Emergency Medicine

International Emergency Medicine Projects

Papua New Guinea Medical Project

About
A dire lack of basic health care currently exists in large parts of the island nation of Papua New Guinea. Through the collaboration of Stanford University students and faculty with the indigenous people of the Sepik River Basin and the Central Highlands, we are establishing a system of health care stations along the Sepik River and in the Enga highlands. Our projects endeavor to build enduring and committed relationships with the communities in these areas via small, reproducible health care delivery programs. Ultimately, our goal is to create an independent healthcare system - fully staffed, supported, and sustained by the local villages, with no need for outside influence or direction. Not only does this PNG project provide an invaluable learning experience for Stanford students, housestaff, and faculty; but it has provided crucial medical service for the people native to this region.

Project
PNGMPThere are three primary components of the medical project. The medical component includes establishing clinics along the Sepik River Basin and in the Enga Highlands. Volunteers stock and manage the clinics directly along side the local healthcare providers and trainees. The extreme needs of these regions provide students and residents with invaluable experience in developing clinical intuition and resourcefulness without the aid of modern laboratory and radiographic assistance. The medical project strives to deliver the best possible medical care to an area in extreme need, and to combine this with the highest standards of scientific investigation, for the continual health care improvement of the local communities.

Medic Course The other components are more sustainable, and are educational in nature. While the project falls into the realm of preventative medicine, it provides interested students with a course curriculum at Stanford, focusing on tropical medicine and international healthcare. Most importantly, it facilitates the training of village health aids in Papua New Guinea to care for their own communities. The PNGMP programs empower the village medics to care for the people without compromising their independence. This long-term relationship and commitment has provided an opportunity for interested Stanford pre-medical and medical students, as well as housestaff, to serve in the setting of international health/tropical medicine.

Press/News
Getting Better: The Stanford - Papua New Guinea Medical Project
(Stanford Magazine) [Nov/Dec 2001]
Spreading Health: A Stanford Medical Project nurtures a Sustainable Health Care System
(Stanford Medicine 19:1) [Winter 2002]

Contacts
For more information email:  Papua New Guinea Medical Project 
Website:  http://www.stanford.edu/group/pngmp

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Vietnam Medical Project

In 2001, the Papua New Guinea Medical Project set out to expand its program to other impoverished regions of the world. The Stanford Vietnam Medical Project was created with the goal of replicating the successes of the Papua New Guinea in the poor farming communities of northern and central Vietnam. Vietnam was chosen due to similar health care and medical educational needs as the people of Papua New Guinea; but with a vastly different socioeconomic and political environment.

With the cooperation of the Vietnamese government, a team from Stanford traveled to Vietnam in the summer of 2002 to assess the needs of the Ninh Binh Province in northern Vietnam. Our team was directed to the rural Nho Quan and Quang Nam districts where there was no existing health care institutions and limited government healthcare infrastructure. There, primary clinics were set up and run with community volunteers and local health officials. A health worker training program was developed, and with the aid of student volunteers from Hanoi to translate, and educated 40 local community members in early symptom identification, basic first aid, and preventive medicine.

We devised a training course to raise the awareness of public health and hygiene in the community. The training course teach local villagers in simple preventive care, basic first aid, disease recognition patterns, and hygiene practices. In addition, we train the local Vietnamese medics to operate the clinics ensuring that the clinics are self-sufficient throughout the year. The medics learn how to conduct patient physical examinations, document relevant health care findings, monitor supplies and medications, and work with existing medical providers to establish continuing care. With each successive year of involvement the original medics became increasingly responsible for the maintenance of the program. As more village medics were recruited into the program, experienced medics were then encouraged to become "medic teachers" for their own community and for nearby villages.

The summer of 2008 saw the expansion of the clinical and medical education program into the Nghe An Province in north central Vietnam. Functioning much in the same way as the program had in its past, the Vietnam Medical Project served communities devastated by recent flooding; while conducting educational programs which targeted a wide audience ranging from small children to health care professionals. Upon our return to Hanoi, free clinics were conducted aside government health care personal providing for the needs of street children and the local homeless.

In 2009, the program concluded with a team visit to the Mekong Delta and government requested work in developing a neonatal health program. Working with the Project Vietnam NGO, the team went the remotest parts of the Mekong developing an outreach infrastructure and nursing education program.



Publications:
"Healing Journeys: Teaching Medicine, Nurturing Hope" by Marilyn Winkleby and Julie Steele (Fall 2003)
"True to the Oath: Brown Med Alumni Cross Continents to Deliver Care" by Brown Medicine 9.1 (Spring 2004)

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Apollo EMT-Intermediate Training Program

Stanford faculty and residents created and implemented a comprehensive EMT-Intermediate Program for paramedics at Apollo Hospital in Hyderabad and Chennai. These highly trained paramedics have had intensive field experience and some have gone on to become paramedic instructors, as well as ACLS/BLS instructors in India. They have played a crucial role in the development of EM/EMS in India.

"For much of India—and the developing world—emergency medical services that we take for granted in the United States are not available, and calls for help go unheeded. All of us with ties to India can recite an incident where a family member or friend met an untimely demise because of a lack of pre-hospital care."
  − S.V. Mahadevan MD, Associate Professor of Surgery



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GVK EMRI Post-Graduate Program in Emergency Care (PGPEC)

Development of a Self-Sustaining Paramedic Educational Program in India: The Stanford-EMRI Partnership

On May 9th 2007, Stanford University School of Medicine Dean, Philip Pizzo, and Emergency Management and Research Institute (EMRI) CEO, Venkat Changavalli, signed a Memorandum of Understanding to develop India’s first collaborative two-year paramedic program (Figure 1), to be taught at EMRI’s campus in Hyderabad, Andhra Pradesh.

Figure 1
Figure 1: Dean Philip Pizzo and Venkat Changavalli sign the MOU in the presence of former AP Chief Minister Y.S. Rajasekhara Reddy

The goals of the program were four-fold: (1) train Indian paramedics; (2) train Indian paramedic instructors; (3) train each to international standards; and, (4) develop a world-class Indian training facility.

The Chinese have a proverb, ”Give a man a fish and you feed him for a day; teach a man to fish and you feed him for a lifetime.” With this in mind, this novel program aimed to educate paramedic students while simultaneously training paramedic instructors, thereby ensuring future sustainability.

