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Funding and support: By Annals policy, all authors are required todisclose any and all commercial, financial, and other relationshipsin any way related to the subject of this article as per ICMJEconflict of interest guidelines (see www.icmje.org). The authorshave stated that no such relationships exist.

1. McMullan JT, Hinckley W, Bentley J, et al. Reperfusion is delayedbeyond guideline recommendations in patients requiringinterhospital helicopter transfer for treatment of ST-segmentelevation myocardial infarction. Ann Emerg Med. 2011;57:213-220.

2. Rokos IC, French WJ, Koenig WJ, et al. Integration of pre-hospitalEKG and STEMI receiving center (SRC) networks: impact on door-to-balloon times across 10 independent regions. JACC CardiovascInterv. 2009;2:339-346.

3. Pitta SV, Myers LA, Bjerke CM, et al. Using prehospital EKG toimprove door-to-balloon time for the transferred patients withSTEMI: a case of extreme performance. Circ Cardiovasc QualOutcomes. 2010;3:93-97.

4. Garvey JL, MacLeod BA, Sopko G, et al. Pre-hospital 12-lead EKGprograms: a call for implementation by EMS systems providingALS. J Am Coll Cardiol. 2006;47:485-491.

5. Rao A, et al. Impact of the prehospital ECG on door-to-balloon timein ST elevation myocardial infarction. Catheter Cardiovasc Interv.2010;75:174-178.

In reply:We thank the commentator for the interest in our study, and

we agree with the sentiment.1 Our study was designedspecifically to detail where targeted quality improvement effortsmight improve care for ST-segment elevation myocardialinfarction (STEMI) patients presenting to non-percutaneouscoronary intervention hospitals and requiring helicoptertransfer. Our intent was to explore the assumption thathelicopter transfer is indeed optimized and, if not, whatstrategies might be used to improve performance. There arefactors unique to the use of helicopter transfer that likelycontributed to our findings, which suggested, in our system atleast, that use of a helicopter does not automatically fix theproblem and further optimization would be needed.

We found that the longest interval was between helicopterrequest (by the referring hospital emergency department [ED])to arrival at the receiving hospital and is composed of manyelements beyond in-air flight time: the dispatch process,movement of the crew to and from the helicopter, warm-up andliftoff procedures, loading and offloading strategies, and timespent at the patient’s bedside. We have used this information tostreamline our internal processes, including minimizing thenumber of infusions that are continued and encouraging “hot”loading and unloading of the patient when safe.

We share the concern of the significant delay to initiate thetransfer process. Traditionally, transportation is requested onlyafter the treating physician first determines that ideal carecannot be provided at the originating hospital and an acceptingphysician at another facility is contacted and agrees to assumecare. In response to this finding, our helicopter service hasstarted an “autolaunch” process in which we will respond before

an accepting physician is identified; additionally, we have m

576 Annals of Emergency Medicine

dentified percutaneous coronary intervention centers that willutomatically accept a STEMI transfer when an acceptinghysician cannot be found.

As the commentator observed, emergency medical servicesEMS) activation and out-of-hospital ECGs can shorteneperfusion times in coordinated STEMI systems. Althougheveral of our subjects used 911 and had an out-of-hospitalCG, our results are from a region without organized STEMIare. These findings suggest that without downstreamrganization, the potential benefits of evidence-based out-of-ospital care are lost, and we contend that our data provideurther evidence for regional change where this has not yetccurred.

The actual number of patients diagnosed by out-of-hospitalCG is not known because many EMS records were missing,

llegible, or incomplete. However, in 21 cases, an EMSiagnostic ECG was found within the ED record. In ongoingork, we are modeling potential time savings if EMS activated aelicopter response according to the out-of-hospital ECG result.egardless of availability of out-of-hospital ECGs, we found

hat the use of a helicopter in a nonoptimized STEMI system isot a guarantee of timely reperfusion. A limitation of our study

s the absence of comparators to ground interhospital transfernd ground transport directly to a percutaneous coronaryntervention facility (ie, hospital bypass); therefore, we cannotomment on how much time may be saved by flying instead ofriving. What is clear, however, is that having a helicopter tose for STEMI transfers does not itself constitute a STEMIystem.

ason T. McMullan, MDniversity of Cincinnatiepartment of Emergency Medicineincinnati, OH

oi:10.1016/j.annemergmed.2011.06.006

unding and support By Annals policy, all authors are required toisclose any and all commercial, financial, and other relationships

n any way related to the subject of this article as per ICMJEonflict of interest guidelines (see www.icmje.org). The authoras stated that no such relationships exist.

