This is the second year that the St. Luke’s-Roosevelt Global Health Division team has been the lead visiting faculty for the 4th year medical students’ 6 week long Emergency Medicine Module. In January 2017, these students will begin their clinical rotations at Beira Central Hospital, where they will have the opportunity to apply their emergency medicine skills!
The Emergency Module involves morning lectures, afternoon problem based learning groups, and skills stations. The topics cover general principles of emergency care and focus on areas that the students are likely to encounter in their local practice (sepsis, malaria, altered mental status, acute presentations of chronic illnesses, severe malnutrition, dehydration, tropical diseases, snake and other poisonous bites, pesticide exposures, motor vehicle accidents, mass casualties, etc).
Mozambique is among the least developed countries with an epidemiological transition: high rates of infections (malaria, tropical diseases, HIV, TB, etc) along with increasing rates of noncommunicable diseases, and injuries.
The students are a delight — smart, eager, welcoming, optimistic, full of energy and curiosity. Their English is excellent (they are taught medicine in English and Portuguese) and would often ask us to give the lectures in English rather than Portuguese (despite the fact that most of our GH Division faculty speaks Portuguese-fairly well)!
The students threw themselves into the Advanced Trauma Life Support (ATLS) skills stations – Primary Survey – ABCDE, Secondary Survey, intubation, needle decompression, chest tubes, etc. Out of the 40 students about 6 came forward after the ATLS course to form an Emergency Medicine Interest Group! They’d also like to participate in our research activities.
We will continue our research on students’ perception of emergency medicine to better understand their readiness for an Emergency Medicine specialty in Mozambique. We will continue evaluating the Emergency Medicine Module, its applicability to the reality of practice in Mozambique’s medical and emergency services.
The Global Health Division started collaborating with the leadership at Beira Central Hospital (HCB) and UCM on a needs assessment and morbidity and mortality analysis at the emergency department at the Hospital Central in Beira (the regional referral hospital sees over 100,000 patients/year through their emergency department. We will to evaluate gaps in emergency care and readiness. The subsequent analysis will set intervention priorities to improve services, outcomes and mortality over coming years.
This is an exciting time for emergency medicine in Beira!
More on the collaboration:
Mount Sinai St Luke’s/Mount Sinai West Department of EM Global Health Division Emergency Medicine Capacity Building in Beira, Mozambique
The goal of the Mount Sinai St Luke’s/ West Global Health Division’s project in Beira, Mozambique is to build emergency medicine human resource capacity at the Universidade Catolica de Mozambique (UCM) and the Central Hospital.
The project’s initial phase focuses on education and training of essential Emergency Medicine concepts:
(1) Strengthening and evaluation of the existing Emergency Medicine Module (EMM) for 4th year medical students at Beira’s Universidade Catolica de Mozambique (UCM)
(2) Strengthening Beira Central Hospital’s (BCH) emergency medicine staff ‘s knowledge of essential emergency medicine triage, assessment and management
Mozambique, with a population of approximately 25 million people, ranks 178/187 on the United Nations Development Program and has more than half of its population living below the poverty line The country gained its independence from Portugal in 1975, and is still suffering from the effects of the civil conflict that ended, officially, in 1992. The Mozambican government is committed to economic development, improved living standards, and good governance. However, Mozambique persistently ranks among the least developed countries in the world, despite their aims toward improvement. The Under 5 Mortality stands at 79 per 1,000 live births, infant mortality at 57 per 1,000 live births, maternal mortality at 489 per 100,000 live births, and life expectancy at 52 years. The country is in an epidemiologic and demographic transition with persistently high rates of infectious diseases (malaria, TB, HIV/AIDS, etc.), rising rates of non-communicable diseases, and increasing numbers of injuries as the country develops, ages, and becomes more urban.
The health system is composed of public and private (for profit and non-profit) sectors, with the public sector serving as the main provider of healthcare and covering 60% of the population. The total number of physicians registered in the National Health System was 1,268 in 2014 (<0.5 physicians/1000 population), of whom 23% were foreigners.
The Mozambican Ministry of Health (MoH) has recognized the need to invest in the improvement in quality of care in every aspect of service delivery and at every level; human resources, infrastructure, and ongoing maintenance of systems and structures. The MoH has been scaling up the health workforce and expanding health facilities to increase coverage and access to services. Mozambique has many bilateral and multilateral development partners supporting its “Sector Wide Approach to Health” (SWAp*). In an effort to strengthen partnerships for health and the health system, the Health Sector Strategic Plan aims to improve the quality of service provisions and strives to increase the efficiency of these provisions, as well as resource utilization. In this context the MoH, with the aid of the WHO country office, has organized “train the trainers” workshops across the country in emergency and essential surgical care. These trainings are based upon the WHO Integrated Management for Emergency and Essential Surgical Care (IMEESC) tools.
UCM Medical School, founded in 2000 in collaboration with Ipswich Hospital in Suffolk, England, and BCH, is the second largest medical school in Mozambique. The medical school focuses on problem-based learning, uses the University of Maastricht methodology and is taught, mainly, in English. Though there are no emergency medicine residency training programs in the country, UCM Medical School has dedicated a 6-week emergency medicine module-focused training for 4th year medical students. Medical schools in Mozambique are structured as 6-year programs, with years 1-4 dedicated to basic medical education and years 5-6 reserved for clinical, in-hospital training. The EMM includes a 4 day adapted ATLS course, a 1-day resuscitation skills training, a 1-day introductory ultrasound skills session, and problem based learning sessions/didactic sessions on various emergency topics in adult and pediatric medicine. The modules form the basis of EM knowledge that these medical students receive prior to clinical rotations at the BCH and prior to their practice as junior physicians. As such, these modules aim to foster critical thinking among the participants and help them master aspects of “first world training” which may then be adapted to a resource-constrained setting. To our knowledge it is unique among Medical Schools in Mozambique. The previous course coordinator (an EM trained U.S. physician) has left Mozambique and the present coordinator is a UCM graduate, faculty member who practices internal medicine at BCH. Both local faculty (surgery) and visiting faculty participate in the EM Module training.