The Post-Graduate Program in Emergency Care (PGPEC), India’s first internationally affiliated paramedic program, was inaugurated on July 15th, 2007. 128 students and 24 paramedic instructor-trainees were initially selected for the PGPEC (Figure 2).

Figure 2
Figure 2: PGPEC Students and Advanced Clinical Educators

The PGPEC students were all B.Sc. graduates who were selected on the basis of an English proficiency test, physical fitness evaluation and personal interview. Of the PGPEC students, 126 were from Andhra Pradesh and two from Uttar Pradesh. The paramedic instructor-trainees were selected on the basis of their prior expertise in prehospital care and a personal interview. The paramedic-instructor trainees were known as Advanced Clinical Educators (ACEs) (Figure 3). The inaugural group of ACEs was made up of allopathic physicians, homeopathic doctors and EMTs.

Figure 3
Figure 3: Advanced Clinical Educators (ACEs)

The PGPEC curriculum was jointly developed by Stanford School of Medicine and EMRI. The curriculum was based on the United States EMT-Paramedic (EMT-P) National Standard Curriculum; however, it included diseases, conditions and cultural issues relevant to the practice of prehospital care in India. The curriculum emphasized uniquely Indian prehospital emergencies such as snakebites, organophosphate poisoning and obstetric emergencies (which account for nearly one-third of EMRI’s calls in India). The PGPEC curriculum also included chief complaint-based emergency medicine instruction, a feature not found in other EMS training programs.

The final curriculum incorporated classroom-based, hospital-based and prehospital-based components. The didactic curriculum was divided into 15 two-week modules. Each module was structured similarly to optimize resources and time, and allow for the simultaneous instruction of both students and instructor-trainees (Figure 4).

Figure 4
Figure 4: Two-week standardized modular curriculum demonstrating concurrent training of paramedic students and instructor-trainees


Figure 5
Figure 5: Dr. Matthew Strehlow teaching at the EMRI campus in Hyderabad

During each educational module, US-based faculty provided on-site classroom-based lectures to both students and instructor-trainees using original PowerPoint presentations (Figure 5).










Figure 6
Figure 6: An ACE teaching intubation skills to the PGPEC students

US-based faculty also conducted training-of-the-trainer sessions for the paramedic instructor-trainees, who learned to lecture and conduct hands-on procedural skills workshops under the direct supervision and mentorship of the US-based faculty (Figure 6).







In addition to classroom-based lectures and hands-on skills workshops, the students participated in interactive case-based studies (Figure 7), medical simulation and distance learning. The use of patient simulators allowed students to address real-life clinical scenarios and practice life-saving skills without the risk of harming a real patient (Figures 8,9).

Figure 7
Figure 7: Interactive case-based studies: Treating the patient with chest pain

Through high-definition videoconferencing, leaders in emergency care from around the world were able to share their expertise directly with the PGPEC students in India without having to travel overseas.

Figure 8
Figure 8: PGPEC students performing the Heimlich maneuver
Figure 9
Figure 9: PGPEC students practicing ACLS skills on a high definition patient simulator

The educational curriculum also included standardized international training courses such as Advanced Cardiac Life Support (ACLS), Pediatric Advanced Life Support (PALS) and International Trauma Life Support (ITLS). When comparing ACLS test performance of 117 PGPEC students with 43 U.S. paramedic students, the average score was 86% (+/- 11%) for the Indian students, and 87% (+/- 6%) for the U.S. students. The PGPEC students performed at a level equivalent to their U.S. counterparts on ACLS written testing despite English being the third language learned for 75%.

We also experimented with incorporating non-traditional subjects into our prehospital educational curriculum. All PGPEC students participated in an innovative two-week curriculum focusing on leadership, communication, team-building and personal confidence. Following completion of this unique educational program, PGPEC students reported significant improvement in their leadership and communication skills.

The PGPEC curriculum also included hospital-based rotations in emergency medicine, intensive care, coronary care, obstetrics and gynecology, pediatrics and burns. PGPEC students were supervised by ACEs and hospital-based physicians during these clinical rotations.

Prehospital field training was provided through direct observation, supervised practice via on-line medical direction, and case-based review (Figure 10). Students and paramedic instructor-trainees were continually assessed with written, oral and hands-on-skills testing.

Figure 10
Figure 10: Practicing use of the Kendrick field extrication device

Following completion of their didactic modules, hospital rotations and initial field training (18 months of training overall), the PGPEC students were administered a final written examination. Remarkably, all 120 students passed their final written examination on the first attempt.

For the final six months of the program, the students were assigned to field training locations throughout India. At the completion of this field training, the students returned to Hyderabad for final oral examinations (case-based) given by the ACEs and Stanford faculty. On July 16th, 2009, after two grueling years of training, the first batch of PGPEC students graduated (Figure 12), a proud moment for Stanford, EMRI and India. Since their graduation, the first batch of PGPEC students have gone on to work as paramedics, EMT instructors, researchers, and physician extenders, all across India.

Figure 11
Figure 11: The first batch of PGPEC students taking the paramedic oath at their graduation ceremony

Launching a paramedic educational program in India was not without obstacles and challenges. First, we had to recruit the right students and instructors to be successful. Remarkably, our students were willing to commit two-years of their lives to an unproven career path, and in doing so became part of the first generation of Indian paramedics. And, many of our ACEs left successful medical careers to join us and fill a needed void in EMS education in India.

Language also proved to be a significant barrier. Though all students had learned English, their true comfort and proficiency widely varied. They had trouble with ours accents and we with theirs. Many students struggled early on as our educational materials and instruction was in English. However, by modifying the curriculum to include medical English classes, small group sessions with the ACEs, and leadership and communication training, we observed a dramatic improvement in language proficiency over time. By their graduation, all of the students were facile with medical and conversational English.

As with all educational endeavors of this magnitude, attrition was a factor. A number of instructors and even some students left the PGPEC due to family commitments and illness, financial hardships, and alternative opportunities. Despite these hurdles, the overall retention rate and success of the PGPEC far exceeded our expectations. We proudly marveled as our students and ACEs developed into skilled clinicians, responsible role models and future leaders.

