NEWS AND PERSPECTIVE

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Introduction

nnals News and Perspective explores topics relevanto emergency medicine, in particular those in whichur specialty interacts with the political, ethical,ociologic, legal and business spheres of our society.

ld War, American Pakistan. Photo courtesy of emergenc

4 Annals of Emergency Medicine

anagement will be rare. By design, it will not be a‘breaking news’’ section with the latest (andndigested) developments, but instead a reflectivenvestigation of recent and emerging trends. If youave any feedback about this section, please forwardt to us at feedback@acep.org.

Discussion of specific clinical problems and their

0196-0644/$-see front matterCopyright © 2006 by the American College of Emergency Physicians.

EMERGENCY MEDICINE GOES GLOBAL: SPECIALTY STEPS UP HUMANITARIAN ROLEEric Berger

Special Contributor to Annals News and Perspective

David Lanier flies in to a remote village in northern Pakistanto treat victims of a suspected cholera outbreak in the aftermathof a killer earthquake.

Joel Selanikio choppers into coastal Aceh, Indonesia, hishelicopter surrounded by desperate villagers struggling tosurvive in the wake of the Asian tsunami.

Barbara Burke struggles to treat a patient dying of LassaFever in Sierra Leone.

They join the growing ranks of emergency physicianvolunteers with non-governmental organizations (NGOs)providing desperatelyneeded care in globalhealth tragedies.

“My opinion is thatemergency medicinedoctors are really ideallytrained for this kind ofwork,” Lanier said.“Most of the casesyou’re going to see inany developingcountries are going to beyour bread and butteremergency cases:diarrhea, respiratoryproblems. . .. Most ofthe work we do in theUnited States is similarlylow-tech and hands on,so more than any otherspecialty you just have alevel of comfort.”

Before the end of the

doctors, usually surgeons, internists and pediatricians, providedmost humanitarian medical aid to the Third World. But whenthe United States emerged as the only remaining superpower, aglobal polarizing effect began to threaten the safety ofAmericans abroad, even on humanitarian missions, saidemergency physician Frederick “Skip” Burkle Jr. Added to that,managed care has led to time constraints.

“Managed care doesn’t tolerate its physicians leaving onlong-term missions,” said Burkle, director of the Asia-PacificCenter for Biosecurity, Disaster & Conflict Research at the

University of Hawaii.“Our medical systemdoesn’t promoteinternational missions.”

Emergency medicine,by virtue of shift work,schedule flexibility andbroad clinical training, isbecoming an idealsource for NGOsseeking physicianvolunteers. Dr. RachelMoresky conducted asurvey, published inPrehospital and DisasterMedicine in 2001,finding 45% of NGOssend emergencyphysicians to the field.

“There’s an increasingrole for EPs, and I thinkthat’s being realized,” saidMoresky, Director of

Emergency physician David Lanier, a volunteer with Doctors WithoutBorders, checks the skin turgor of a dehydrated child in the aftermathof a 7.6-magnitude earthquake that killed tens of thousands in

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International Emergencyphysician David Lanier.

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Medicine Fellowshipstarting this year at NewYork-Presbyterian, theUniversity Hospitals ofColumbia and Cornell.“I think it’s changing.There’s definitely ashift.”

Doctors WithoutBorders, the US branchof Médecins SansFrontières (MSF), sentabout 210 Americanvolunteers overseas thisyear, more than everbefore. And more NGOsoffer short- and long-term opportunitiesabroad.

Selanikio, anAmerican emergencyphysician whovolunteered just days afterthe Asian tsunami in late 2004, recalled the travails of reachingvictims in coastal Aceh, Indonesia. The villages were only accessibleby boat or helicopter, and most marine docking facilities weredestroyed by the waves.

After several days, the International Rescue Committee securedtransport from the US military, which took Selanikio and othersupport staff to one village not yet visited a week after the naturaldisaster.

“It was kind of a scene out of a Vietnam movie, that was thekind of thing where I remember . . . wondering what have Igotten myself into,” he said. “We found a field of tall grass inwhich to land, and people were just running at the helicopter.They clearly were just desperate for some kind of medical care.”

