bezoars are a documented cause of small bowel obstruction, and should be considered when intraluminal bowel obstruction occurs. Bezoars causing small bowel obstruction require surgical treatment.

Successful computed tomography angiogram through tibial intraosseous access: a case report.

BACKGROUND: Intraosseous access has been used increasingly with proven efficacy in emergent situations for adults when intravenous access could not be obtained. OBJECTIVE: Our aim was to demonstrate if tibial intraosseous (IO) is an effective route for iodinated contrast administration and pulmonary vasculature visualization. CASE REPORT: We report on an obtunded patient requiring a computed tomography angiogram to help with diagnosis and tibial IO was the only viable access appropriate to withstand the pressure of a computed tomography iodinated contrast load. Tibial IO access was used successfully for administration of iodinated contrast to evaluate for massive pulmonary embolism in an obtunded patient in extremis secondary to cardiovascular instability. CONCLUSIONS: The pulmonary arteries were opacified and demonstrated a high-quality CT angiogram can be done via tibial IO device.

The Impact of Global Health Experiences on the Emergency Medicine Residency Milestones.

OBJECTIVES: Identify the impact of experiences in global health (GH) on the Accreditation Council for Graduate Medical Education (ACGME) competencies in emergency medicine (EM) residents and describe the individual characteristics of EM residents with global health experience compared to those without. METHODS: From 2015 to 2018, 117 residents from 13 nationally accredited United States EM residency training programs were surveyed. Specifically, the survey gathered demographic data and information regarding timing, type, location and duration of short term experiences in global health (STEGH). The survey collected both qualitative and quantitative data regarding resident experiences, including number of procedures performed and self-assessment of the impact on their residency milestones. ACGME milestone data from survey respondents was collected from each resident's training program coordinators. Chi-squared analysis and t-tests were conducted to assess differences between residents with STEGH and those without. A generalized linear model (GLM) was utilized to assess the effects of time and experience with interaction on achieving milestones in each of the competency domains, to compare milestone achievement over time between residents with STEGH and those without. RESULTS: Out of 117 EM residents, 60 were female (44%), the mean age was 30 years (standard deviation = 3.1), and 84 (71.8%) reported STEGH in general, including prior to residency (64.5%). 33 (28.2%) reported having completed STEGH during residency. The results of the GLM analysis showed that residents with STEGH during residency had significantly higher scores compared to those without the experience or STEGH pre-residency across all six competencies. CONCLUSIONS: STEGH in EM residents was associated with higher milestone achievement in certain ACGME competency domains including medical knowledge, practice-based learning and improvement, and professionalism. Participation in STEGH during residency appeared to show the strongest effect, with higher scores across all six competencies.

Global Health Training in U.S. Emergency Medicine Residency Programs.

OBJECTIVES: Formal education in global health (GH) and short-term experiences in GH (STEGH) are offered by many emergency medicine (EM) residency programs in the United States. In an increasingly connected world, training in GH and STEGH can provide essential knowledge and practical skills to trainees, particularly at the graduate medical education level. The current core programmatic components and the essential competencies and curricula that support ethical and effective STEGH, however, still vary widely. The authors conducted a survey of the 228 EM residency programs in the United States to describe the current state of GH training and STEGH. METHODS: An online survey was developed in REDCap by a team of GH faculty. In July 2018, programs were invited to participate via individual invitation of program directors from a directory. The programs received two reminders to participate until January 2019. RESULTS: Of the 84 programs that responded, 75% offer STEGH and 39% have longitudinal GH curricula. Within these programs, only 55% have dedicated GH faculty and only 70% have dedicated sites. Both faculty and residents encounter funding and insurance barriers; most notably, only 20% of programs that offer STEGH provide evacuation insurance for their residents. Most residents (95%) engage in clinical work along with teaching and other activities, but 24% of programs do not allow these activities to fulfill any residency requirements. Finally, only 80 and 85% of programs offer preparatory and debriefing activities for residents, respectively. CONCLUSIONS: While the results of this survey show progress relative to prior surveys, there are still barriers to implementing GH curricula and supporting safe, ethical, and effective STEGH, particularly in the form of continued financial and logistic support for faculty and for residents, in U.S. EM training programs.

Leadership Matters: Needs Assessment and Framework for the International Federation for Emergency Medicine Administrative Leadership Curriculum.

