ACEP Now is an official publication of the American College of Emergency Physicians. ACEP Now offers real-time clinical news, news from the American College of Emergency Physicians, and news on practice trends and health care reform for the emergency medicine physician.
A call to join the Editorial Board for what is to be the leading new Open Access journal in the field
ACEP’s new Open Access journal, Journal of the American College of Emergency Physicians Open (JACEP Open), seeks individuals with experience in peer review and editing to join our exciting new venture as decision editors. Editors will be fully involved in the peer review process, including the review of submitted manuscript, soliciting comments from expert peer reviewers, and helping the Editor in Chief to choose the best articles to feature in the journal.
JACEP Open will start accepting papers this fall, post papers online in January 2020, and publish its first issue in February 2020.
to bring together a broad range of experts in emergency care from around the world
individuals who will further the mission of the journal, including encouraging submissions from peers internationally
people who will be energetic and invested in the success of the journal
Please join our Editor in Chief, Dr. Henry Wang, in blazing this exciting trail. Send your CV and a letter of interest to Martha Villagomez, no later than August 1st, 2019.
About Dr. Wang
Henry E. Wang, MD, MS, is professor and vice chair for research of the department of emergency medicine at the University of Texas Health Science Center at Houston. He is one of the world’s most prolific emergency medicine scientists and is internationally recognized for his scientific work in out-of-hospital airway management, resuscitation, and sepsis epidemiology. Dr. Wang was a deputy editor for Annals of Emergency Medicine and has served on the editorial boards of Academic Emergency Medicine, PeerJ and Prehospital Emergency Care.
The winners of our 2019 Outstanding Medical Student Awards have been announced! This honor recognizes students who excel in compassionate care of patients, professional behavior, and service to the community and/or specialty. Winners receive a year of free ACEP membership and free registration to the Scientific Assembly. This year’s winners are:
Arthur Broadstock, The Ohio State University College of Medicine
Alexandria Gregory, Saint Louis University School of Medicine
Jonathan Lee, University of California, Irvine
Andrea Quiñones-Rivera, University of California, San Francisco
Stephanie Winslow, University of Florida College of Medicine
The following students received honorable mentions: Adrienne Caiado (Penn State College of Medicine), Reed Macy (University of Texas Southwestern), and Dylan Lukato (University of Wisconsin School of Medicine and Public Health).
ACEP held a meeting with the Occupational Safety and Health Administration (OSHA) to discuss strengthening protections for health care workers, especially those in the emergency department, from workplace violence. Currently, no such federal regulation exists, but OSHA has begun to explore its development. ACEP has long advocated for such protections; most recently, ACEP drew attention to the issue by releasing results of a survey that reported nearly half of emergency physicians polled had been physically assaulted, with more than 60 percent of assaults occurring in the past year. ACEP worked with congressional offices to refine H.R. 1309, The Workplace Violence Prevention for Health Care and Social Service Workers Act, and recently sent a letter of support asking Congress to consider how emergency departments, in particular, are staffed to ensure the important provisions of this legislation are implemented appropriately. Stay updated on this issue.
ACEP recently added two new point-of-care (POC) tools to its growing library. BUPE is a quick and easy tool to assess patients for opioid withdrawal and the use of buprenorphine. It provides indications, side effects, and expected responses to buprenorphine. Eric Ketcham, MD, FACEP, presented the new buprenorphine tool at the Rx Drug Abuse & Heroin Summit in Atlanta this April.
The AFIB tool helps determine the best way to control rapid atrial fibrillation and assists with identifying patients who can be converted to sinus rhythm in the emergency department. Find both of these resources in our library of bedside tools.
ACEP Now by Kevin M. Klauer, Do, Ejd, Facep - 3w ago
Leading an organization as large and diverse as ACEP requires a focus on both the urgent problems of the moment and the long-term health of the organization and its members. For ACEP President Vidor E. Friedman, MD, FACEP, centering his efforts on improving life for emergency physicians and advocating for shared areas of concern have allowed him to tackle both current issues and long-term strategy initiatives.
From a leadership perspective, Dr. Friedman has accomplished much in a short time. Instead of spending the usual year as ACEP President-Elect, he only spent three months in the role before assuming the presidency in September 2018. He was elected by the ACEP Board of Directors in June 2018 to serve as President-Elect following the resignation of former ACEP President-Elect, John Rogers, MD, FACEP.
