Inside This Issue
Does Gender Influence Symptoms of Acute Myocardial Infarction?
Michael Wilk, MSIII and Matthew Pirotte, MD
Loyola University Chicago Stritch School of Medicine
Chest pain. Shortness of breath. Radiating pain down the left shoulder. Most senior medical students and EM residents can quickly come up with a broad differential diagnosis for these presenting symptoms, which should include acute myocardial infarction (AMI), as it is commonly known. However, patients rarely present to the emergency department (ED) with textbook symptoms of an AMI. In regards to symptom presentation, should our consideration for diagnosing an AMI change based on gender alone?
Recent studies have demonstrated that women are more likely to experience an AMI without chest pain (also known as a silent MI) than men (42.0% vs. 30.7%).1 More importantly, women with AMIs have a higher mortality rate and these gender inequalities were most pronounced for patients under the age of 50. A full causal relationship for the higher mortality rate of younger female patients has yet to be elucidated. However, it is probably a combination of delayed patient presentation to the ED due to their perception of symptoms and a delay in diagnosis by the physician leading to less aggressive treatment and interventions.
Women are more likely to present with acute complaints of shortness of breath, weakness and unusual or excessive fatigue.2 Other atypical symptoms women exhibit more frequently than men include indigestion, palpitations, nausea and hand numbness.3 Furthermore, many women exhibit similar prodromal symptoms in the days and even weeks preceding ED presentation and thus this information should be inquired about while gathering the patientís history. Additionally, all clinicians should be aware of the higher incidence of silent MIs in patients with diabetes mellitus.4
While gender differences in the symptoms of AMI do indeed exist, chest pain far and away remains the most common presenting symptom for both men and women.5 However, clinicians should remain aware that younger females are more likely to experience atypical symptoms underlying an AMI and thus retain a higher index of clinical suspicion in this specific population.
- Canto JG, Rogers WJ, Goldberg RJ, et al. Association of age and sex with myocardial infarction symptom presentation and in-hospital mortality. JAMA. 2012;307(8):813–822.
- McSweeney JC, Cody M, O’Sullivan P, Elberson K, Moser DK, Garvin BJ. Women’s early warning symptoms of acute myocardial infarction. Circulation. 2003;108(21):2619–2623.
- DeVon HA, Ryan CJ, Ochs AL, Shapiro M. Symptoms across the continuum of acute coronary syndromes: Differences between women and men. American Journal of Critical Care. 2008;17(1):14-25.
- Arenja N, Mueller C, Ehl NF, Brinkert M, Roost K, Reichlin T, Sou SM, Hochgruber T, Osswald S, Zellweger MJ. Prevalence, extent, and independent predictors of silent myocardial infarction. Am J Med. 2013 Jun;126(6):515-22. doi: 10.1016/j.amjmed.2012.11.028. Epub 2013 Apr 15.
- Khan NA, Daskalopoulou SS, Karp I, Eisenberg MJ, Pelletier R, Tsadok MA, Dasgupta K, Norris CM, Pilote L; GENESIS PRAXY Team. Sex differences in acute coronary syndrome symptom presentation in young patients. JAMA Intern Med. 2013 Nov 11;173(20):1863-71. doi: 10.1001/jamainternmed.2013.10149.
Acute Aortic Syndrome
Nathan Haas, MD PGY-1
University of Michigan
The acute onset of severe, ripping chest pain radiating to the back quickly brings to mind the diagnosis of aortic dissection. However, dissection is just one potential etiology of Acute Aortic Syndrome (AAS) which includes the acute presentation of aortic dissection, penetrating atherosclerotic ulcer, intramural hematoma, aneurismal leak and traumatic transection. Overlap frequently exists between these processes, and the various etiologies within AAS in some ways represent more of a spectrum of disease than distinct entities.