As the co-founder of the DataDyne Group, a small organizationthat supports public health in developing countries, Selanikio hasworked in foreign countries for both NGOs and the US Centersfor Disease Control and Prevention. In the last decade volunteerismhas become more professional, he said, and that has led toorganizations requiring longer commitments.

THE DOCTORS WITHOUT BORDERSEXPERIENCE

Lanier volunteered for a mission with MSF to Pakistan last year,after the devastating 7.6-magnitude temblor shook the country’ snorthern provinces in early October. The quake killed about90,000 people, and injured about 70,000, according to the UnitedStates Geological Society. Tens of thousands of buildings collapsed,and many of the injured lived in rural towns settled in narrowvalleys.

Lanier, along with a couple of other doctors, a logistician and a

Pakistani children linger outside a tBorders, the American arm of the NSans Frontières. Photo courtesy of

translator, boarded a helicopter to fly into Gangwal shortly after the

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quake. Five children withwatery diarrhea had died,and health officials wereconcerned cholera mightbe spreading in theregion.

“We just basicallylanded in the middle of acornfield, in a valley,” hesaid. “It was the end ofhuman habitation,shortly beyond therenobody lived, it was toomountainous, rugged andcold. When we set downpeople started streamingaround us, hoping wewould distributematerials.”

As Pashtuns, thevillagers were assumed tobe at least nominallysympathetic to Al-Qaeda,

Osama bin Laden’s network of terror. The MSF mission directortold Lanier he would have to agree to identify himself as aCanadian. MSF officials deny this is policy, but concealing one’snationality does raise philosophical issues, said Richard Stoll, aprofessor of political science and associate dean of social sciences atRice University.

“If American doctors identify themselves as Canadian, then itdoes not help to build goodwill for the United States,” Stoll said.“But there are some places in the world where I think it isreasonable for individuals to make their personal safety the highestpriority.

“Also we should keep in mind that although it would be nice ifothers saw that Americans can be helpful and caring about peoplethey do not know, the most important thing is to actually helppeople. If an American doctor has to claim to be a Canadian inorder to help people, this seems like a small price to pay.”

ANIMOSITY AND THE AMERICANGOVERNMENT

US doctors who have traveled to the Third World generally saythe populations they visit separate Americans from the USgovernment. They may be intensely curious about the US, andquestion why the government does things, but they don’t tend tohold individual citizens accountable. That is not always the case, asBurkle, who has escaped 3 attempts on his life, can attest.According to State Department figures, 2003 was the deadliest yearon record with 76 NGO workers killed, most in Afghanistan andIraq. Once considered neutral, State Department HumanitarianAffairs Analyst Dennis King wrote, humanitarian workers are nowseen as “soft targets” with little protection, and doctors have beenno exception. (See table for list of doctors killed while working for

ospital set up by Doctors WithoutPeace Prize-winning Médecinsgency physician David Lanier.

ent hobel

NGOs).

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“You have to pick and choose,” said Burkle, who teachesemergency medicine fellows at the Harvard HumanitarianInitiative and Johns Hopkins’ Center for Disaster and RefugeeStudies. “You need to know what kind of program they(NGOs) are bringing to the community. Do they give peopletraining or do they just show up? It’s terrifying for somepeople. . ..You really have to be wary. You need to do yourhomework. . .. You really need to be mature enough to researchthis well enough that you’re not getting yourself or others intotrouble.”

MSF, which carries the gravitas of a 1999 Nobel Peace Prize,has strict requirements for doctors who apply; they mustcommit to a 6-month mission initially, with the possibility ofshorter trips after they acquire more experience. Theorganization covers travel, visa and immunization expenses. Italso provides housing in the host country, and per diem basedupon cost of living for necessities and food. Beginningvolunteers also receive a minimum stipend of about $800 amonth.

However, MSF may see the American government as “partof the problem,” and American involvement may be seen as athreat to the neutrality of the organization, Burkle said. Thatneutrality has allowed MSF to operate in theaters where otherNGOs fear to tread.

The president of the American arm, Doctors WithoutBorders, is a family physician, and an internist sits on the board.The International Rescue Committee’s health director is

Table. Doctors killed while working for non-governmentalorganizations, 1997-2004.*

June 2, 2004 – Dr. Egil Tynaes, MD, Norwegian, MedecinsSans Frontieres, in Afghanistan by small arms fire andgrenades.

