Virginia College of Emergency Physicians Post

Thanks VACEP for highlighting us! VACEP is a collection of the finest emergency physicians in the state of Virginia and were very kind to put us front and center on their newsletter.
http://multibriefs.com/briefs/VACEP/VACEP082516.php

Making More News

The project continues slowly but surely, even if our updates do not. The LATE students we worked with are currently doing the post-implementation workup to check on the efficacy of the training program we designed and participated in. The Ministery of Public Health for Ecuador is also planning to spread the training beyond the 350 emergency employees from Cuenca into the surrounding pueblos sometime in September. It has been an honor to work with such dedicated and passionate people! As more numbers and information flow in, we will be sure to let you know more results. For now we are in the write-up stage of the project and trying to survive the dog days of medical school.

We also made some more headlines! Check out http://news.vcu.edu/health/Medical_students_travel_to_Ecuador_to_help_with_emergent_care

Experience Summary Post - Mark

I’m in the firefighter training facility in Cuenca, Ecuador, standing in front of 38 emergency system personnel from the city. Over the next week, the pre-hospital communication course my team researched and designed will be taught to all 350 EMS workers from Ecuador’s third largest city with the stamp and seal of their Ministry of Public Health. The training will be led out by...well, me, a foreign medical student, with thankfully an Ecuadorean physician and my student team members right behind me. As I try to gather my thoughts in a second language on a topic I knew nothing of 10 months ago, I have to think - How did I ever end up here?

Growing up, I was privileged to assist on four mission trips to South America, where I became fluent in Spanish, learned to love Latino culture, and found my life calling in global health. Entering medical school at Virginia Commonwealth University, I began looking for experiences in third-world medicine deeper than what a typical trip offers.

The team in Cuenca's main square

When the opportunity arose to help augment a trauma system project initiated in Ecuador by Dr. Sudha Jayaraman, I immediately jumped aboard, eventually convincing fellow first year students Jeremy Carter and Elissa Trieu to join me. Our team’s ability to work together seamlessly while balancing strengths and weaknesses proved vital as numerous inherent trials of international research existed throughout the project. Although mentorship was available when needed, we were often left to ourselves to decide research details. The autonomy proved both enjoyable and, sometimes, frustrating, but gave us an enriching learning experience.

In order to prepare myself to perform the project, I did my best as a first year medical student to study up on the MIVT checklist (Mechanism of Injury, Suspected Injuries, Vital Signs, and Treatment/Time of Arrival, commonly used in United States EMS presentations) we would be utilizing and shadow every part of the top-ranked Richmond trauma system. Experiences included the trauma bay alongside Dr. Jayaraman, hospital communications center, ambulances ride-alongs, and even life flight transports.

The team at Ingapirca Incan ruins

As we read through the previous research, communication presented a key issue in the Cuenca pre-hospital emergency care system. We decided to design an objective study to assess the quality of information passed at three crucial points in the pre-hospital communication tree, based off a form of the MIVT checklist approved by the Cuencan physicians. Using a yes/no checklist, researchers would be at the three stations and confirm whether or not specific information was passed during the verbal presentations.

No matter how much we prepared beforehand, our team could never have done enough to deserve the life-changing experience that was before us. We were privileged to work with Dr. Juan Carlos Salamea, Ecuador’s chief surgeon, Dr. Alberto Martinez, a wonderful down-to-earth emergency physician, and four energetic medical students from the Liga Academica de Trauma Ecuador, or LATE. Their incredible reception of us, along with that of our host family, to the hidden gem of Cuenca cannot be overstated. Beyond the day excursions, food, and cultural lessons, however, was the real reason we came: to improve the existing pre-hospital communications through research.

Beautiful Cuenca

Plans had changed by the time we arrived, however. Not only would we to collect our data within a two week frame, but we were to then present our findings and suggest improvements at a city-wide conference for all emergency personnel. This would be followed by a comparison post-implementation study. We worked diligently with the LATE students to be ready for the new lofty assignment we had been given.

Data collection proved an ever changing beast. Waiting for ambulances at the hospital was taxing, as we averaged about one patient every two hours at that station. Five times we went to the 911 call center hoping to enter; five times we were turned away, needing a different authority’s signature each time before we were allowed to enter on the sixth attempt. However, the EMS personnel were all extremely welcoming and receptive to the work we were doing, making every pain worth it in the process. When the presentation day came, we knew quite a few in the audience, and there was mutual respect and trust for one another in our collaborative work.

Teaching with Dr. Martinez

How did we become qualified to train? We participated in the process. We asked questions. We diligently collected the data and presented our findings. We communicated complaints from those within the system and suggested improvement processes. We presented towards observed specific needs, such as having a Glasgow scoring role play to correct some misconceptions. And above all, we built relationships with people who helped move the project forward that I expect to last a lifetime.

Our "Ministry Approved" card

At the course’s conclusion, an MIVT information card our team designed was given to all 350 conference attendees. The Ecuador Ministry of Public Health gave a literal stamp of approval to the card, with a mandate for system workers to carry it with them at all times. I saw the EMS team’s desire for change exemplified by a 30 year veteran firefighter being the first one to eagerly accept a card and immediately keep it next to his name badge. Each course we taught brought a new wave of incredibly receptive and inquisitive team members ready to listen and improve.