Aortic dissection results from an intimal tear penetrating the aortic media, with progressive dissection of the media creating a false lumen. Contrarily, a penetrating atherosclerotic ulcer occurs at the site of a preexisting atherosclerotic plaque and is the result of intimal erosion through to the media. Intramural hematoma is defined as a blood collection in the media without the presence of an intimal flap and physiologically is driven by the rupture of vasa vasorum. Aneurismal leaks are related to the acute expansion of a preexisting aortic aneurism. Traumatic transection most frequently occurs secondary to a rapid deceleration injury and classically occurs immediately distal to the left subclavian artery at the ligamentum arteriosum.
Classification of AAS can broadly be dichotomized to Stanford Types A and B. Stanford Type A represents disease involving the ascending aorta and aortic arch (with or without more distal involvement), whereas Stanford Type B represents disease of only the descending aorta (distal to the left subclavian artery) without more proximal involvement.
Initial stabilization of AAS centers on decreasing three metrics, each of which untreated further propagate disease: left ventricular contraction, systemic blood pressure and pain. A beta-blocker (frequently esmolol) is the first agent utilized, and serves the dual purpose of decreasing heart rate (to a goal of less than 60 if tolerated) and blood pressure. If additional anti-hypertensives are required to reach goal (typically a systolic blood pressure of 100-120), vasodilators such as sodium nitroprusside, nicardipine or fenoldopam are added next. It is critical to provide beta-blockade prior to vasodilation to prevent reflex tachycardia, which can further propagate dissection. Morphine is typically the first line analgesic to further minimize catecholamine-driven hypertension and tachycardia.
Stanford Type A dissection is a surgical emergency, and surgical management provides definitive management along with prevention of aortic rupture, pericardial tamponade and aortic regurgitation. Uncomplicated and stable Stanford Type B dissections can be managed medically as above, but can require interventional therapy (stent grafting, fenestration) for aortic expansion, dissection progression, end-organ malperfusion syndromes or recurrent pain.
- Ahmad F, et al. Acute aortic syndrome: Pathology and therapeutic strategies. Postgraduate Medical Journal 82.967 (2006): 305-12. Web.
- Tsai TT, et al. Acute aortic syndromes. Circulation 112.24 (2005): 3802-813. Web.
The Dying Gut: Identifying Patients with Intestinal Ischemia
Ashley Grigsby, DO PGY-1M
Intestinal ischemia is a serious illness with severe and life threatening complications. The likelihood of developing complications improves with earlier diagnosis. However, early diagnosis can be difficult, especially in the setting of no known risk factors.
Acute mesenteric ischemia is any process that causes hypoperfusion to the small intestine. The large intestine can also become ischemic from hypoperfusion, usually referred to as ischemic colitis.1 Intestinal hypoperfusion can be due to arterial or venous obstruction from acute embolism, thrombosis or low-flow states.
We all learned in medical school, “abdominal pain out-of-proportion to physical exam” means acute mesenteric ischemia. However, in real-life situations, many emergency department patients presenting with abdominal pain would fit into this category. The question becomes, who gets a workup and who does not? First, a careful history should be performed; about one third of patients with acute intestinal ischemia will have a previous history of embolic event.1 Patients with peripheral vascular disease, cardiac disease, atrial fibrillation, hypercoaguable states and hypovolemic states are all at increased risk of developing intestinal ischemia.1
Acute arterial embolism usually presents with sudden onset pain over the affected bowel area. Patients with chronic peripheral artery disease may thrombose their mesentery and present with worsening chronic postprandial pain. Acute colonic ischemia usually presents with rapid onset of left sided abdomen; however, if large amounts of colon are involved, patients can have diffuse abdominal pain.1
Physical examination early in the disease course can be completely normal, however, patients can then progress to distension without peritonitis. Once ischemia has become severe with transmural bowel infarction, peritoneal signs develop. By the time examination is severe, patient may have unstable vital signs, evidence of shock and acidosis.1
If the diagnosis is suspected, a workup should be done. Laboratory evaluation should include basic labs and a serum lactate level. The sensitivity for lactate in acute mesenteric ischemia was found to be 86 percent with a specificity of 44 percent. There still remains a minority of patients with true disease who will have a negative lactate; therefore, clinical history and exam should be relied on more than a serum lactate level.2 Radiologic evaluation should not be delayed due to normal laboratory values when suspicion is high.