October 5, 2003 – Dr. Annalena Tonelli, Italian, shot at closerange on the grounds of a tuberculosis treatment center shefounded in Borama in Somaliland.

November 8, 2002 – Un-named Afghan staff doctor of MercyCorps International, died from a bullet wound after beingshot during a visit to a project community.

March 4, 2002 – Dr. Khalil Sulieman, Head of the PalestinianRed Crescent Society Emergency Medical Service (EMS) inJenin, West Bank.

November 20, 2001 – Dr. Kassi Manlan, the World HealthOrganization’s representative to Burundi, found shot on theshore of Lake Tanganyika.

September 15, 1999 – Dr. Ayub Sheikh Yerow, a UNICEFdoctor, shot and wounded in a north Mogadishu, Somalia,hospital. Died the next day.

September 30, 1998 – Dr. Sheptim Robaj, International RedCross, killed when his car hit a landmine in Kosovo. AnotherYugoslav doctor identified as Ilir Tolaj was seriously injured.

Jan 19, 1997 – Dr. Manuel Madrazo, Doctors of the World,when his compound in Ruhengeri, Rwanda was attacked.

*Information gleaned from news reports and NGO bulletins collected bythe US State Department.

Australian Emergency Physician Richard Brennan, and Robert

346 Annals of Emergency Medicine

Simon, chair of the Department of Emergency Medicine atCook County Hospital in Chicago, is the founder and chair ofthe International Medical Corps. Emergency physician JenniferLeaning is a board member and founder of Physicians forHuman Rights, which shared the 1997 Nobel Peace Prize aspart of the steering committee for the International Campaignto Ban Landmines.

Emergency physicians’ role is expected to continue to growwith the formal fellowship training grounds springing up atacademic centers around the country. The Society for AcademicEmergency Medicine lists a dozen international emergencymedicine fellowships on its website (http://www.saem.org/services/fellowsh.htm#inter), and more are in the planningstages.

Moresky notes that fellowship benefits both emergencyphysicians and NGOs by allowing time for long-termrelationships and projects. These programs, which require 1- to2-year commitments, represent the most comprehensivetraining for emergency physicians interested in humanitarianmedicine. Most offer master’s degrees in public health,considered the “union card” for NGO work abroad, Burklesaid.

“You have to understand how emergency medical care fitsinto public health priorities,” Burkle said. “What we’re trying todo is develop this more into a profession. We train them heavilyin the epidemiology, to look at things very evidence based andlook at outcome indicators. Did it have an effect on morbidityor mortality?

“One of the things we’ve learned is it takes more thanachievement indicators – parachuting in and setting up a clinic,and counting how many MREs (meals ready to eat) did wehand out, how many blankets. Do these things really actuallymitigate and have a positive effect on morbidity and mortality?They do create good will, but they probably benefit the healthcare providers by giving them experience more than anythingelse.”

ETHICS AND THE ‘BIG PICTURE’This sort of “big picture” thinking can lead to some heart-

wrenching moral and ethical dilemmas, and it is oftenantithetical to the patient-centered medicine taught in theWestern world. For instance, in eastern Africa, femalecircumcision is commonplace, as are its sequelae, mostly woundinfections, tetanus and other pathogens. Despite criticism thatthey are facilitating mutilation, some NGOs have handed outtetanus shots and sterile scalpels to make infection less likely.Conversely, some times arguably the best course is inaction, abitter pill even for seasoned veterans, which is illustrated by thethousands of amputations performed by Western doctors inwar-torn Somalia, Burkle said. Most died of infection becausethere was no follow-up wound care.

Burkle also witnessed an example of the best intentions goneawry in Rwanda, where doctors ran a full code on a child dying

from cholera, including intra-cardiac epinephrine. After 3

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cardiac arrests, the child died, but there were no resources left totreat the mother stricken with the same disease. She died soonafter, while her remaining children stood outside the tent.

