International Emergency Medicine A Guide for Clinicians in Resource-Limited Settings Joseph Becker, MD and Erika Schroeder, MD, MPH Editors-in-Chief Bhakti Hansoti, MBcHB • Gabrielle Jacquet, MD, MPH Navigating this PDF Handbook of International Emergency Medicine Use left mouse button to advance one page. Use right mouse button to go back one page. Editorial Staff Editors-in-Chief “Home” key on keyboard jumps to cover. “End” key on keyboard jumps to last page. Joseph Becker, MD and Erika Schroeder, MD, MPH Associate Editors Navigate to specific chapters using the table of contents. Bhakti Hansoti, MBcHB and Gabrielle Jacquet, MD, MPH Touch “Escape” to exit full-screen mode. Faculty Editors Kris Arnold, MD S.V. Mahadevan, MD Christine Babcock, MD Ian Martin, MD Elizabeth DeVos, MD Stephanie Kayden, MD, MPH Kate Douglass, MD, MPH Matthew Strehlow, MD Linda Druelinger, MD Christian Theodosis, MD, MPH Troy Foster, MD Susan Thompson, DO Disclaimer Simon Kotlyar, MD, MSc David Walker, MD This handbook is intended as a general guide only. While the editors have taken Suzanne Lippert, MD, MS reasonable measures to ensure the accuracy of drug and dosing information used in this guide, the user is encouraged to consult other resources or consultants Authors when necessary to confirm appropriate therapy, side effects, interactions, and Spencer Adoff, MD Mark Goodman, MD contraindications. The publisher, authors, editors, and sponsoring organizations James Ahn, MD Jessica Holly, MD specifically disclaim any liability for any omissions or errors found in this handbook, Lauren Alexander, MD Aaron Hultgren, MD, MPH for appropriate use, or treatment errors. Furthermore, although this handbook is as Maya Arii, MD, MPH Aliasgher Hussain, MD comprehensive as possible, the vast differences in emergency practice settings may Nanaefua Baidoo, MD Masayuki Iyanaga, MD necessitate treatment approaches other than presented here. EMRA disclaims any Michael Barakat, MD Tomislav Jelic, MD liability or responsibility of the consequences or any actions taken in reliance on the Brock Bemis, MD Eliza Johnson, MD statements or opinions expressed in this book. The materials contained herein are not Suzi Bentley, MD Hong Kim, MD intended to establish policy or procedure. Jeremy Berman, MD Bati Myles, MD William Bishop, MD Erin Nasrallah, MD Copyright © 2013 Jay Blankenship, MD Michelle Niescierenko, MD Emergency Medicine Residents’ Association. All rights reserved. Peter Canning, MD Patrick Ockerse, MD Juliana Capostaso, MD Sachin Patel, MD This book is protected by copyright. No part of this book may be reproduced in Elena Caraman, MD Amritha Raghunathan, MD any form or by any means without written permission from the copyright owner. Sara Cates, MD Srinivasa Rao, MD Andre Crouch, MD Pranav Shetty, MD Printed in the USA. ISBN: 978-1-929854-23-3. Additional copies of this Freddy Davis, MD Sarah Sliva, MD publication are available from Matt Dawson, MD Anjali Srivastava-Shah, MD Emergency Medicine Residents’ Association Natasha Desai, MD Sarah Taylor, MD Shaneen Doctor, MD Andrea Tenner, MD, MPH 1125 Executive Circle Colleen Donovan, MD Caroline Vines, MD Irving, TX 75038-2522 Abiola Fasina, MD Amanda Williams, MD 972-550-0920 Ashish Goel, MD Courtney Wilson, MD www.emra.org EMRA Staff Editor Please send comments or suggestions to [email protected]. Rachel Donihoo, Emergency Medicine Residents’ Association ii Handbook of International Emergency Medicine | EMRA Editorial Staff iii 2012-2013 EMRA Board of Directors Introduction Cameron Decker, MD Jonathan Heidt, MD Welcome to the first edition of EMRA’s International Emergency Medicine President Director-at-Large/RRC-EM handbook. We have drawn upon the experience and guidance of leaders in the Baylor College of Medicine Representative field of international emergency medicine from all over the world, who have Houston, TX Washington University provided editorial direction and direct oversight of the content. The overall aim St. Louis, MO of this text is to provide a base of knowledge and preparation for the provision of Jordan Celeste, MD medical care in resource-constrained environments, where familiarity with and President-Elect Sarah Hoper, MD, JD Brown University Legislative Advisor recognition of clinical, social and cultural differences are important factors in Providence, RI Washington University in St. Louis securing the health of our patients. St Louis, MO Donald Stader, MD The practice of medicine is very much a local issue – with resource availability, Immediate Past-President/Treasurer Graham Ingalsbe, MSIV major contributors to morbidity and mortality and micro-organism ecology Carolinas Medical Center Medical Student Governing Council Chair differing substantially from one region to