Radiologic evaluation should be done in patients without peritonitis. According to the American Gastroenterological Association, patients with peritonitis on exam should have a diagnosis made in the operating room and not await imaging studies.3 For patients with a less concerning physical exam, CT angiography is the preferred initial test for most patients.1 However, some patients with colonic ischemia will have normal CT exam and may require urgent sigmoidoscopy to establish diagnosis.3
Clinicians need to have a high index of suspicion in order to identify patients with intestinal ischemia. It is important to take a careful history and assess for risk factors in patients with severe, often sudden onset of abdominal pain. When the physician has high suspicion imaging should be performed and not rely on laboratory evaluation. Early consultation with general surgery may also facilitate early intervention, and possibly decrease morbidity associated with this serious disease.
- Grubel P, Lamont JT. Overview of intestinal ischemia in adults. Up to date. 2014. Access on 13 January 2014. Available from: http://www.uptodate.com/contents/overview-of-intestinal-ischemia-in-adults?source=search_result&search=acute+mesenteric+ischemia&selectedTitle=1~72.
- Cudnik MT, Darbha S, Jones J, et al. The diagnosis of acute mesenteric ischemia: A systematic review and meta-analysis. Acad Emerg Med 2013; 20:1087.
- American Gastroenterological Association medical position statement: Guidelines on intestinal ischemia. Gastroenterology. 2000;118(5):95.
Foot Pain Out of Proportion to Exam: Lisfranc Injuries
Alexandra Murray, OMSIV
Ohio University Heritage College of Osteopathic Medicine
Classic medical conditions that are associated with “pain out of proportion to exam” include compartment syndrome, necrotizing fasciitis and mesenteric ischemia.1-3 However, another condition that can present with excruciating pain, despite underwhelming exam findings, is a Lisfranc injury.4-6 Lisfranc injuries encompass a broad spectrum of injuries to the tarsometatarsal (TMT) joints that separate the mid-foot and forefoot. These injuries can be purely ligamentous or involve the osseous and articular structures, resulting in dislocation and/or fracture.4-6
Lisfranc injuries comprise only 0.2% of all fractures and can result from direct or indirect trauma. Most cases are associated with high-energy motor vehicle accidents (i.e., ATV accidents) where there is a crush injury to the foot. Indirect trauma from a twisting injury combined with axial loading of the foot can also result in plantar displacement (i.e., sports injury or falling from a step). Most Lisfranc injuries are closed without obvious deformity, making the injury difficult to diagnosis.
Patients typically present with a painful, swollen mid-foot with possible ecchymosis to the plantar aspect.5,6 Weight bearing is not tolerated, but the patient may have relatively minor pain at rest. Side to side compression of the mid-foot should be painful and may be needed to elicit the diagnosis.4-6 X-rays of the foot should include three views and, if possible, these images should be taken while weight bearing.4-6 Non-weight bearing radiographs may not demonstrate an appreciable displacement of the osseous structures, causing the injury to be initially overlooked in up to 50% of cases.6 Dislocations and fractures are commonly found in combination. An avulsion fracture of the base of the second metatarsal or medial cuneiform, referred to as a “fleck sign,” can often be seen with Lisfranc injuries.4-6
Treatment of all Lisfranc injuries requires urgent orthopedic evaluation and follow up, whether treated conservatively or surgically.4-6 Without treatment, many Lisfranc injuries progress to post-traumatic arthritis, worsening instability and deformity.4-6 These injuries need anatomical reduction to improve outcome, which can generally only be accomplished with surgery.4-6 Patients should be placed in a non-weight bearing cast until orthopedic evaluation can be performed.5
Lisfranc injuries comprise a spectrum of injuries to the tarsometatarsal joints that can present with foot pain out of proportion to exam.4-6 These injuries may appear relatively benign; however, it is important to keep in mind that even significant injuries can reduce spontaneously, thereby hiding the initial deformity.4 Therefore, it is important that the clinician keep a high index of suspicion for this type of injury in any patient with pain and swelling over the mid-foot.