Over the course of our two-year engagement, Stanford sent twenty-five instructors (ten EM faculty members, three EM fellows, six EM residents, five students, four US-trained paramedics, and two nurses) to teach at the EMRI campus in Hyderabad. In July 2009, we turned over the complete responsibility for the paramedic-training program to the ACEs and EMRI staff, a defining moment in Indian EMS education. From 2007-2009, EMRI and Stanford established a novel, comprehensive paramedic training program that simultaneously trained its inaugural class of paramedic students and instructors, thereby ensuring future viability. It is our sincere hope that the EMRI-Stanford paramedic program will serve as a replicable paradigm for the development of sustainable educational courses elsewhere in India and in other developing nations.

References:
Goodwin T, Delasobera BE, Camacho J, Koskovich M, D’Souza P, Gilbert GH, Strehlow MC, Mahadevan S.: Indian and U.S. Paramedic Students: Comparison of Exam Performance for AHA ACLS Training. Acad Emerg Med 16(4): Suppl_1:47, 2009.

Mahadevan S, Strehlow M, Chiao A, Ramana Rao GV, Shelke D, Rajhans P.: Development of a Self-Sustaining Paramedic Educational Program in India. EMCON, Guwahati, India, 2009.

Mahadevan S, Strehlow M, Jena B, Dubey A.: Epidemiology of Prehospital Emergencies in Andhra Pradesh, India, 2007. Ann Emerg Med 54 (3) Suppl 1: 80, 2009

Mantha A, Gupta A, Strehlow M, Mahadevan S.: Development of Focused Leadership Curriculum for Paramedic Students in India. EMCON, Guwahati, India, 2009

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GVK EMRI Research Institute

Faculty, fellows, emergency medicine residents and medical students from Stanford School of Medicine and GVK EMRI have jointly conducted a series of prospective research studies analyzing the epidemiology and outcomes of prehospital patients (with various presenting medical complaints) utilizing a new research methodology known as Online Medical Research (OLMR). OLMR data collection specialists gather real-time demographic and clinical information from EMTs in the field and follow-up information from patients, their family, or their caregivers. To date, we have conducted OLMR studies on the following emergency chief complaints: obstetric emergencies, chest pain, vehicular trauma, GI emergencies, seizures, poisoning/suicide, burns, shortness of breath and non-vehicular trauma. To date, we have enrolled over 7000 GVK EMRI patients in OLMR protocols. These novel epidemiologic studies describe important considerations in patients requiring prehospital emergency care in India. Our initial research goals were to define the population of patients who call for emergency medical service and identify risk factors for morbidity and mortality. Future research will assess the impact of changes or advances in the delivery of prehospital care (e.g., introduction of EMS protocols) in India. This valuable data will help guide healthcare development and resource utilization, preventative public heath measures, and EMS expansion in India. Poster

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Nepal Ambulance Service EMS Development

The Division of Emergency Medicine in the Department of Surgery is once again taking its expertise around the world. Representing the Stanford Emergency Medicine International (SEMI), Drs. S.V. Mahadevan and Paul Auerbach were in Nepal in November to attend the graduation of the very first Emergency Medical Technician (EMT) class in the country, as well as assist with technical issues before the launch of Nepal’s first emergency medical services (EMS) system in early January.

Prior to SEMI’s involvement, Nepal has lacked both a formal prehospital emergency care training program as well as centralized EMS.  After learning about the successful launch of a the Stanford-GVK EMRI paramedic-training program in Andhra Pradesh, India, the Nepal Ambulance Service (NAS) approached SEMI to assist with the development of their own pre-hospital training program as well as creation of an EMS system for the Kathmandu valley, home to nearly one million people.
In partnership with NAS, Stanford emergency medicine faculty have successfully created, coordinated and taught Nepal’s very first EMT (Emergency Medical Technician) training program. During the summer and fall, 18 physician instructors and two undergraduates have traveled to Nepal to provide instruction to Nepal’s very first EMTs.  The instructors included Aditya Mantha, Nathaniel Lee Coggins, Scott Bradley, Charlene Kiang, Uta Shimizu, Jennifer Kanapicki, Jessica Pierog, Rebecca Walker, Dwain Coggins, Rebecca Smith-Coggins, Phil Harter, Colin Bucks, Peter D’Souza, Laleh Gharahbaghian, Lori Rutman, Ian Brown, Paul Auerbach, Kelly Murphy, Matt Strehlow, and S.V. Mahadevan.  The twelve-week course commenced on August 8th and finished on November 13th. Fifty bright, enthusiastic Nepali EMTs graduated on November 17th, 2010, in an historic ceremony.

Prior to their work in Nepal, SEMI put together India’s first successful advanced prehospital care program, a two-year course that lead to the development of a prehospital care training institute in Hyderabad, India.  Their success in India provided SEMI’s director, S.V. Mahadevan, with the confidence to expand their program to other countries.  Nepal is site of the Division of emergency medicine’s second pre-hospital educational program, and other countries, such as Ethiopia, are waiting in the wings.  “We like to align with countries and organizations that are passionate about providing emergency care to those in need,“ Dr. Mahadevan said, when asked how the Division chooses the countries to assist.

Though many countries are eager for assistance, cultural differences and language barriers are some the challenges that must be faced and surmounted. “In Nepal, before beginning the EMT course, we taught a one week leadership course to instill the typically reserved Nepali students with confidence,” Dr. Mahadevan said, explaining how it was important for the emergency medical responders to take charge of emergency situations.

“We are sowing the seeds of emergency medicine in countries that haven’t traditionally had access to emergency care, both in the prehospital and hospital settings.  With our collective expertise, and prior experience, we strive to help developing nations build educational programs and EMS systems from scratch.”

For more information, please visit the website for the Nepal Ambulance Service, or watch the video.

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GVK EMRI District Hospital Training Program

Faculty and fellows from Stanford University School of Medicine were responsible for development and deployment of the District Hospital Physician Training Program (DHPT). The DHPT is an intensive 5-day course created by internationally recognized educators to address the educational deficiencies of physicians practicing in India. The course addresses a wide range of clinical topics essential to the practice of emergency medicine, and emphasizes a methodical approach to emergency patient evaluation and management. Each DHPT course is customizable to the specific instructional needs of the participants and features high quality PowerPoint presentations, hands-on skills workshops, interactive case-based discussions, and a detailed syllabus (200 pages) with color images, practical illustrations and methodical tables. Course

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Stanford-Wisconsin-MoH Ethiopia EMS Evaluation

EXCERPT FROM SEMI REPORT TO ETHIOPIAN MINISTRY OF HEALTH

It is our pleasure, as Stanford Emergency Medicine International (SEMI), to submit a report to the Ministry of Health (MOH) in support of their efforts to develop a comprehensive Emergency Medical Services (EMS) plan for Ethiopia. The purpose of our report is to delineate goals and provide recommendations for EMS development in Ethiopia with specific focus on Addis Ababa. We have included key recommendations and lessons learned from our experience with EMS development in other nations. Our observations may hopefully serve as an adjunct to the current technical working draft (being developed by the EMS task force), which has appropriately identified objectives for the initiation of a coordinated EMS system. We are honored to participate in this collaboration and appreciate the support from both the Ministry of Health of Ethiopia and the non-profit organization People-to-People.