In the past, UCM Medical School had also, independently, taught a multidisciplinary 1-day emergency medicine postgraduate course to BCH emergency room medical staff (technician, nurses and doctors). This course focused on team building, skills based approach to initial assessments, and resuscitation, and management of life threatening conditions. However, the clinical lead (an EM trained English physician) for the postgraduate program has left the country and a new lead is being sought. Because of this void, at present, it is unclear whether another UCM-initiated training for emergency room staff will take place. Thus, the MSSL/West GH Division team is providing a needed service.
BCH is the UCM Medical School’s teaching hospital and one of the country’s three-referral hospitals. It covers a total catchment area of over one million people, with 733 beds with inpatient and outpatient services in Internal Medicine, Surgery/Orthopedics, Pediatrics, Ob-Gyn,. In addition, it has a blood bank, pathology lab, four operating rooms, x-ray/CT/US imaging capabilities, and adult and pediatric emergency rooms. The hospital is staffed with a mix of national and foreign physician specialists, junior physicians (fulfilling their mandatory 2 year clinical service at the end of medical school), technicians and nurses.
BCH has recently renovated its Emergency Room with a “high dependency” (critical care) section and a regular emergency section. The Director of the ED, Dr. Dunao, is committed to improving the quality of care and improving access for the population. The 2014 census stood at approximately 113,000 visits (adult and pediatrics) with a 29% admission rate. Presently local senior and junior physicians staff the Emergency Department.
GHD Project (1) – Strengthening and Evaluation of the Emergency Medicine Module
The Global Health Division began supporting the UCM Medical School’s EMM in 2015. Faculty members (Drs Sunderwirth, Singh, and Cramer), an EM resident Dr. Mangan, and a former MSSL/West Global Health Fellow, Dr. Uebbing, directed the BLS, NALS, and ATLS mini-courses, produced and held didactic EM topic lectures/discussion groups, and moderated problem based learning EM topics. The team participated in the module’s evaluation and in the end of year Objective Structured Clinical Examinations (OSCE) for the 4th year medical students. A member of the team was always present during the entire 6 weeks.
The Global Health Team is committed to continued participation in this physician education and training program. To better understand the UCM medical students knowledge, attitudes and practices (KAP) of emergency medicine, as well as their acceptance of EM as a specialty, we are surveying all medical students who complete the EMM. The survey results will inform our collaboration with the EMM Director, Dr. Monica, and with the Coordinator, Dr. Ismenia Todo,, will aid in the evaluation of the present curriculum, and will guide the addition of new components to the EMM, in order to reflect developing evidence and best practices in emergency medicine.
To our knowledge, there has not been a formal KAP assessment of Emergency Medicine in Mozambique, and projections of interest in pursuing this field as a profession are difficult to make since the country lacks any formal EM residency training programs. As more physicians in Mozambique are assigned to work in emergency medicine settings, we can hope a sufficient number of experienced professionals will develop, who may then be recruited to teach the EMM. The Global Health Division projects an involvement with UCM School of Medicine of at least 5 years, in order to help fill the current gap in emergency medicine providers and to train a cadre of EM healthcare professionals in country.
GHD Project (2) - Strengthening BCH Emergency Medicine Services
With the assignment of a new director, Dr. Dunao, and recent renovations of the emergency room at BCH, the GHD will reestablish its position as a partner in advancing emergency medicine capacity. In collaboration with Dr. Dunao and his staff, we will clarify existing gaps in staff training and agree on sustainable educational programs. An area of need, already identified, includes nursing training in pediatric resuscitation (APLS or PALS). Furthermore, the MoH has assigned UCM graduates to the BCH emergency room as junior physicians. These physicians would be logical teachers for the “Train the Trainer” courses, for sustaining EMM at the UCM medical school, and for leading resuscitation courses (BLS, ACLS, ATLS, NALS, PALS/APLS) for BCH’s inpatient and emergency nurses and physicians. Train the trainer courses will rapidly build nursing and physician capacity in resuscitation, emergency assessment and management. Building on experiences in other sub-Saharan African countries with similar challenges in providing emergency care services, we plan on collaborating with the BCH to adapt existing short courses for physicians practicing in an emergency medicine setting to the local pathology and resources that exist in the country.
Finally, in conjunction with local staff, we aim to analyze the trends in emergency room and inpatient morbidity and mortality (top ten causes), looking at data from before and after the implementation of the emergency medicine teaching courses. This will inform program coordinators over time about the impact and effectiveness of current trainings as well as system needs. It is hoped that collaboration between the GH Team and local coordinators will occur, and that recommendations for ways forward in emergency training will be based upon the information gleaned.
GHD projects a commitment of five years.
Mount Sinai St Luke’s Mount Sinai West faculty participants for Nov.-Dec 2016: Ramona Sunderwirth, Ramon Millan, Natasha Demehri, Kyle Cramer, Turan Saul, and Tatiana Havryliuk