Dr. Friedman recently sat down with ACEP Now Medical Editor in Chief Kevin Klauer, DO, EJD, FACEP, to discuss his goals as ACEP President. Here are some highlights from their conversation.
KK: Let’s talk about your initial goals as ACEP President. What did you really want to try to accomplish in this year?
VF: Well, these were interesting times. The reality is that most president-elects have a year to prepare. I only had three months to prepare, following John Rogers’ transition out of the role. I didn’t have as much time to think about what my personal goals were for the presidency. I wanted to do what I could in this year to improve life for emergency physicians and particularly for future emergency physicians. I think most presidents go into it thinking of the things that they would like to accomplish. However, the crises of the moment that we have to deal with have a tendency to hijack the agenda to a certain extent.
There were internal things that I wanted to try to accomplish this year. My goal was to help the Board be more strategic in its operations. What I mean by that is over the last 10 years, the Board has become very operational. I’m glad that our annual Board retreat went well and that we were able to focus on how to help the Board become more strategic in its functioning.
In terms of what’s happened since I’ve assumed office, I knew going into it that the issues around out-of-network billing were going to be important this year. There’s a tremendous bipartisan desire to do something in that arena. In fact, it’s including the White House and the Secretary of Health and Human Services. They’ve decided that [surprise] billing is something they’re going to focus on.
I’ve been advocating for our profession and our College in Washington, D.C., at least once or twice a month since the annual meeting. That doesn’t include multiple phone calls trying to bring all the parties to the table internally around this issue, which we have struggled with as a profession. I think we’ve made some good progress. Having said that, I think we have to be realistic that the forces against us are pretty significant. But we’ll continue to fight for our right to take care of patients in the way we want to care for them, for our profession, and for our right to be fairly compensated. That’s really been the central focus so far in my presidency.
KK: I’m certain you had imagined “the day in the life” of your presidency. How has that changed for you?
VF: I think the biggest difference is that I didn’t anticipate the amount of time that would be required during this presidency for our lobbying efforts in D.C. Our D.C. office is doing a tremendous job, and I don’t intend to take anything away from their efforts. However, as president, I’m the spokesperson for our College, and I need to be there articulating things from the physician’s perspective that are best delivered by the president. I knew this would be a piece of what I did this year but didn’t realize it was going to be such a big piece. Like you said, the issues of the day really help define the presidency.
I’ll try to highlight some of the things that I would like to see the College do. One area that I would encourage the College to be engaged in is firearm injury prevention and firearm safety. I recently met with the American College of Surgeons (ACS) last month. They put together a meeting of 49 medical specialties and societies to discuss this issue. I really have to give the ACS kudos that they internally did a deep dive and were able to come to some consensus on the things they did agree on around firearm safety. That helped their leadership be more focused and more proactive. I want our College to do that as well. Are we going to agree 100 percent on everything? No. But instead of focusing on the issues that split us apart, I’d like us to be clear about the things that we do agree on so that we can advocate for those together. We can advocate better if we have a clear understanding of where our membership stands on the issues.
KK: How do you meet the needs of the membership on such a polarizing topic without disenfranchising a component of the membership?
VF: Well, you’re never going to meet everyone’s needs 100 percent of the time. That’s a fool’s errand. However, we can ask them where they stand on particular aspects of this issue and try to get a clear understanding of where the majority, hopefully the vast majority, does agree. That’s a reasonable place to start, which may be accomplished by doing a survey of our Council, the representative body of our College. [Editor’s note: At its April meeting, the ACEP Board of Directors voted to survey the Council for a representative viewpoint on firearm-associated research, safety, and policy.]
I don’t think anyone wants our patients to continue to suffer from firearm injuries. It’s just a question of what we see as reasonable solutions. Frankly, we know that there’s a paucity of research in this area. I think that there’s broad consensus that supporting research into firearm injury prevention is worth doing. That’s one example of a place where I believe there to be consensus.
KK: You’re so right. You can provide the greatest benefit, perhaps, by tackling some of the most challenging topics, so I’m glad you’ve taken it on. Moving to another topic, are there any successes that you’d like to share with the membership?
VF: Well, I can’t really take credit for it, but it happened on my watch. The conversations that we had with The Joint Commission about the ability to eat in the emergency department on your shift may be the thing that I’m most remembered for as president. That’s a huge success.