What will come from this experience? I know I have been changed beyond the research opportunity I initially sought, as I am now looking into career options in global health. But this project quickly moved beyond me and my team, and is continuing to grow into something bigger. The Ecuadorean government has requested our presentation be shared with the emergency personnel of the villages surrounding Cuenca, with plans for an annual refresher course in the works. Our updated findings will be shared with physicians in the hospital in hopes they make the necessary changes as well. And my greatest hope is to return to Ecuador someday and see our card in use during a perfect MIVT presentation, our research findings helping to save the life of yet another patient passing through the Cuenca trauma system, the system our labors helped change. 

Mark is a second year medical student at Virginia Commonwealth University and is originally from Logan, Utah. Medical and service experiences in Central and South America have made him fluent in Spanish and shaped his current interests in emergency care and global health systems. When he can get away from the books, he is also an active outdoors man and is the founder of the Medical Student Athletic Club at VCU. He can be reached at hopkinsm2@vcu.edu for further details on the project.

Training, the Beginning of Change (Ojalá)

Finally, after hours of waiting for ambulances to collect information, getting sick, struggling through Spanish, multiple attempts with the Ministry of Health to get the correct permission, and months of trying to make the correct contacts, we were able to see some of the payoffs for our research. I am not saying our research is done by any means, but on Monday, we taught our first class of EMS professionals...and it felt great. We were actually a little taken back by how eager most of them seemed to be at the training. As a seasoned paramedic told us, he had never previously received instruction regarding standardized communication when transferring a patient to the hospital. In fact, many people we spoke to during the training commented that they wished for more training opportunities like this. Looking back on the mandatory trainings I have attended (e.g. HIPAA), I have never really been eager to go, let alone ask for more. I was impressed by their general interest and passion for their field. For the first time in Ecuador, it finally felt like what we were doing could make a positive, long-lasting impact. It might actually stick.

For the next week, we (Dr. Martinez, Dr. Salamea, LATE students, and VCU students) taught two hour-long sessions a day about MIVT, while the class (about 35 people in each) stayed for another two hours to learn about proper radio protocol, and how to organize a trauma scene. As the Ministry of Health posted on their Facebook page, the training consisted of "337 participants of the MSP, Red Cross, Firemen, IESS and Sis-ECU 911." Essentially, the training included all of the pre-hospital providers in the third largest city, and medical Mecca, of Ecuador. Our presentation included the pathway of communication in the Ecuadorian pre-hospital system, stressed the importance of their role in transferring the patient using MIVT, presented our data from the previous weeks, ran through assigning a Glasgow score, provided a real example of poor communication, and finished with an exercise that allowed the class to use their newly approved MIVT cards to present to a partner as if at the hospital.

MIVT, or IMLST in Spanish, approved by the Ecuadorian Ministry of Health. We designed the card based on MIVT protocol and information requested by receiving hospitals as determined by a previous ITSDP project. The card was designed to fit in with their ID cards--to be readily available. 

The class using their new MIVT cards to work through the exercise.

Now for a bit for the pessimist inside me. I have been wary of that "special summer project" where that ambitious, naive person travels to a developing nation to build a well for a community in need, when in a year, the machinery breaks and the project is rendered useless. The person leaves the village that year with some amazing photos, a fun experience, but in the end, did nothing to help the community in the long-run. That is exactly how I did NOT want this project to go. Working with Dr. Martinez and the LATE students has calmed that fear regarding this project. Pepe, Emmy, Caro and Fernando, the LATE students, taught so well and have proved their commitment to the project (even during their finals). Dr. Martinez was incredible. He drove home many of the points as we taught, and with years of experience with emergency medicine, he related well with the EMS personnel. Some doctors in South America (or anywhere for that matter) may come off at times as haughty and hard to work with, but he was just the opposite of that. His humble character allowed for open discussion, yet commanded respect from the listeners. It was clear that he is motivated to improve his community...even without proper compensation for his efforts (he is not getting any special bonuses for helping with the research and training). On the other hand, it appeared that the majority of the classes truly appreciated the training and took it seriously. I am sure more training will be due in the future, but I feel it is a great start for change. I think the future of this work is in good hands. 

Caro and Emmy introducing MIVT.

 Instruction by Dr. Martinez with Mark and Pepe. 

As my travels throughout the world have taught, you can find people everywhere that are intelligent, competent, and motivated to improve their own communities. I am grateful for the people of Cuenca for allowing me to experience their health system first-hand, for the many lessons learned, for the friendships made, and for the hope that my short time there performing this research may have lasting implications for good (even if it was just a small mark). 

I will never forget the ambulance ride-along with Leonardo and Victor to the "top" of the Andes. It was great to run into many familiar faces at the training. 

Implementation Project Video from Cuencan Government

We made the news in Cuenca! Check out this PR bit from the Ministry of Public Health, the government branch in charge of Ecuador's free healthcare system, on what we were helping them to accomplish. Training went well and the project will continue now into the post study process. More updates and thoughts on training will be posted soon.