“Now you have a dead mother, a dead child and 2 orphanswho ain’t going to make it in that culture,” Burkle said. “Thereare a lot of very difficult decisions you need to make. Thedecision to doing anything is based on a lot of things, not justmedicine.”

Emergency physicians must prepare for cultural clashes aswell. Burkle recalled several instances of being unable to treatpatients because of obdurate tribal elders, and Lanier’s attemptsto evacuate a young woman with spinal fractures were thwartedbecause the family could not spare a chaperone.

At a minimum, emergency physicians wishing to dohumanitarian work in developing nations should attend trainingsessions, such as the one-week course at the Cleveland Clinic orthe 3-week Health Emergencies in Large Populations courseoffered at Johns Hopkins.

PRACTICING WITH THE BARE NECESSITIESPhysicians abroad work in a range of conditions, and

veterans stressed the need for flexibility and strong physicalexam skills. Some locations may have no electricity or evenrunning water, and equipment will be limited to intravenouscatheters, fluids and antibiotics.

“You’ve got your eyes, your hands, your ears,” Burkle said.“Do you have the expertise to practice the science and the art ofmedicine without all the bells and whistles that you are used to?That’s the shock.”

Others, like a Kenya hospital where Dr. Scott Sasser worked,may have reasonable facilities and serve 100,000 patients a year.

But such conditions may be no easier. Sasser, an assistantprofessor in the Department of Emergency Medicine at theEmory University School of Medicine who has worked in andout of Africa for the last decade, says his Kenya post wore himdown. Just half a dozen physicians handled the patient load.Sasser assumed responsibility for not only the emergencydepartment, but about 70 patients in the pediatric ward. And helived at the hospital.

“It was a 24-hour-a-day job,” he said of the Kenya

assignment, where he was sponsored by World Medical

Special Contributor to Anna

the community in general.

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Mission, the medical arm of the faith-based organizationSamaritan’s Purse.

But at the same time, as an American physician, Sasser saidhe never felt more free. A lot of the headaches of a US practice,liability, insurance and paperwork, simply didn’t exist. Insteadof high-tech diagnostics, the doctor-patient relationship wasstrictly hands on.

“There’s a certain freedom that’s wonderful,” he said.“You’re only taking notes to help you take care of the patientthe next day. It takes you back to the roots of what it’s likebeing a doctor. You perform the exam, there’s no expensive test.So you get more human contact, you rely more on your senses;it feels like what you’ve been trained to do as a clinician.”

MAKING A DIFFERENCEDoctors seeking just 2- or 3-week rotations in foreign

countries should generally seek smaller, faith-based efforts, butit can still take months or more than a year to prepare. BenBusch, an emergency medicine resident at Doctors Hospital inColumbus, Ohio, collected medicines and supplies fromhundreds of doctor’s offices in Columbus for victims of theAsian tsunami. But he didn’t reach Sri Lanka until March lastyear. After contacting several organizations, he finally found thefaith-based group MercyWorks which helped sponsor the trip.

Busch, involved in international relief efforts since hismedical school days at Michigan State University, shares theview that growing numbers of doctors are interested in travelingabroad to offer care in developing nations. The interestespecially exists, he said, among younger doctors.

More medical schools are offering their studentsinternational opportunities simply because the young doctors-in-training are demanding it, he said.

“I think people have a better cultural awareness because theworld is so small these days,” he said. “The desire probablycomes from the fact that today’s young doctors have grown upin a more global culture. We see all this terrible stuff going onaround the globe, and we want to make a difference.”

Eric Berger is a science writer at the Houston Chronicle. Hecan be reached at.sci.writer@gmail.com

doi:10.1016/j.annemergmed.2006.02.016

A CLASH OF PRACTICE MODELS: DEBATE ROILS AROUND MEGA-GROUP MEDICINEGeorge Flynn

ls News and Perspective

In government, the political arguments rage on about whatextent of local control is best for a democracy. Business sectorsdebate the same issues, whether a large corporation or locallyowned businesses is better suited for consumers, employees and

Increasingly, the delivery of emergency medicine triggersthose same fundamental disputes. With a basic trend towardconsolidation of emergency physician contract providers overthe past several years, the dialogue also is escalating about the

impacts on physicians and the patients served by them.

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