- Murdock M, Murdoch MM. Compartment syndrome: A review of the literature. Clin Podiatr Med Surg. 2012 Apr;29(2):301-10.
- Hussein QA, Anaya DA. Necrotizing soft tissue infections. Crit Care Clin. 2013 Oct;29(4):795-806.
- Renner P, et al. Intestinal ischemia: Current treatment concepts. Langenbecks Arch Surg. 2011 Jan;396(1):3-11.
- Loveday D, Robinson A. Lisfranc injuries. Br J Hosp Med (Lond). 2008 Jul;69(7):399-402.
- Eleftheriou KI, Rosenfeld PF, Calder JD. Lisfranc injuries: An update. Knee Surg Sports Traumatol Arthrosc. 2013 Jun;21(6):1434-46.
- Welck MJ, Zinchenko R, Rudge B. Lisfranc injuries. Injury. 2014 Dec 10. pii: S0020-1383(14)00612-3. doi: 10.1016/j.injury.2014.11.026. [Epub ahead of print].
Pediatric Emergencies Part 3: Head Injuries
Jenna Erickson, MSIV
Chicago Medical School
Head injuries are a common chief complaint evaluated in the emergency department. In children, head injuries are also often accompanied by a frantic caretaker. It is important to keep an objective mind when analyzing head injury in the pediatric population to reduce unnecessary admissions and radiation exposure without missing an important diagnosis. Rather than outlining the various possible head injuries, the focus of this article will instead be on the clinical decision making process of the emergency physician.
Several studies have been conducted to examine the methods necessary to determine when imaging and admission are necessary in the case of pediatric head injuries. Osmond et al., evaluated a clinical decision rule called CATCH for determining necessity of computed tomography (CT) imaging in children with minor head injury. The derived decision rule consisted of four high-risk factors (Glasgow coma scale score still less than 15 within two hours of injury, suspicion of open skull fracture, worsening headache and irritability) and three additional medium-risk factors (large, boggy hematoma of the scalp, signs of basal skull fracture and dangerous mechanism of injury). The high-risk fractures were 100% sensitive (95% CI: 86.2%-100.0%) for predicting the need for neurologic intervention and would require 30.2% of the patients to undergo CT, whereas the medium-risk factors resulted in 98.1% sensitivity (95% CI: 94.6%-99.4%) for the prediction of brain injury detected on CT and would require that 52.0% of the patients undergo CT. Though there are limitations to this study it does begin to outline what specific objective criteria can be used to reduce unnecessary CT imaging.
Another study on the subject investigated the use of National Institute of Clinical Excellence (NICE) guidelines on CT imaging in pediatric head injury cases. In this study the authors focused on whether or not CT imaging reduced the rate of unnecessary admissions. These guidelines include a wider range of signs and symptoms to indicate a high-risk patient. In addition to the factors outlined in the previous study, criteria for CT scanning also included vomiting, post-traumatic seizure, amnesia lasting more than 30 minutes or a focal motor deficit. The authors reported a decrease in admissions due to the increased CT scanning in the emergency department, arguing for the wider range of inclusion criteria to reduce the costs of health care due to admission. They did not, however, comment on the increased radiation exposure in pediatric patients.
Fortunately, the American College of Radiology (ACR) publishes appropriateness criteria that outline when imaging is necessary throughout different clinical scenarios in medicine. This criterion is examined and updated with the latest study findings every three years. In the case of pediatric patients with head injuries, the ACR considers multiple factors to determine whether or not CT imaging is warranted. In addition to clinical signs and symptoms, radiation exposure, financial implications and clinical outcome are discussed in the most recent ACR appropriateness criteria updated in 2012. Overall the ACR support the use of CT imaging for pediatric head injuries at the clinician’s discretion when their decision is based on one of many published guidelines on the subject. The complete ACR appropriateness criteria can be found at the link below.