KK: Well, I personally will thank you and our staff for that one, Vidor.
VF: You’re very welcome, Kevin. I had little to do with it. But since I get to take all the credit for the things that go wrong, I might as well take a little credit for some of the stuff that goes well.
KK: That’s fair enough.
VF: I think we have continued to improve and deepen our collaborative efforts with other specialties and with the American Medical Association (AMA). I think that we have worked very diligently to position ourselves well within the AMA over the last decade. Our AMA delegation continues to grow and be very impactful.
Another area I feel strongly about is emergency physician well-being. Physician suicide is the endpoint of a predictable continuum. Depressed physicians have a difficult time accessing appropriate resources to deal with that depression. One of the things that I’m pushing us to do is to help our chapters advocate to state medical boards to refine their questionnaires for licensure. Similar efforts should be taken with the hospital credentialing procedures.
Many, if not most, processes ask, “Have you ever been treated for mental illness?” An affirmative response is often interpreted as a red flag for patient safety. Being treated for medical or mental illness is no one’s business unless it will prevent you from doing your job safely.
I’d like us to work with the AMA to expand the offerings that physicians have, improving access to resources when they’re in trouble. Burnout is a big issue in emergency medicine, with depression being a key component.
KK: What do you hope to accomplish with the remaining time you have, Vidor?
VF: I’ve been working with our staff to develop end-of-life care initiatives. There’s a tremendous need to decrease health care costs in this country, and we, as emergency physicians, have a better understanding of where some of that excess cost exists. Most people don’t have end-of-life care orders. This is partly because up until two years ago, physicians in the United States were not reimbursed for conducting advanced care planning discussions. That’s changing, but slowly. I think it would behoove us, and our membership, to accelerate the adoption of conducting those important conversations while patients are still in a position to do so. This is an area that I’d like to work on.
I also want to continue to work on physician wellness, not just around resiliency, but to work on the environmental causes that lead to burnout. I think our BalancED conference was a really good start, and I hope we’ll be able to continue that effort in the coming years.
KK: Those are all wonderful goals. If anyone can accomplish that much in the second half of a presidential term, it’s Vidor Friedman. Thanks for the time, Vidor, and thank you for your service and excellent leadership.
ACEP Now by Kenneth Alan Totz, Do, Jd, Facep - 3w ago
Illustration: Chris Whissen
The First Amendment to the U.S. Constitution states in totality, “Congress shall make no law respecting an establishment of religion, or prohibiting the free exercise thereof; or abridging the freedom of speech, or of the press; or the right of the people peaceably to assemble, and to petition the Government for a redress of grievances.” This freedom of speech, so often cited, is not absolute. For example, you cannot legally yell, “Fire!” in a crowded movie theater, intentionally publish untruthful facts about another person, or untruthfully advertise commercial products.
Recently, commercial speech has been the center of much debate in medical-legal circles.
The Food and Drug Administration (FDA) received its congressional power to regulate medicines and medical devices through the Federal Food, Drug, and Cosmetic Act (FFDCA) of 1938.1 Through this act, the FDA controls the commercialization of new medical products through a rigorous multistage approval process. The process not only allows entry of products into the stream of commerce but also determines the labeling of those products. Product labeling articulates the specifically approved uses supported by previously performed medical research, along with side effects and other precautions to be considered. Unapproved indications or off-label uses communicated in the product labeling will identify the product as being mislabeled or misbranded and subject the manufacturer to FDA scrutiny and penalties. Although the approval process may yield additional product benefits, only FDA-approved indications are permitted on the label.
The FDA recognized that significant costs and lengthy approval times precluded many manufacturers from pursuing additional useful indications for their medical products. As such, the FDA introduced the FDA Modernization Act (FDAMA) of 1997, which allowed manufacturers to disseminate literature and have discussions regarding off-label uses of its medical products. Unfortunately, any communications regarding off-label uses had to occur following the filing or imminent filing of a supplemental new drug application (sNDA).
Until recently, discussions of off-label uses between pharmaceutical representatives and medical professionals outside the scope of the FDAMA were considered criminal offenses. Dissemination of off-label medical product usages were limited to discussions at non-pharmaceutical-sponsored continuing medical education events, independent drug compendia resources, peer-reviewed journal articles, and other non-pharmaceutical manufacturer internet resources.