A comprehensive EMS system is a critical component of national public health and safety. EMS is integral to the patient safety net, healthcare accessibility, and disaster management. In most developing nations, steady progress has been made in vital areas such as providing access to clean water and sanitation facilities, and combating infectious diseases. Unfortunately, new public health challenges have arisen, most prominently severely limited access to quality emergency medical care.

Traumatic, cardiovascular, and obstetric emergencies continue to be leading causes of morbidity and mortality in most developing nations and the impact of these diseases on the overall health of the population is rising dramatically. Well functioning EMS systems can dramatically curb the impact of these diseases. For example, traumatic injuries from road traffic accidents are a leading cause of death worldwide in individuals under the age of 45 years old. A disproportionate number of these deaths, up to 90%, occur in low-income nations. A person suffering traumatic injuries in a developing nation would have a six-fold greater chance of dying than a person with similar injuries in a developed nation.

Furthermore, the World Health Organization (WHO) highlighted the importance of obstetric emergencies by setting the reduction of maternal and neonatal mortality as one of only eight millennium goals. The WHO goes on to recommend the presence of skilled attendants at deliveries as a primary method of decreasing morbidity and mortality in this population. In 2005, an estimated 22,000 women within Ethiopia died due to causes “related to or aggravated by pregnancy or its management,” including childbirth. This accounts for 28% of deaths among females of reproductive age. EMS can greatly improve access to skilled medical providers during medical emergencies.

The current state of prehospital emergency care in Addis Ababa, Ethiopia is outlined in our report. To summarize, EMS in Ethiopia is severely limited. There is no single, well-established toll-free emergency telephone number, no centralized EMS dispatch center, only a few, scattered, ill-equipped ambulances, and no standardized training for prehospital personnel. In response to the current state, the Ministry of Health (MOH) in Ethiopia has formally identified the development of emergency medical services as a priority. By recognizing EMS as an essential service alongside Fire and Police, the MOH has taken a critical initial step in improving medical care in Ethiopia. Further efforts currently underway at reforming EMS include a national EMS technical working group and the initiation of a medical specialty in emergency medicine.

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GVK EMRI EMS Protocol Manual

Faculty and fellows from Stanford University School of Medicine were responsible for development of Prehospital Emergency Care Protocols, India’s first guidelines for the delivery of prehospital care. The development and implementation of EMS protocol standards facilitate the uniform treatment of injuries and illnesses such that all patients receive the current standard of medical care at the most appropriate location. Results from Online Medical Research demonstrated significant opportunities to improve the care of common emergencies and highlighted the critical importance of utilizing international quality protocols developed specifically for India. Prior to March 2011, these protocols were non-existent or insufficient in quality. Experts from Stanford University School of Medicine have developed 53 EMS protocols for GVK EMRI for use by physicians, EMTs and educators.

These EMS medical protocols (practice guidelines) will provide the highest quality patient care, ensure countrywide uniformity and consistency of prehospital care, and promote current evidence-based practice related to EMS (when this evidence is available). These EMS protocols will also account for and accommodate regional medical practices and medications, and language and cultural issues.

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Patan Academy of Sciences Epidemiology Research

Prospective Evaluation of Patients Presenting to an Emergency Department in Kathmandu

Due to the struggling economy of developing nations such as Nepal, healthcare budgets are often not sufficient to serve the entire population. The minimal healthcare infrastructure, along with the burden of disease, both infectious and chronic, exacerbates the poor health of the population, especially among the most disadvantaged populations. Due to the need to allocate limited healthcare resources, developing countries such as Nepal have been unable to invest in the establishment and maintenance of an effective emergency medical system.

Morbidity and mortality due to trauma and injury are high in Nepal- annually, 530,000 DALYs are lost to injury in Nepal. Since most injuries occur within the economically active population, this high burden of injury directly impacts the nation’s development by depleting the already scarce human and monetary resources available. Studies have shown that many conditions that contribute to the burden of disease in low and middle-income countries can be improved through prompt emergency care. For many patients in developing countries, the emergency room often also serves as the first point of contact with the medical system. However, there is often a gap between the need for emergency services and the resources available in providing the needed services , including facilities and trained personnel.

As such, collaborative emergency projects are emerging in several countries in the developing world. The Stanford Emergency Medicine International (SEMI), under the leadership of Dr. S.V. Mahadevan, has developed short-term projects that build emergency medical capacities in several nations, including the establishment of India’s first advanced prehospital care program as well as the development of Nepal’s first EMT program.

A prospective study demonstrated that while an emergency medical framework in fact exists in the Kathmandu valley, service and quality of care was found to be lacking . In 2010, the Nepal Ambulance Service, in collaboration with SEMI, developed Nepal’s first EMS system and its first pre-hospital training program for paramedics. This is an important step towards strengthening the emergency medical system in Nepal.

Further training programs for emergency physicians need to be established in order to improve an emergency department’s capacity to care for patients sustainably. A residency training in emergency medicine does not currently exist in Nepal. However, Patan Hospital, a major tertiary-care hospital in Kathmandu, has expressed an interest in developing such a program in collaboration with SEMI. The first step towards this goal is to evaluate the epidemiology of patients presenting to the emergency department, since a comprehensive and effective curriculum cannot be developed without knowledge of the types of patient profiles and cases most commonly seen at the hospital. A baseline of the population and conditions served by Patan Hospital’s emergency room as well as information on the quality of care that was provided is important in the design and implementation of quality improvement programs such as a residence in emergency medicine curriculum.