another. As well, the social, financial Charlotte, NC University of Miami, Miller School of and bureaucratic responsibilities inherent in licensing and the practice of Medicine medicine differ dramatically from nation to nation. While these challenges Ije Akunyili, MD, MPA Miami, FL may seem significant, medical students, residents and attending physicians are Vice Speaker of the Council seeking international medical experiences in increasing numbers, and many University of Texas - Houston Chadd Kraus, DO, MPH medical education institutions are developing global health mission statements, Houston, TX Academic Affairs Representative Lehigh Valley Health Network curricula and leadership. Despite the good intentions of the majority of those John Anderson, MD Bethlehem, PA seeking medical experiences abroad, pitfalls abound; it is all too easy to fall ACEP Representative into the trap of overestimating one’s experience, abilities, and ultimate utility Denver Health Medical Center Stephanie Krema, MD in medical arenas outside those in which we are accustomed to practicing. Denver, CO Secretary & EM Resident Editor-in-Chief Indeed, when arriving in a new and foreign practice setting, it is easy to become University of Louisville a burden rather than an asset to local providers and health systems. This text David Chiu, MD Louisville, KY seeks to assist the reader in meeting these challenges. Technology Coordinator Beth Israel Deaconness Matt Rudy, MD This is a “know before you go” handbook that presents details and information Boston, MA Speaker of the Council to consider while preparing for an international medical experience. The content Washington University in St. Louis is intended to be an easily accessible reference guide for physicians or trainees Kene Chukwuanu, MD St. Louis, MO Membership Coordinator staffing a casualty department or other acute medical facility. St. Louis University School of Medicine Given the nature of international medical experiences, some disclaimers St Louis, MO regarding personal comportment and the use of this text are required. n First, do no harm. Lack of supervision or available specialist referral EMRA Staff does not justify potentially dangerous medical or surgical therapies or interventions if the provider is not familiar or experienced in their execution, Michele Packard-Milam, CAE Linda Baker indications, pros, cons, adverse outcomes and other relevant treatment Executive Director Marketing & Operations Manager options. n Leah Stefanini Chalyce Bland One should, at all times, respect and adhere to the laws of the country, Meetings & Advertising Manager Administrative Coordinator medical board, licensing body or municipality in which one practices. Medical licensing procedures may differ dramatically, even within the same Rachel Donihoo country, and failure to follow these rules can lead to civil and/or criminal Publications & Communications liability. Coordinator iv Handbook of International Emergency Medicine | EMRA Introduction v n One should also remember that, in many societies, physicians and other medical providers are regarded with respect and are afforded positions of Table of Contents relative authority. As such, behavior both inside and outside of the hospital may have a significant bearing on your success as a trainee or provider. It Chapter 1: Types of International Health Experiences .......................... 1 is always important to be aware of and respect societal and cultural norms Practicing Medicine in Resource-Limited Settings .................... 3 regarding attire, behavior and language. Chapter 2: Pre-Departure ..................................................... 5 Framework for Planning ............................................ 5 n There is a robust section on medical ethics in this book. The case examples, After You Return.................................................... 7 while by no means exhaustive, seek to provide the trainee or practitioner Example Packing List ............................................... 8 with food for thought regarding medical practice, both at home and Security While in the Field .......................................... 10 abroad. Supervision may be lacking in many international medical Health and Sanitation .............................................. 11 settings. Students or trainees who are not licensed or permitted to perform Regional Considerations ............................................ 12 a procedure without supervision in their home institutions, in general, Vaccinations ....................................................... 12 should not be acting without supervision abroad. If one is participating Malaria Prophylaxis ................................................. 23 in an observership, it is important