. McMullan JT, Hinckley W, Bentley J, et al. Reperfusion is delayedbeyond guideline recommendations in patients requiring inter-hospital helicopter transfer for treatment of ST-segment elevationmyocardial infarction. Ann Emerg Med. 2011;57:213-220.

nternational Emergency Medicine and Globalealth: Training and Career Paths for Emergencyedicine Residents

To the Editor:I share the enthusiasm of Morton and Vu1 for global

edicine but wish to add a few cautionary notes. American

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physicians are trained in an environment that is uniquelytechnologic in focus and resistant to economic limitations.We train and practice, at least in urban areas, with essentiallyunlimited access to tests, consultants, and specialists. Accessto a modern laboratory and radiology suite, the availability oforthopedic and other specialty surgeons, and the ability totriage pregnant patients directly to labor and delivery iscertainly good for patients. But this leads to a ratherrestricted idea of what treatments are under our purview.Completing a typical US emergency medicine residency willnot make one competent to perform a Giemsa stain todiagnose malaria or use forceps for blocked labor, both ofwhich may be essential parts of emergency care in a resource-limited environment.

Three things are necessary to practice effectively: didacticknowledge of the diseases one will encounter, practical skills,and legal authorization. Knowledge can be gained from anappropriate fellowship or one of the internationallyrecognized diploma courses in tropical medicine and hygiene(Diploma of Tropical Medicine and Hygiene).2 Practicalskills, particularly the ability to perform rather than justinterpret laboratory tests, can be learned in a fellowship orDiploma of Tropical Medicine and Hygiene course and bychoosing residency electives carefully. However, a practicalexperience in the field that is supervised by local physicianscan be invaluable in polishing both medical and socioculturalskills. Legal authorization should not be overlooked. It isboth illegal and unethical to practice medicine without alocally valid license or similar approval. It amazes me thatmany physicians do not seem to think that this appliesoverseas.

A final point: it helps to check your ego at the customs desk.We all have a tendency to believe that our practice is correct andthat those who do things differently are simply wrong, buthubris is not a healthy approach to global health. One of thebest aspects of international work is that it allows anopportunity to learn different skills and reflect on otherapproaches to health care. I have certainly learned more frommy foreign colleagues than I have taught them.

Mark Hauswald, MS, MD, (DTM&H London)Emergency MedicineGlobal HealthUniversity of New MexicoAlbuquerque, NM

doi:10.1016/j.annemergmed.2011.05.037

Funding and support: By Annals policy, all authors are required todisclose any and all commercial, financial, and other relationshipsin any way related to the subject of this article as per ICMJEconflict of interest guidelines (see www.icmje.org). The author

has stated that no such relationships exist. N

Volume , . : December

. Morton MJ, Vu A. International emergency medicine and globalhealth: training and career paths for emergency medicineresidents. Ann Emerg Med. 2011;57:520-525.

. American Society of Tropical Medicine and Hygiene. Available at:http://www.astmh.org. Accessed July 13, 2011.

In reply:Dr. Hauswald provides an excellent perspective about

linical practice in resource-limited settings. Althoughmerican physicians are trained in a technologicallydvanced environment with unlimited access to specializedervices, the appeal of global health and internationalmergency medicine fellowships is that they do offerpportunities for American physicians to learn how to worknd improve their diagnostic skills in resource-limitednvironments. Most (if not all) opportunities offered bynternational emergency medicine and global healthellowships cover aspects of local accreditation and licensing;n regard to more independent endeavors, providers shouldndeed be mindful of ensuring accreditation in the localnvironment. However, our experience is that on theeceiving end, organizations are more than happy to facilitatehese types of administrative tasks in exchange for the healthare expertise that visiting physicians provide.

The Diploma of Tropical Medicine and Hygienerograms he mentions are available not only at the Londonchool of Tropical Medicine and Hygiene, at which herained, but also at several universities in the United States.hese programs’ duration ranges from 13 weeks to 3 years,ith various types of certification involved (more

nformation is available at http://www.astmh.org). However,t is doubtful that the 3-month course mentioned is likely toive emergency providers mastery of such complexechniques as the use of forceps for obstructed labor. Readingnd interpreting one’s own laboratory tests is also a standard part ofducational experiences in many international emergency medicineellowships and other overseas practice opportunities. However,dditional exposure to these techniques in the form of a Diplomaf Tropical Medicine and Hygiene program can certainly be ofssistance for those practicing in resource-limited environments.

e also agree with Dr. Hauswald’s comment that the visitinghysician often is the student, rather than the teacher, in theirverseas clinical work experience.

Aspects of the Diploma of Tropical Medicine and Hygieneurriculum are covered in a number of wilderness medicine andustere medicine courses and fellowships offered throughrograms such as those at Stanford University and theniversity of Utah.1,2 These courses focus on the practice ofedicine in any type of low-resource environment (whether in

he United States or abroad). Further, the combined wilderness,ustere, and international emergency medicine fellowship is ofourse available at Dr. Hauswald’s institution, the University of

ew Mexico.3

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