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URC/CHS Cambodia Emergency Medicine Case-Based Educational Curriculum

Goal: Identify the most common emergency complaints/conditions and develop evidence-based algorithms and checklists to address

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Stanford-URC/CHS Cambodia Emergency Triage and Resuscitation Room Project

Stanford Emergency Medicine International (SEMI) and URC-CHS have partnered with USAID to address throughput and delivery of emergency care in hospitals in Cambodia. To further this goal, SEMI developed a novel triage system, One-Two-Triage (OTT), which was initially deployed in select government hospitals in Cambodia in December, 2011.

Low and middle-income countries, like Cambodia, are often unable to apply the triage systems used in high-income countries because of a lack of both resources and experienced health care providers. Patients with emergent conditions often wait in dangerously long lines for registration or intake, placing them at increased risk for preventable morbidity and mortality.

Rapid identification of these patients and immediate interventions can prevent clinical deterioration and improve resource utilization (by assigning appropriate wait times to those with less urgent reasons for their visit).

The One-Two-Triage system is an objective, comprehensive triage scale for adults and pediatric patients that can be applied with minimal healthcare training or resources. OTT standardizes the identification of patients needing emergency care in austere environments. While OTT addresses common emergency illnesses that are global, portions of the system are specifically targeted to the cultural context and emergency illnesses of Cambodia.

One-Two-Triage is a two-stage triage process whereby critical and emergent patients are immediately identified based on their ability to respond to a query regarding their chief complaint, objective measures such as pulse oximetry and heart rate, and their chief complaint itself. Patients undergo the second stage of triaging if they do not meet criteria for critical or emergent. Urgent and non-urgent patients are delineated using a set of up to six chief-complaint based, binary questions and vital signs. The triage system uses a job aid to remind providers of relevant questions and help them rapidly and effectively prioritize patients into one of four levels: Red (Resuscitation), Orange (Emergent), Yellow (Urgent) and Green (Non-urgent).

Training in OTT was originally conducted in English by Stanford faculty with Khmer translators in five hospitals in Cambodia. As the system proved successful and demand grew, the training was standardized in Khmer and turned over to on-the-ground Khmer staff.







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URC/CHS Cambodia SEECC Course

Introduction

Stanford Emergency Medicine International is partnering with URC (with support from USAID) to strengthen the delivery of emergency care in Cambodia. One of the objectives of this two-year project is to develop an educational course focusing on essential emergency medical care. This course, SEECC (Seminars on Essential Emergency Care), took place in Battambang, Cambodia, from May 21st-24th, 2012.

Cambodia
The SEECC course was inaugurated May 21, 2012 by his Excellency, H.E. Prof, Heng Tay Kry, Secretary of State of the Ministry of Health of Cambodia.

Background

At present, Cambodia does not have a formal medical curriculum or standardized training in emergency medicine. Many treatable emergency conditions are neither recognized nor addressed at Cambodian hospitals as a result of these educational deficiencies. The SEECC course was designed to address clinical topics essential to the practice of emergency medicine in Cambodia, and emphasize a methodical approach to emergency patient evaluation and management. The SEECC curriculum emphasizes the use of available medical equipment and medications to address common emergency medical conditions and reduce morbidity and mortality.

Course Description

The SEECC course features high quality PowerPoint presentations, hands-on skills workshops, interactive case-based discussions, and a detailed syllabus with practical illustrations. The PowerPoint presentations and the syllabus were translated from English into Khmai. During the SEECC course, all of the lectures were given in English with a real-time translation into Khmai. These lectures were videotaped using specialized screen-capture software, which allows simultaneous viewing of both the PowerPoint presentation and the lecturers.

The hands-on skills workshops focused on basic life support and advanced airway management. These skills stations allowed the course participants to practice hands-on cardiopulmonary resuscitation and airway management using mannequins. The participants familiarized themselves with skills requisite for the practice of emergency medicine (such as chest compressions, bag-mask ventilation and endotracheal intubation).

During the case-based discussions, facilitators led small groups of participants in interactive discussions of common emergency medical scenarios. Emphasis was placed on a methodical approach to patient evaluation and the importance of time-sensitive emergency interventions. Common medical myths and pitfalls were also discussed.

Videotaped Lecture Examples

Example

Hands-on Skills Workshops

Workshop 1

Workshop 2

Case-based Workshops

Workshop 3

Workshop 4

Closing Ceremony

Closing remarks were provided by H.E. Tep Lun, General Director, Ministry of Health.

Conclusion

The inaugural SEECC course was successfully conducted in Battambang, Cambodia, from May 21st-24th, 2012. At the conclusion of the course, all of the course participants were given a detailed printed syllabus (in Khmai) covering the entire course curriculum. The course participants also received continuing medical education certificates endorsed by the Cambodian Ministry of Health, URC and Stanford Emergency Medicine International.

As with all traditional seminar series, the lectures and case-based discussions were conducted live (with active participation of the Stanford faculty and the local instructors). What made this seminar series unique was the real-time translation of all of the lectures into Khmai (to try to improve participant comprehension) and the specialized video capture of each lecture (allowing all the lectures to be re-viewed or utilized for future training).

Our future goals are to conduct a second SEECC course (part 2) that will address relevant emergency medical topics (such as trauma, allergic emergencies, altered mental status, poisoning, snakebites, burns and wound management) and to further develop and train local Cambodian facilitators (utilizing a “train the trainer” model) for the sustained dissemination of the SEECC courses across Cambodia. It is our hope that this newly created emergency medicine educational curriculum will strengthen the clinical evaluation and treatment skills of local doctors and nurses, and lead to better outcomes for Cambodian emergency patients.

Cambodia 2

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URC/CHS Emergency Epidemiology Research

Prospective evaluation of pediatric patients presenting to a provincial hospital emergency department in Cambodia

Many developing countries lack sufficient medical resources, and do not have an established emergency medicine services system. Patients often expend tremendous resources and travel great distances seeking care, and face long waiting times and lack of coordination. Due to the shortage of data about emergency medical care, many health providers in hospitals and clinics in developing nations are unaware of the acute conditions presenting with the highest frequency. Furthermore, hospitals in developing countries tend to be ill equipped to treat medical emergencies and frequently do not follow international treatment protocols specifically designed for patients in resource-limited settings.