Although guidelines for CT imaging after pediatric head injury may differ slightly, by applying guidelines to the clinical decision making process the emergency physician can make the decision confidently. Keeping up with recent literature on the subject is made simple by reviewing the ACR appropriateness criteria, which will be updated in 2015.
- Osmond MH, Klassen TP, Wells GA, et al. CATCH: A clinical decision rule for the use of computed tomography in children with minor head injury. CMAJ. 2010; 182:341-8.
- Dunning J, Daly JP, Malhotra R, et al. The implications of NICE guidelines on the management of children presenting with head injury. Arch Dis Child. 2004; 89:763.
- American College of Radiology ACR Appropriateness Criteria®. Clinical Condition: Head Trauma. Accessed 17 January, 2015. http://www.acr.org/~/media/C94E6287904E4D1CB185A7A63D1C0A37.pdf.
Kaitlin Fries, OMSIV
Ohio University Heritage College of Osteopathic Medicine
As of January 10th, 2015, influenza activity in the United States remained high, with 46 states having reported experiencing widespread flu activity.3,4 Only 24 of these states were still experiencing high activity, which is a decrease from the previous weeks and could represent an early sign that flu activity is beginning to decline in parts of the country.4 In the most recent CDC report, there was also a reduction in the percentage of positive respiratory samples.4 However, severity indicators such as hospitalizations and deaths were still on a sharp incline.4
Since October 1st, the Influenza Hospitalization Surveillance Network has confirmed 8,199 laboratory specimen testing positive for the flu.4 Approximately 95% of these confirmed cases are due to the mutated Influenza A H3N2 virus.2,3 This mutated strand is showing good sensitivity to neuraminidase inhibitors.2 Early this season, CDC Chief Tom Frieden reported, “Unfortunately, about half of the H3N2 virus that we’ve analyzed this season are different from the H3N2 virus that’s included in this year’s flu vaccine. They are different enough that we’re concerned that protection from vaccinations against these drifted H3N2 viruses may be lower than we usually see.”1 Due to the public’s reduced protection from the virus, it is imperative for primary care providers and emergency room physicians to have a high index of suspicion for influenza. H3N2 is associated with higher rates of complications and hospitalizations then other strands of influenza.3 Prompt treatment with antivirals is important for those with severe symptoms, hospitalized cases and any individual who is at risk for serious flu complications.4
This isn’t the first time the U.S. has experienced a H3N2 prevalent season. Back in 2012-2013 H3N2 related deaths peaked at 9.9%.3 However, during that season the flu vaccine was still found to be 43% effective, which is why health officials are still pushing the public to get vaccinated.3,4 In comparison, during this season, H3N2 related deaths peaked at 6.8% and 45 children’s lives have been taken by this deadly virus.3 Flu-related hospitalizations are being reported up 40% from last season, with a majority of those being attributed to the 65+ population.3,4 Overall, the proportion of deaths attributed to influenza is still above the epidemic threshold.4
- Capehart J. The current flu outbreak could use some of last year's Ebola panic. Retrieved January 10, 2015, from http://www.washingtonpost.com/blogs/post-partisan/wp/2015/01/06/the-current-flu-outbreak-could-use-some-of-last-years-ebola-panic/.
- Influenza update. Retrieved January 12, 2015, from http://www.who.int/influenza/surveillance_monitoring/updates/latest_update_GIP_surveillance/en/.
- Kounang N. The flu spreads to more states - CNN.com. Retrieved January 10, 2015, from http://www.cnn.com/2015/01/05/health/flu-activitity-spreads/.
- Situation update: Summary of weekly fluview. Retrieved January 16, 2015, from http://www.cdc.gov/flu/weekly/summary.htm.
Ebola in the ED (Popular Press)
Nicholas Pettit, PhD OMSIII
Ohio University Heritage College of Osteopathic Medicine
While the Ebola virus has certainly fallen out of the public eye within the last few months, this deadly virus is still important to talk about and understand. With the United States having around 5,000 emergency departments (ED) that service around 130 million visits per year it is very unlikely that the average emergency physician (EP) would come across Ebola. However, the mental exercise about being prepared for emergency situations, contagious viruses or other bioterrorism issues is something that every EP, nurse and student should be prepared for.