OBJECTIVES: The objective was to research and develop a novel curriculum on administrative leadership development within the discipline of emergency medicine (EM) with the goal of establishing and implementing it through the world's EM professional organizations. METHODS: From 2016 to 2018 an assessment of different administrative and leadership programs was performed by researching and reviewing previously outlined curricula. Using the data from this assessment, a questionnaire was developed, that was subsequently sent to members of the International Federation for Emergency Medicine's (IFEM) listserv. RESULTS: A total of 377 people from 38 different countries participated in the survey. The majority of respondents identified themselves as EM specialists (81%, 306/377), while others identified themselves as EM resident physicians (9.5%, 36/377) and non-EM specialist physicians (4.5%, 17/377). A large majority of respondents articulated that there was a paucity of developed curricula focusing on leadership, administrative, and management principles within their institution, training program, or professional organization. Across all topic areas, fewer than 30% of polled individuals indicated that they had formal education related to individual and programmatic leadership development, change management, assessment methodology, negotiation skills, financial analysis, media relations, and health care policy. Quality improvement (QI) was the only curricular element that a majority of respondents had integrated into their clinical practice (61%). Qualitative data analysis of the narrative comments was performed with further evaluation of thematic components. CONCLUSIONS: The results of this study further support the findings that the majority of EM providers queried do not have a longitudinal curriculum that fosters administrative and leadership development nor advocate for its importance in relation to the quality of care. Given this gap, we propose that medical education at all levels-medical schools, EM resident/specialty training programs, and professional organizations-should consider creating administrative and leadership development programs. Additionally, development of any curriculum should require a global understanding of health care systems and awareness of the unique contexts of a given location and its available resources.

The Practitioner's Guide to Global Health: an interactive, online, open-access curriculum preparing medical learners for global health experiences.

BACKGROUND: Short-term experiences in global health (STEGH) are increasingly common in medical education, as they can provide learners with opportunities for service, learning, and sharing perspectives. Academic institutions need high-quality preparatory curricula and mentorship to prepare learners for potential challenges in ethics, cultural sensitivity, and personal safety; however, availability and quality of these are variable. OBJECTIVE: The objective of this study is to create and evaluate an open-access, interactive massive open online course (MOOC) that prepares learners to safely and effectively participate in STEGH, permits flexible and asynchronous learning, is free of charge, and provides a certificate upon successful completion. METHODS: Global health experts from 8 countries, 42 institutions, and 7 specialties collaborated to create The Practitioner's Guide to Global Health (PGGH): the first course of this kind on the edX platform. Demographic data, pre- and posttests, and course evaluations were collected and analyzed. RESULTS: Within its first year, PGGH enrolled 5935 learners from 163 countries. In a limited sample of 109 learners, mean posttest scores were significantly improved (p < 0.01). In the course's second year, 213 sampled learners had significant improvement (p < 0.001). CONCLUSION: We created and evaluated the first interactive, asynchronous, free-of-charge global health preparation MOOC. The course has had significant interest from US-based and international learners, and posttest scores have shown significant improvement.

The impact of emergency physician-initiated primary percutaneous coronary intervention on mean door-to-balloon time in patients with ST-segment-elevation myocardial infarction.

STUDY OBJECTIVE: We seek to evaluate how accurately the emergency physician initiates percutaneous coronary intervention for patients presenting to the emergency department (ED) with ST-segment-elevation myocardial infarction (STEMI) and the impact of emergency physician-initiated percutaneous coronary intervention on mean door-to-balloon time. METHODS: We conducted a before-and-after cohort study of consecutive STEMI patients presenting to a 608-bed tertiary care hospital during a 32-month period. During the first 19 months, percutaneous coronary intervention was available only by consultation with an on-call interventionist. In the subsequent 13 months, percutaneous coronary intervention was initiated by the emergency physician independent of cardiology consultation. All patients presenting during the study period with an appropriate clinical history and characteristic ECG findings of STEMI were eligible. Patients with greater than 12 hours of symptoms, contraindications to percutaneous coronary intervention, a valid do-not-resuscitate order, who died before percutaneous coronary intervention was attempted, who initially refused, or whose door-to-balloon time was greater than 6 hours were excluded. The accuracy of emergency physician identification of STEMI was confirmed by an independent cardiologist. All hospital medical records with a discharge diagnosis of acute myocardial infarction (International Classification of Diseases, Ninth Revision code 410.xx) were reviewed to confirm that no STEMI patients went unidentified. A t test was used to compare mean door-to-balloon time in each cohort. RESULTS: A total of 172 patients were enrolled in this investigation, 95 STEMI patients in the initial 19-month period and 77 patients in the subsequent 13 months, when percutaneous coronary intervention was initiated solely at the discretion of the emergency physician. Percutaneous coronary intervention was inappropriately initiated by the emergency physician only once, and no ED patients with STEMI were overlooked, resulting in 100% sensitivity (95% confidence interval [CI] 97.3% to 100%) and 99.6% specificity (95% CI 97.7% to 99.9%). Mean door-to-balloon time in the emergency physician-initiated percutaneous coronary intervention cohort improved by 40 minutes (95% CI 26 to 54 minutes) from 131 to 91 minutes. CONCLUSION: The emergency physician is able to accurately initiate percutaneous coronary intervention for ED patients presenting with STEMI independent of cardiology consultation. Emergency physician-initiated percutaneous coronary intervention significantly reduces mean door-to-balloon time for these patients.

Corrigendum to Attitude of interns towards implementation and contribution of undergraduate Emergency Medicine training: Experience of an Ethiopian Medical School: [African Journal of Emergency Medicine 7(3): 108-112].

[This corrects the article DOI: 10.1016/j.afjem.2017.04.008.].

Attitude of interns towards implementation and contribution of undergraduate Emergency Medicine training: Experience of an Ethiopian Medical School.