The goal of the proposed study is to assess and describe the epidemiology of patients presenting to emergency departments (EDs) at two provincial hospitals in Cambodia. We will collect data on patients’ chief complaint(s), demographic information, treatment, and disposition, and assess the health outcomes of these patients.. We are hopeful that this information will help guide the development of emergency care practice guidelines and high-impact training modules (for Cambodian healthcare professionals), aimed at improving quality of care for all patients presenting to EDs in Cambodia. Should these training modules deliver measurable improvements to outcomes of patients in Cambodian EDs, this approach might provide a model for improving pediatric emergency medical services in resource-limited settings globally.


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GVK EMRI Pediatric District Hospital Training Program

Faculty and fellows from Stanford University School of Medicine were responsible for development and deployment of the Pediatric District Hospital Physician Training Program (PDHPT). The PDHPT is an intensive 3-day course created by internationally recognized educators to address the educational deficiencies of physicians practicing in India. The course addresses a wide range of clinical topics essential to the practice of emergency medicine, and emphasizes a methodical approach to emergency pediatric patient evaluation and management. Each PDHPT course is customizable to the specific instructional needs of the participants and features high quality PowerPoint presentations, hands-on skills workshops, interactive case-based discussions, and a detailed syllabus with color images, practical illustrations and methodical tables.


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Stanford-Child Life Foundation: Epidemiology of Pediatric Patients presenting to a Public Emergency Department in Karachi, Pakistan

Pakistan is a South Asian country with a population of almost 180 million people. Despite significant steps to improve national healthcare delivery over the past several years, Pakistan consistently performs poorly on many international health indicators. With infant and under-five mortality rates of 70 and 87 per 1000 live births in 2010, respectively, pediatric morbidity and mortality remains a significant problem in Pakistan.

In particular, Pakistan has been slow to develop a functional pediatric emergency medical system. With Millennium Development Goal 4 detailing the need to reduce under-five mortality rates by two-thirds before 2015, focusing on pediatric emergencies that contribute to preventable long-term morbidity and/or mortality is crucial. These issues make integrating pediatric-focused research and training into the Pakistani emergency medical system especially important.

There are few studies describing the epidemiology of emergency conditions among patients in Pakistan, and most of the available data focuses on pre-hospital care. During the summer of 2013, Stanford Emergency Medicine International (SEMI) collaborated with the Child Life Foundation in Karachi to bridge this gap. Our inaugural research project is part of a broader program that aims to build capacity amongst pediatric emergency rooms at public hospitals in Karachi. During our first phase, we are assessing the demographic and epidemiologic trends in pediatric patients who present to the emergency department at the National Institute of Child Health, Karachi, to gain a better understanding of the types and frequencies of chief complaints.

This data will aid in the development of training modules, educational materials, and practice guidelines specific to the needs of the pediatric patient population. Furthermore, by tracking outcomes, a baseline will also be established by which to measure the future impact of these training programs. In these ways, SEMI’s research will fill a gap in the Pakistani emergency medicine literature by identifying the most common medical issues with which pediatric patients present to the emergency department, so that local providers can focus efforts on improving their diagnosis and treatment.

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Stanford - GVK EMRI Assessment of EMT-Basic Skills and Knowledge

Emergency medicine is part of the “10/90 gap in health research whereby less than 10% of global research investment is spent on problems affecting 90% of the world’s population.” The non-profit GVK Emergency Management and Research Institute (EMRI), India’s first centralized emergency medical services with a single telephone number (1-0-8), started in 2005 to address this global issue. GVK EMRI now operates in 13 states in India, serves over 700 million people, deploys over 5000 ambulances, and handles over 15000 emergencies per day.

GVK EMRI’s training institute, the Emergency Medicine Learning Centre (EMLC), has conducted training programs for a variety of levels of EM responders, including a six-week basic EMT course and induction program for the 10,000+ EMT responders who provide the vast majority of GVK EMRI’s prehospital medical care across India.

A key to the successful provision of prehospital care in India is the ability of the EMTs to recognize emergency conditions and provide life-saving treatment. During the summer of 2013, Stanford Emergency Medicine International conducted a study to assess the competency of practicing EMTs (who has successfully completed the basic EMT course). Prior to this study, the knowledge and skill levels of these EMTs had never been formally evaluated.

We assessed the knowledge and skills of EMTs in three Indian states served by GVK EMRI: Karnataka, Tamil Nadu, and Gujarat. We provided a snapshot of the current skill level of Indian EMTs to characterize the key gaps in EMT training, stratified by region, rural vs. urban practice setting, age, gender, years of training, and total number of patients treated. We administered written exams to assess theoretical knowledge and Objectively Structured Clinical Exams (OSCE) to assess practical knowledge.

The study has identified several clinical arenas where EMTs have room for improvement. The study results will be utilized to guide the development of standardized multimedia educational modules and practical hand-on training programs for these EMTs. Following enrollment of all 10000+ GVK EMRI EMTs in this directed educational curriculum, we will assess their progress and formally quantify any improvement. The broader scope of our work is to help India and other nations with similar health challenges design their pre-hospital care curriculum and focus their training appropriately.

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Nepal Medical Project

During the final stages of the Nepal Ambulance Service EMT training program, the condition of Nepal's rural medical infrastructure was presented as in dire need of modernization. In the summer of 2013, following the two year combined effort of Stanford EM faculty, Nepali community leaders, and the charitable work of the Fletcher Thompson architectual firm to develop blue-prints for modern rural medical clinics in Nepal, a team of Stanford students and faculty travelled to the Solukhumbu region of Nepal to commence a community health volunteer education program to staff the first clinic.

The program was modeled after the successful Papua New Guinea Medical Project; focusing on the primary health care needs of the region and developing a region speciifc training program to educate the local population and develop preventive and early identification treatment processes. The community health volunteer training program follows USAID education curriculum standards but also features new teaching techniques and development of Stanford based visual learning modules.

When funding is complete, the new clinic will be built by Nepali workers with Nepali resources and will be fully staffed and supported by locally trained community health volunteers, along with government trained community health care workers, nurses, and physicians.

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Stanford Essential Prehospital Care Refresher Training Course (2013-Current)

Since it’s inception in 2005, GVK EMRI’s ambulance service has grown into the world’s largest EMS system. In 2014, GVK EMRI provided rapid medical care and emergency transport to nearly 700 million people in 17 Indian states and union territories. Over the past 8 years, GVK-EMRI has provided specialized training to over 10,000 EMT’s, who provide care to an average of 22,000 patients in India every day. Once they are assigned to the field, these EMTs have the opportunity to apply their theoretical knowledge and gain practical experience through each patient encounter. However, ensuring that the EMTs retain core knowledge and procedural competency in a rapidly growing and geographically diverse group can be challenging.