About the virus:
- Five subtypes exist
- Originated near Gabon or Guinea, then spread to Liberia, Congo, Nigeria and Senegal
- Transmission is by physical contact and via bodily fluids (not airborn)
- 80% have fever; 40-50% have flu like symptoms
- <10% hemorrhage
- Mortality ranges from 50-80%
Certainly all EDs have now undergone emergency preparedness in the unlikely event that a deadly virus should enter the ED doors. However, as a student rotating in emergency medicine, I am not familiar with the various local practices, which intrigued me into writing this article.
Per the CDC, staff members (including students) should follow three simple steps: identify, isolate and inform.
- Ask about relevant exposure history to an Ebola-associated country within the last 21 days
- Ask about the following symptoms: fever, headache, muscle pain, vomiting, diarrhea and hemorrhage
- Isolate the patient in a private room with a private bathroom
- Designate roles to provide patient care
- Maintain a log of all healthcare workers that come in to contact with the patient
- Use appropriate PPE (face shield, surgical facemask, impermeable gown and two pairs of gloves)
- Notify hospital infection control
- Notify local health department
- Identify, isolate, inform: Emergency department evaluation and management for patients under investigation (PUIs) for ebola virus disease (EVD). CDC.gov 1/14/15. Available at http://www.cdc.gov/vhf/ebola/hcp/ed-management-patients-possible-ebola.html. Accessed 1/16/15.
- Ebola diagnosis and treatment. Emcrit.org. 9/8/14. Available at http://emcrit.org/blogpost/ebola-diagnosis-treatment/. Accessed 1/16/15.
The American Board of Emergency Medicine (ABEM) and Maintenance of Certification (MOC)
Nicole Battaglioli, MD
I recently attended the American Board of Emergency Medicine (ABEM) summit regarding EM maintenance of certification (MOC). Before attending the meeting, I did not know much about the requirements I would need to fulfill to maintain my board certification after passing oral and written boards. Providing patient access to a board-certified EP is at the heart of AAEM and AAEM/RSA’s aim, and as resident members of the AAEM community it is important to understand MOC.
What is MOC?
The Maintenance of Certification Program has been developed in many ways as a joint venture between ABEM and the American Board of Medical Specialties (ABMS) as a means to ensure a high standard of activities for physicians looking to maintain their board certification after initial certification. The program focuses on ongoing learning, practice improvement and individual assessment of physicians. The MOC program also incorporates the six ABMS/Accreditation Council for Graduate Medical Education (ACGME) Core Competencies: Practice Based Learning and Improvement, Patient Care and Procedural Skills, Systems-based Practice, Medical Knowledge, Interpersonal and Communication Skills and Professionalism. Providing physicians with a scaffold to maintain their certification through continuous learning helps ensure that board-certified physicians remain current and up to date on evolving topics in the field of emergency medicine. MOC is divided into four main components that are outlined below.
Part 1: Professionalism and Professional Standing
Participants must hold a current, active and valid/unrestricted license. Any additional license must also be unrestricted.
Part 2: Lifelong Learning and Self-Assessment
This is broken down into two components; Lifelong Learning and Self-Assessment (LLSA) activities and Continuing Medical Education (CME) credits. LLSA activities involve an annual set of readings (journal articles) with an open book test to follow. A separate patient safety LLSA was developed in cooperation with the American College of Emergency Physicians (ACEP). Physicians are required to complete four LLSAs per each five-year period of certification. One patient safety LLSA is required once per ten-year period. CME credits are offered through a variety of venues — an average of 25 AMA PRA Category 1 Credits™ are required per year.
Part 3: Assessment of Knowledge, Judgment and Skills
ABEM requires that a proctored exam referred to as the ConCert exam be taken every 10 years. This exam can be taken any time during the last five years of each 10-year period.
