Wednesday, April 3, 2013

Emergency Ultrasound in Colombia - David Beversluis

GME Centers of Expertise Global Health Blog

David Beversluis MD MPH
Emergency Medicine PGY3
Characterizing Emergency Medicine in Colombia

Blog entry number 2! I'm quickly finishing up my time here in Colombia and will unfortunately soon need to get myself back to Boston and start up work in the hospital again. I've got a few days left though and spending as much of it on a sunny beach as possible.

The last 2 weeks have been filled with hospital visits and plenty of interesting work on the research phase of my elective. I finished my work in several Bogota EDs and then met up with the PI for my project, Dr. Christian Arbelaez (BWH EM attending), in the airport on the way to Medellin. We spent about 4 days working there, joined on the first day by my co-resident Christina Wilson, and then moved to Cartagena where we spent several additional days as a group visiting several hospitals and the university medical school. As I mentioned in my previous post we're working on two projects during this time here in Colombia. First, Christian, in his role as the ACEP Ambassador for Colombia is spearheading a project to characterize the EM system here in Colombia. This project will eventually result in a joint report with several Colombian EM colleagues describing the system in general and the state of EM residency programs in the country. For this project we're conducing site visits and focus groups at most of the major hospitals in Bogota, Medellin, and Cartagena to see their EDs and understand their work flow, systems, etc. Several of these visits occurred last year and now during this trip we've continued this work. An important aspect of this process is creating lasting collaborative relationships with the residency program directors, faculty and residents. As these partnerships grow there will be space for future electives, curriculum development and various clinical and systems research.

There are currently 5 EM residency programs with between 3-8 residents each year, typically lasting 3 years. This is a growing and very active group of residents who are working to carve out a space for the new and growing specialty. Interestingly, many of the battles that were fought over the past decades in the US, and are now mostly resolved, are repeating themselves here. There are strained relationships with other specialists, including the surgeons and internists who have traditionally run the emergency departments and hospitals. Building recognition and respect for emergency medicine and getting a very conservative medical establishment to view it as an essential part of how hospitals should function takes years, a process which is only beginning in many parts of the Colombian healthcare system. There is also a huge need to establish improved infrastructure, including ED space, staff and technology, to meet the increasing patient burden. Finally, there is a need for better training, both for the current generation of EM specialists but mostly for the thousands of general practitioners that actually staff the majority of the healthcare system and emergency departments in Colombia. These GPs usually have only 1 year of post graduate training and provide good general care but are ill-equipped to function effectively in a professional, modern ED. As this specialty grows in this country a lot of work will be needed to professionalize and make effective use of this huge workforce in the emergency system.

The second part of our research effort here is exploring the current state of point of care ultrasound within these residencies with an eventual goal of trying to support the use of this very important tool in EM practice in Colombia. We are using an ultrasound needs assessment survey which was developed 2 years ago by Trish Henwood (another HAEMR resident) for her work in Rwanda. Last year Trish and others surveyed most of the EM residents in Bogota; now we're extending our sampling pool to include the residents in the two programs in Medellin. The survey is approx 2 pages long, in spanish, and relatively quick to complete. It gives us valuable insight into how EM residents use ultrasound in their clinical work currently, what they'd like in terms of ultrasound education, and what they perceive as barriers to the growth of ultrasound in their specialty. Of the 5 EM residencies most do not have an active ultrasound curriculum but rather use ultrasound haphazardly at the several hospitals where machines are available. Almost all of the residents would like more access and training in ultrasonography and feel that it would be important to their clinical practice. Despite this however they identified barriers such as difficult political relationships with radiologists and lack of trained teachers. The difficulty with radiologist will be especially difficulty to overcome as there are clear financial incentives to maintain the status quo; radiologist are paid well to perform ultrasounds and have little desire to give up any ground to the new specialty of emergency medicine. In fact, there is a national law in place which restricts EM use of ultrasound without specific credentials. This pressure from the entrenched and powerful interests often results in pressure from hospital administrations toward EM docs wishing to use ultrasound in their care or integrate it more deeply into training programs. To overcome these pressures EM will need to keep growing in influence and begin to advocate for its position more forcefully in their hospitals, universities and eventually nationally.

As I wrap up my time here in Colombia and continue to process the things I've seen and learned, analyze our data and now begin to write up our findings I'm again thankful for the support from the GME travel grant to be able to come down here during a busy time of residency. Its been a fantastic experience filled with deepening relationships with Colombian colleagues. I'll definitely be back in the future and am excited to watch our emerging specialty continue to grow in this country.

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