In order to bridge this gap, Stanford Emergency Medicine International (SEMI) has been tasked with developing a series of focused EMT refresher training modules. The goal of this focused educational intervention will be to provide a simplified, practical approach to the most common and critical presentations faced by EMTs in Indian setting.

The Essential Prehospital Care Refresher Training Course comprises five different modules: Fundamental Emergency Care, Medical Emergencies, Obstetric Emergencies, Pediatric Emergencies and Traumatic Emergencies.

Each two-day training module will be made up of a series of short topic lectures and interactive, hands-on practical sessions. The brief lecture series will cover only what an EMT really needs to know and focus on practical aspects of recognizing ill patients and the provision of immediate, life-saving interventions (Figure 1). The hands-on sessions will reinforce the lecture content, creating a context for applying knowledge and skills in a mentored environment (Figure 2).

0900 PRE-TEST
0930 EMS ROLES & RESPONSIBILITY (OVERVIEW)
0945 ROUTINE MEDICAL/TRAUMA MANAGEMENT (OVERVIEW)
1000 PRE-ARRIVAL PREPARATION
1015 SCENE-SIZE UP
1030 INITIAL ASSESSMENT
1045 GENERAL IMPRESSION
1100 POSITION PATIENT
1115 TEA BREAK
1130 CIRCULATION
1145 AIRWAY
1200 BREATHING
1215 EXTREMITY HEMORRHAGE CONTROL (PROCEDURE)
1230 CPR (PROCEDURE)
1245 AED (PROCEDURE)
0100 LUNCH
0200 SUCTIONING (PROCEDURE)
0215 MANUAL AIRWAY MANEUVERS (PROCEDURE)
0230 OPA/NPA (PROCEDURE)
0245 VENTILATION (PROCEDURE)
0300 TEA BREAK
0315 PROCEDURE PRACTICE (HANDS-ON)
0415 RAPID MEDICAL/TRAUMA EXAM
0430 BASELINE VITAL SIGNS
0445 DAY 1 OVERVIEW

Figure 1: Essential Prehospital Care Course (Fundamental Emergency Care), Day 1

As of January 2015, SEMI has rolled out the first three modules (Fundamental Emergency Care, Medical Emergencies, Obstetric Emergencies) with plans to debut the Pediatrics and Trauma modules in late 2015 and 2016. Preliminary testing and data analysis suggests that these inaugural programs have been very effective in addressing the educational deficiencies of practicing EMTs. In order to reach more providers who work all across the country of India, SEMI plans to study a number of novel approaches to disseminating such life-saving information, including video-based and web-based training platforms.

Acker
Figure 2: Dr Peter Acker conducting a hands-on educational session on tourniquet placement

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A Bridge to Africa: Online Emergency Medicine Training for Uganda (2014)

Authored by Anne Tecklenburg Strehlow

There are over 9,000 miles separating the East African country of Uganda from the Western coast of the United States. It is a huge divide, in terms of distance. Greater still is the divide between the two nations in terms of quality medical care and advanced medical training. But a novel online training course, focused on emergency care and developed by physicians at Stanford University, is bridging that divide.

While Emergency Medicine is a valued subspecialty in the United States and a core requirement for students at most medical schools, the same cannot be said for most Low and Middle Income Countries (LMIC). In LMICs, few medical schools offer such courses, and most providers have limited, if any, training in identifying or treating medical emergencies. While the challenges in LMICs are many, they are not without solutions. Dr. S.V. Mahadevan and Dr. Matthew Strehlow, the directors of Stanford Emergency Medicine International (SEMI), have dedicated dozens of years between them to tackling these challenges worldwide. Uganda has been the focus of their recent efforts. Partnering with students at Uganda’s Makerere University in Kampala, they have developed an online course – Surg 210 - "Managing Emergencies: What Every Doctor Must Know".

Figure 1: Dr. Matthew Strehlow and Dr. S.V. Mahadevan introduce the course, "Managing Emergencies: What Every Doctor Must Know"

THE NUTS AND BOLTS
In April 2014, Managing Emergencies: What Every Doctor Must Know launched simultaneously at Makerere University and Stanford University School of Medicine. Offering the five-week online course at both institutions enabled the SEMI team to compare the effectiveness of the curriculum and delivery methods across diverse audiences. The program consists of 20 training modules, each comprising a collection of short, interactive video lectures. Related case presentations in the form of brief video clips taken from the popular television drama, ER, accompany each module. This informal format prompts students to openly participate in discussions spanning a range of common acute ailments, such as fever, chest pain, shortness of breath, and trauma. As not to confuse the show ER with today’s reality, follow-up video clips featuring guest experts offer concise explanations of the proper handling of each emergency situation. Students also had the opportunity to participate in interactive online forums with their instructors. The five-week didactic coursework was followed by a one-day live, procedure-based seminar, taught onsite at both universities.

Figure 2 Figure 2: Dr. Mahadevan assists guest expert Dr. Kristan Staudenmayer, Assistant Professor of Surgery at Stanford University, during an ER case presentation

“The curriculum was devised to address the most common clinical entities seen in the daily practice of emergency medicine, both in the United States and abroad. We utilized short 10-15 minute video lectures to provide high-yield information while ensuring that our audience remained engaged.” said Dr. S.V. Mahadevan.

CHARTING A NEW COURSE
Dr. Strehlow and Dr. Mahadevan have taken an alternative pedagogical approach with their online course as compared to methodologies they have employed in previous projects. A course directed at medical students and other novice practitioners offered an opportunity to assist a younger audience of providers with building a strong foundation at the onset of their medical careers. Meanwhile the extended nature of academic coursework spread over weeks rather than days increases the odds that students’ will retain information long term, a major challenge for many short, intensive training seminars. As added perks, the course permits students to not only view past modules and case presentations after their initial viewing, if desired, but also access the modules from their mobile devices. The on-demand accessibility of the course further ensures retention by increasing students’ engagement with the material.

“While the conventional approach to medical education development programs in LMIC countries is to offer short-term seminars taught by invited speakers from other countries, this rarely guarantees a change in medical practice,” said Dr. Strehlow. “We used open-ended case questions with online discussion forums to stimulate peer-peer interactions and problem-based learning. While all teaching methodologies have their limits, we strive to come up with new and better approaches that are sustainable and impactful.”