                          Leonardo and Victor, two of our favorite ambulance ride-along workers. Some abulances have doctors, such as Leo, on board.

Teaching with Dr. Alberto Martinez, our Ecuadorean mentor, who is just incredible. Here he is patiently answering some of many complaints ambulance personnel brought up about the system during the training

Jeremy as the patient for our Glasgow training

We were pleased with how ready and willing to learn everyone was in the training

The training team with the Ministry of Public Health representatives

The students we were privileged to work with and now miss dearly

Ministry Approved

Also, a quick quote from the World Health Organization on communication in a pre-hospital setting: "Necessary components of planning of systems for trauma management include communication and transport. Communication takes into account the radio communication between EMS units and receiving hospitals. Prior notification by such radio communication allows trauma team activation and preparation for immediate care of severely injured patients upon arrival."
http://apps.who.int/iris/bitstream/10665/42565/1/9241546409_eng.pdf 

Adios data collection, hello training

With the data collection behind us, the second leg of our project consists of the training class. This three hour class is broken into three segments: 1) MIVT 2) Radio communication 3) Scene Management. And we're responsible for the first part. (To read up more about this training - go to http://cuandoencuenca.blogspot.com/2016/07/you-want-us-to-do-what.html) Two classes a day, five days this week. This equals ten classes that'll train the entire EMS personnel of Cuenca. Ready..set...go!

Everyone was really receptive and interested in the material, but more to come soon about the classes!

Caro, Mark, and Jeremy all fired up for the first day of Training

Ha-BLAS es-PAN-ol?

The three of us are pretty outgoing people. We're the type of people to talk to everyone we meet, from the taxi driver on our way to the hospital to the waitress serving us lunch. And, I think that's what's made this language thing so much harder than expected.

After spending two years in Mexico, Mark is fluent in Spanish. Jeremy and I, on the other hand, had a lot more to learn. Jeremy took two years in middle school and I took Spanish through middle school until 10th grade. To put it lightly, it had been a very very long time since either of us had seriously studied Spanish. I was actually amazed by what came back, who knew so much from sophomore year of high school actually stuck! I was never especially good at Spanish then, which made this even more surprising.

When I got to Cuenca, I knew for a fact that I wanted to take Spanish classes. At $10/hour for a private class, I figured it was well worth it, in order to best accelerate the learning process. Whenever interacting with Dr. Salamea and the other LATE students, we spoke solely in Spanish - something I really appreciated. It forced us to get into Spanish and taught us a lot of medical Spanish.

By the end of this trip, I would say that I'm now at an intermediate level of Spanish. I can understand what people are saying and I can say whatever I need to say (I've gotten really good at word origami - rephrasing my sentences whenever I don't know a word to best utilize my current vocabulary). That's where the problem is, though. For me, it's been really hard to get to know people well when you can't joke with them, and when you can't have conversations at a deeper level than your average daily chatter. There's a difference between being capable of communication and being comfortable with using word play and irony.

I feel like it's generally believed that your personality is an inherent part of who you are. But here, I've found the opposite - I actually think that talking in a different language can actually change your personality. Mark and Jeremy watched me as I spoke with some Chinese tourists in Cantonese. They said that my whole body language changed when I spoke in Cantonese, and my demeanor did too. In Spanish, I'm much quieter, whereas for Mark, it's the opposite, and he's actually much more outgoing in Spanish! At the end of the day, it's actually exhausting to have done nothing but speak in Spanish. Your mind is cranking nonstop and constantly on the move. It made me less likely to strike up conversations with random strangers, because I just got tired.

This was really eye opening. Growing up speaking English in an English speaking country, I never really seriously considered language barriers on social relationships. I knew they were an issue when someone couldn't express what they needed, like medical help in a hospital or were lost and needed directions. But, your confidence in your language abilities can also affect so much. My parents immigrated to the US in their twenties. They're fluent in English, give or take an Asian accent, but they've never chosen to speak English at home. They feel more comfortable when speaking Chinese, and now I can better appreciate a sense of why. It's difficult to get the same easy going joking going on in a foreign language. So many jokes and conversations revolve around word manipulation (puns, etc), lingo, and cultural references specific to the area.

Despite acknowledging this hurdle, I feel like we've gotten to really know our LATE friends. They've taken us to soccer games, hiking, and many more adventures. One of my favorite memories was when we went hiking with Caro, one of the LATE students we worked with. We took a bus around town to get to Giron, where we then walked 6km alongside some beautiful countryside before finally getting to start our hike (or should i call it a vertical rock scramble) up along the side of a waterfall. We spoke Spanish the whole day, and it was great to get to spend the whole day with her, away from the pressures of time and school. No matter the country, med school is the same. We joked about our classes, how stressful studying is, what we want to do with our futures, etc. (funnily enough, she taught us the word "maton"...which literally translates to gunner - some things just don't change!)

For me, language was a huge part of this trip. Getting a chance to learn Spanish (especially medical Spanish) better is a great skill to have. Furthermore, the international perspective on the familiarity of language is enlightening.