Thursday, March 21, 2013

Emergency Medicine in Colombia

GME Centers of Expertise Global Health Blog

David Beversluis MD MPH
Emergency Medicine PGY3
Characterizing Emergency Medicine in Colombia
(written 3/15/2013)

I'm now about 3 weeks into my 6 week elective here in Colombia and enjoying every minute.  And thrilled to get the news (even after I started) of support from the Centers of Expertise Travel Grant.  Thanks to all those working to provide this support to us residents committed to international work during residency!

I've split my elective time here in Colombia into two 3 week blocks.  First is a 3 week clinical experience working in several emergency departments in Bogota.  I'm just finishing this now and I'll write a bit more below about my impressions of working here below.  The second phase of my elective is to carry on the work of an ongoing survey of emergency medicine programs in several cities around the country.  This is work that was started by a few of my EM colleagues during a visit last year.  Much of this 'characterization' has already been done here in Bogota.  Our efforts during this trip focus on the other cities in the country that have active EM training programs.  I'll be flying north to Medellin tonight, and then next week to Cartagena to visit various hospitals, to lead some small group discussions with residents and to administer our surveys.   I'll also be meeting up with Dr. Christian Arbelaez one of the EM attendings at BWH, and the American College of Emergency Physicians (ACEP) Ambassador to Colombia.  His rich connections into the EM community here in Colombia are what is really making this project possible.  And I'm also very excited to be joined by Christina Wilson one of the HAEMR PGY2s for the next couple weeks in Cartagena.  So, more on that all in a future blog post...

During the last few weeks I've been spending my days at a couple of the emergency departments around Bogota.  Its been very interesting to see and observe the differences between our systems.  Emergency medicine in Colombia remains in a nascent phase, but is slowly expanding in influence and scale.  The first EM residency was started in Medellin in the mid-90s and there are now 5 programs total throughout the country.  This new specialty is still relatively unknown in Colombia however, with most urgent care provided by general practitioners with only 1 year of post-grad training.  Most Urgencias in the country are staffed exclusively by these doctors who consult surgery or internal medicine specialist for more difficult cases.  Several hospitals however are beginning to see the value of having EM trained staff and supervision, for patient care, throughput, cost-control and many other similar reasons.  The hospitals where I spent my time are all slowly making progress in also the transition and slowly advancing the field of EM here in Colombia.

During my first and second weeks I rotated at the Javeriana University San Ignacio Hospital in Bogota.  This is a large urban university hospital with access to plenty of internal resources but which is pushed to the limits by over-crowding issues.  The ED is designed for a quarter of the patients that it sees every day.  This leads to wait times for minor patients of up to 24 hours and to ED length of stay times of several days.  I spent time examining and speaking with patients who had been in the ED for 2-3 days sitting on rows of 8 or more chairs crammed into ED bays designed for one bed.  The amazing thing is how appreciative these patients remain despite this lack of space and staff to move them through the ED more quickly.  In the acute areas the flow and care is much better and patients are typically receiving top quality care from dedicated EM residents and physicians.  New patients are seen quickly and triaged to appropriate specialists as needed, for example I was impressed my first day there by a STEMI patient who quickly made it to the cath lab in under an hour.  Likewise, several septic and coding patients that I helped care for received great evidence based emergency care from the team.  Despite the overwhelming press of patients in the department these EM trained residents were successfully deploying and triaging their resources to address the most critically ill group.

For my final week of clinical work I switched to Mederi hospital.  This is another university based hospital in Bogota which takes residents from the San Rosario EM program.  The clinical care was similar with plenty of typical ED pathology including strokes, sepsis and coding patients.  Interestingly there was almost no trauma during my time in Bogota.  This is partly due to the hospitals and neighborhoods I was in, but also due to the overall development of Bogota.  Over the last 2 decades the city has become relatively safe.  So much so that the residents rotate for several months in Cali in the south to get a bit close to the FARC vs. military and urban poverty trauma which has mostly been resolved in the capital.  Despite the lack of trauma, I did get several procedures, which was one of the goals of my trip.  These hospitals are mostly still doing subclavian lines for central access which is something we've moved away from in Boston with our easy access to ultrasound; I got to put in plenty of these.  It was also great to intubate by direct laryngoscopy without the backup of our video assisted systems in Boston.

So, overall, my clinical experience was good from a procedures and clinical perspective, I'll definitely take some of these skills back to my work in Boston.  I can also feel my spanish slowly improving; I'll be using this ability in my work for the rest of my life.  Finally though, I'm glad to have this 3 weeks of experience and insight before I start the next phase of my work here.  Having seen Colombian emergency medicine from the inside will help me as I conduct interviews and site visits in Medellin and Cartagena and understand the emergency system as a whole.  I can't wait to see these places and keep up going with this fun work.


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