The idea for the online course had been brewing or some time, but it was a Stanford seed grant competition focusing on international online learning that propelled the concept into reality. With the financial backing and logistical support of Stanford’s Office of the Vice Provost for Online Learning (VPOL) and the Office of International Affairs (OIA), Dr. Strehlow and Dr. Mahadevan delved actively into the development and production of the program. The VPOL Instructional Design and Pedagogy Team offered insight on the creation of modules designed to engage and inspire students, despite the absence of personal interactions with the instructors, while at the same time creating a classroom-like atmosphere for students sitting opposite a computer screen. Likewise, the Video Production Team aided in the production of professional videos that remained consistent throughout the duration of the course, regardless of the instructor or guest lecturer presenting the material.

“We recognized early on that the success of the project hinged on the production of high-quality educational videos. By leaning on the expertise of Stanford’s VPOL, we were able to create a series of multimedia-teaching tools that had a truly professional look and feel.” said Dr. Joseph Becker, a Stanford physician, who plays a key role in the production and maintenance of the course.

OUT OF THE GATES
The spring trial course enrolled nearly 100 students between the two universities and wrapped up in June. Despite rave reviews from students, SEMI has continued to evaluate and hone the curriculum. The ultimate goal is to ensure both long-term retention of the material and procedural confidence that will enable students to put their skills into practice. To assess and compare the achievement of students who participated in the online course, a team of Stanford physicians returned to Uganda in August to offer a traditional, seminar version of the course, taught face to face. The nearly 100 enrolled students were presented with an identical curriculum spanning five highly intensive days, a dramatic difference from the online course.

Figure 3 Figure 3: Live course students and Stanford faculty at Makerere University (August 2014)

“While the work ethic and motivation of the students attending the seminar was incredible, the rigorous schedule was obviously fatiguing,” said Dr. Peter Acker, a former Stanford international fellow with a continued commitment to the project. “The shortened schedule did not afford time for the more thorough skills course the online students received. Similarly, discussions and questions often had to be cut short to ensure that we could present all the course material. The students admitted that the long days made it difficult to prepare for the next day’s lectures, an issue that the online course was able to avoid.”

Ultimately, the three student cohorts – Stanford, Makerere online, and Makerere in person – will be compared, offering insight into the effectiveness of the course’s methods, as well as its overall impact on the students’ understanding and skill level. But the initial success of Managing Emergencies: What Every Doctor Must Know has SEMI already looking into the future. They are in discussions with Makerere University concerning the logistics of making the online course a requirement for all future incoming medical students. They also have their eyes set beyond Uganda’s borders, initiating talks with other LMICs – Tanzania, Kenya, India, Nepal, and Cambodia – whose medical practitioners would equally benefit from basic training in emergency care. “Uganda is not unique its desire for improved emergency medical training for its students,” said Dr. Mahadevan. “Clearly universities in other parts of the world – Asia, South America, Africa – have the same desire. The question is, “How can we help to make that happen?””

The online course has the potential to be far-reaching. The design of the course platform makes it amenable to alterations, allowing for the inclusion of regionally specific topics.

“The modules and content of the online course can be easily customized,” said Dr. Rebecca Walker an Assistant Professor at Stanford who works with the international program. “We can add relevant modules based on a country’s unique needs and circumstances, such as training focused on tuberculosis, malaria, or organophosphate poisonings…ailments that may have a substantial impact on one community, but may be relatively insignificant for others.”

For those living in LMICs, access to adequate emergency medical services is an unrealized luxury. Insufficient training of medical practitioners, the absence of triage systems to prioritize patients, and the dearth of necessary equipment and supplies collectively hamper the development of a sustainable and effective emergency medical infrastructure. Yet, they each need to be addressed individually. SEMI’s online course aimed at educating medical students on the concepts of emergency care is a first vital tool for Ugandan medical practitioners. Such knowledge is key towards bridging the great medical divide.

“Emergency medicine is in its infancy globally, but the seed has been planted. There is a real hunger for that knowledge,” said Dr. Mahadevan. “Arming health care providers with adequate information and the skills to handle every patient that enters their clinic makes a big difference in the confidence of the provider, but it can mean the difference between survival and death for their patients.”

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Global Online Emergency Medicine Course (2015)

Emergency Care: What Every Provider Should Know

This online course will cover the key concepts that define the field of emergency medicine, with the goal of teaching life-saving treatments for patients presenting with life-threatening emergencies. If you are a healthcare provider who would like to sign up for the course, or you are a hospital or school administrator interested in training your providers, click here.

Walker

Background

Around the world, the field of Emergency Medicine is still in its infancy, which means that many emergency departments and casualty wards are currently staffed by trainees, nurses, or physicians who may not have completed specialized training in Emergency Medicine. This course addresses that important need by bolstering and supplementing training programs in parts of the world where the specialty of Emergency Medicine is still evolving.

The course is directed to healthcare providers around the world are in the position of providing emergency care, but might not have had the opportunity to learn critical skills from faculty or senior providers. Our goal is to increase the capacity of current emergency providers to deliver quick effective care to improve outcomes from serious conditions like heart attacks, strokes, car accidents, and severe infections.

While short-term ‘seminar’ courses have been a conventional manner of delivering education in person to areas of the world that may lack trained faculty in emergency medicine, this course offers a way to repeat the teaching as often as it is needed, without the logistical challenges and costs associated with travel and live conferences.

Logistics

The online course will require Internet access. We also provide background reading as easy to download pdfs on the website. Our goal is to make the course available to any provider who is interested. If you are a hospital administrator or teaching physician, and would like to make this course a requirement for your providers, we are happy to provide that service and will work with you to determine what the best way might be to reach your goals. If Internet access is a problem, contact us and we can discuss alternatives.

Walker 2

Course Description

Content is presented in the form of concise didactic lectures, with high quality graphics, photos and video clips used to highlight key points that are directly relevant to clinical care. We have used a problem-based approach to learning that can be easily used to supplement the large number of burgeoning residency programs in emergency medicine. We use clips from the television show “ER” to discuss critical management decisions in specific cases to highlight quick actions that can mean the difference between life and death for your patient.

If resources and faculty are available locally, a procedure/skills lab is something that can complement the online course to practice the skills discussed and reinforces key concepts introduced in the class.

Walker 3

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