Part 4: Improvement in Medical Practice
ABEM requires active clinicians to participate in practice-based learning and improvement as either an individual or as a part of a group. This includes a requirement to participate in a patient care practice improvement (PI) project and a requirement to participate in a communication/professionalism patient feedback program. Participants in MOC must certify online once every five years that they have participated in a patient care PI project and a feedback program (i.e., Press Ganey etc.)
Getting Started With International Emergency Medicine
Shane Sergent, DO and Sophia Johnson, DO
Conemaugh Memorial Medical Center
The establishment of our own modern emergency medical services (EMS) was in response to a paper from the National Academy of Sciences highlighting the correlation between the high number of fatalities from accidents and the inadequacy of emergent care.1 Shortly after, the United Kingdom, Australia, Canada, Hong Kong and Singapore developed their own respective emergency medicine systems in the 1970s and 1980s.2 Over the years, this initiative has decreased the number of fatalities from accidents. However, today many developing countries continue to have an extremely high number of fatalities per number of vehicles, and the lack of emergency medicine and EMS in these countries exacerbates this public health issue.3
Ideally, transplanting EMS into international communities would be the most simplistic approach; however, each country has its own barriers. Some of the most recognized barriers that exist include lack of infrastructure, shortage of funds or local demographics. Others are often overlooked, like the road conditions or modes of transportation. Problems such as these attract many EPs to international medicine and have provided the basis for the growing body of international EM research on the effects of different interventions.
Today, interest in international medicine has grown exponentially. With a simple search, you can find many international conferences, organizations, relief and development efforts, physician exchanges and even international emergency medicine fellowships. However, some are still left wondering what international emergency medicine is.
International emergency medicine is a relatively new subspecialty of emergency medicine. The first fellowship was started at Loma Linda University in 1994.2 Today, many programs exist with various curriculum and requirements. A primary focus is on the multiple facets of emergency medicine such as pre-hospital care, research and data collection, systems development, infrastructure expansion, improving public health and providing time-sensitive patient care and treating diseases that we do not routinely see in practice of EM in the United States. For example, a recent trip to the Amazon left one of the authors diagnosing and treating multiple cases of tropical diseases, TB and parasitic infections. International emergency medicine experiences expand our ability to recognize and consider a wider differential diagnosis upon returning to our home environment.
If you are interested in international emergency medicine, but are left wondering where to start, a good place would be to attend one of the many international conferences. The larger conferences pertaining to emergency medicine are the International Conference on Emergency Medicine (ICEM) and the World Association for Disaster and Emergency Medicine Conference (WADEM). If you have an interest in development of emergency care systems organizations such as Emergency International or the International Federation for Emergency Medicine would be helpful resources. Perhaps jumping headfirst is the best approach; doing an international elective or establishing an international rotation with your residency program is a great approach as well. Many organizations exist to help students and residents find opportunities for international rotations in various locations around the globe. One we have used is DO Care; http://www.docareintl.org/. Other long term options that exist are Doctors Without Borders or AmeriCares.4
- Razzak JA, Kellermann AL. Emergency medical care in developing countries: Is it worthwhile? Bulletin of the World Health Organization 80 (11): 900–5. doi:10.1590/S0042-96862002001100011. PMC 2567674. PMID 12481213.
- Alagappan K, Holliman JC. History of the development of international emergency medicine. Emergency Medicine Clinics of North America (W. B. Saunders Company) 23 (1): 1–10. doi:10.1016/j.emc.2004.09.013. PMID 15663970.
- Jochberger S, Ismailova F, Lederer W, et al. Anesthesia and its allied disciplines in the developing world: A nationwide survey of the republic of zambia". Anesthesia & Analgesia 106 (3): 942–8. doi:10.1213/ane.0b013e318166ecb8. PMID 18292444.
- Arnold JL. International emergency medicine and the recent development of emergency medicine worldwide. Annals of Emergency Medicine 33 (1): 97–103. doi:10.1016/s0196-0644(99)70424-5. PMID 9867895.