INTRODUCTION: Emergency Medicine is a medical specialty based on knowledge and skills required for the prevention, diagnosis and management of the acute and urgent aspects of illness and injury affecting patients of all age groups with a full spectrum of undifferentiated physical and behavioural disorders. Addis Ababa University School of Medicine started its Emergency Medicine Residency in 2010 and Emergency Medicine training for fourth-year medical students started in 2013. This study aims to assess attitudes of fifth year medical students towards Emergency Medicine training and its contribution to their final year of medical school training. METHODS: Two hundred fifth year medical students participated in the study by convenience sampling. Self-administered questionnaires and Likert scales were used for data collection. Descriptive frequencies and chi-square analysis were done for categorical data. Ethical oversight was provided by the Institutional Review Board of the Addis Ababa University College of Health Sciences. RESULTS: Of the 200 participants, 150 were male and 50 were female. 80% agreed its relevance for undergraduates. Relevance was significantly associated with recommendation to other medical schools (χ 2 = 8.34, Pr = 0.004). 72% of respondents agreed lectures are appropriate teaching methods, 70% agreed group activity, 68.5% skill sessions, 67.5% morning discussions, 64% diagnostic session, 60% duty exposures and 45% seminars. Difficulties faced during internship are primarily attributed to lack of facilities, ranging from the setup of the emergency centre to instruments and emergency drugs. 60% of respondents agreed that Emergency Medicine training is important to future careers. 65% agreed recommending training to other medical schools. CONCLUSION: An Emergency Medicine rotation during the final year of medical school provides opportunities to learn about undifferentiated medical emergencies and it should be included for other medical schools in the country. Participants suggest that leadership aspects of Emergency Medicine need more emphasis as the curriculum is further developed in the future.

Development of a Global Health Milestones Tool for Learners in Emergency Medicine: A Pilot Project.

OBJECTIVES: In medical education and training, increasing numbers of institutions and learners are participating in global health experiences. Within the context of competency-based education and assessment methodologies, a standardized assessment tool may prove valuable to all of the aforementioned stakeholders. Milestones are now used as the standard for trainee assessment in graduate medical education. Thus, the development of a similar, milestone-based tool was undertaken, with learners in emergency medicine (EM) and global health in mind. METHODS: The Global Emergency Medicine Think Tank Education Working Group convened at the 2016 Society for Academic Medicine Annual Meeting in New Orleans, Louisiana. Using the Interprofessional Global Health Competencies published by the Consortium of Universities for Global Health's Education Committee as a foundation, the working group developed individual milestones based on the 11 stated domains. An iterative review process was implemented by teams focused on each domain to develop a final product. RESULTS: Milestones were developed in each of the 11 domains, with five competency levels for each domain. Specific learning resources were identified for each competency level and assessment methodologies were aligned with the milestones framework. The Global Health Milestones Tool for learners in EM is designed for continuous usage by learners and mentors across a career. CONCLUSIONS: This Global Health Milestones Tool for learners in EM may prove valuable to numerous stakeholders. The next steps include a formalized pilot program for testing the tool's validity and usability across training programs, as well as an assessment of perceived utility and applicability by collaborating colleagues working in training sites abroad.

Identifying inaccuracies on emergency medicine residency applications.

BACKGROUND: Previous trials have showed a 10-30% rate of inaccuracies on applications to individual residency programs. No studies have attempted to corroborate this on a national level. Attempts by residency programs to diminish the frequency of inaccuracies on applications have not been reported. We seek to clarify the national incidence of inaccuracies on applications to emergency medicine residency programs. METHODS: This is a multi-center, single-blinded, randomized, cohort study of all applicants from LCME accredited schools to involved EM residency programs. Applications were randomly selected to investigate claims of AOA election, advanced degrees and publications. Errors were reported to applicants' deans and the NRMP. RESULTS: Nine residencies reviewed 493 applications (28.6% of all applicants who applied to any EM program). 56 applications (11.4%, 95%CI 8.6-14.2%) contained at least one error. Excluding "benign" errors, 9.8% (95% CI 7.2-12.4%), contained at least one error. 41% (95% CI 35.0-47.0%) of all publications contained an error. All AOA membership claims were verified, but 13.7% (95%CI 4.4-23.1%) of claimed advanced degrees were inaccurate. Inter-rater reliability of evaluations was good. Investigators were reluctant to notify applicants' dean's offices and the NRMP. CONCLUSION: This is the largest study to date of accuracy on application for residency and the first such multi-centered trial. High rates of incorrect data were found on applications. This data will serve as a baseline for future years of the project, with emphasis on reporting inaccuracies and warning applicants of the project's goals.

The role of graduate medical education in global health: proceedings from the 2013 Academic Emergency Medicine consensus conference.

The past 40 years have seen expanded development of emergency medicine (EM) postgraduate residency training programs worldwide. An important part of this educational experience is the ability of resident trainees to participate in experiences abroad. However, little is known about how these experiences shape trainees and the populations they serve. During the 2013 Academic Emergency Medicine consensus conference, a group of educators met to define and outline current trends in graduate medical education (GME) emergency care research. The authors discuss future research questions bridging the gap of GME and global health.