All this changed in 2017 when the Arizona legislature passed HB 2382, the Free Speech in Medicine Act. The law forbids punishment by any Arizona state agency of a pharmaceutical manufacturer, its representatives, or medical health professional for the “truthful promotion of an off-label use of a drug, biological product, or device.” Proponents of the bill touted the free speech protections of the First Amendment that should allow such open conversations and the ability to freely pass along any beneficial alternate uses of the medical products as foundational support for its adoption.2
Opponents of the law feared drug makers would use the off-label pathway as an easier route to widespread drug adoption without the rigorous oversight of the traditional multistage FDA approval process. Challengers to the law also opined that the pharmaceutical industry would be disincentivized to share adverse medical information regarding off-label uses, culminating in another Fen-Phen disaster.
In any event, the Arizona law received the attention of many other state legislatures that ultimately moved to pass their own versions of the Free Speech in Medicine Act. Missouri, Mississippi, Tennessee, and Colorado have recently proposed similar versions of the Arizona law, but only Tennessee’s version had become law at press time.
The federal courts have similarly ruled favorably for the pharmaceutical industry when it has been prosecuted under the off-label restrictions of the FFDCA. In United States v. Caronia,an appeals court overturned the lower district court’s conviction of a pharmaceutical representative who had discussed off-label usages of a previously FDA-approved narcolepsy drug, Xyrem. The court held, “The government cannot prosecute pharmaceutical manufacturers and their representatives under the FFDCA for speech promoting the lawful, off-label use of an FDA-approved drug.”3 The U.S. Court of Appeals for the Second Circuit further clarified that any false or misleading promotions would not be entitled to similar First Amendment protections.
In contrast to the defensive posture of the defendant in the Caronia case, Amarin Pharmaceuticals went on the offensive against the FDA in Amarin Pharma, Inc. v. United States FDA, after the FDA failed to approve one of its cholesterol medications for extended indications. The FDA insisted it would consider the drug misbranded should Amarin elect to share any of its favorable research data with physicians.4 In Amarin, the district court dealt another blow to the FDA by reaffirming its earlier findings in Caronia—that is, that First Amendment commercial speech protections apply to truthful and non-misleading speech.
So the next time your favorite drug rep comes calling, feel free to discuss off-label uses of their medical products. You may be quite surprised to learn some of your colleagues have found some novel and helpful uses for common medications and/or medical devices in your emergency department.
Note: No information within this report should be construed as medical or legal advice. Independent medical and/or legal advice should be sought based on each individual’s particular circumstances.
Dr. Totz is facility medical director at First Choice Emergency Room at Adeptus Health in Texas.
ACEP Now by Tyler W. Barrett, Md, Msci, Facep - 3w ago
Editor’s Note: Cutting through the red tape to make certain that you get paid for every dollar you earn has become more difficult than ever, particularly in our current climate of health care reform and ICD-10 transition. The ACEP Coding and Nomenclature Committee has partnered with ACEP Now to provide you with practical, impactful tips to help you navigate through this coding and reimbursement maze.
Question: What do I need to document to ensure appropriate reimbursement when a patient receives intravenous fluids?
Answer: Incredibly, some payers are down-coding or, worse, denying facility charge payment for ED evaluations that do not clearly document the medical necessity for intravenous fluid administration.1 Documentation of nausea, vomiting, or diarrhea alone may be insufficient to justify intravenous hydration.
To ensure appropriate reimbursement, emergency clinicians should include medical documentation supporting the need for intravenous hydration. The ED note should include the standard history, physical examination, and medical decision-making elements that support the need for intravenous hydration. Common examples include physical examination or diagnostic testing results indicating acute dehydration, abnormal fluid losses, unstable vital signs, or systemic inflammatory response syndrome criteria (ie, fever, dry mucous membranes, skin tenting, delayed capillary refill, tachypnea, hypotension, or tachycardia) or abnormal laboratory testing such as an elevated white blood cell count, blood urea nitrogen and/or creatinine, glucose, creatine phosphokinase, sodium, calcium, or lactate. Additional supporting documentation may include the patient’s inability to tolerate oral hydration, need for rapid intravascular volume expansion (ie, hypotension, sepsis, or shock), or treatment of other causes of abnormal fluids losses (eg, heat-related illness, thermal burns, or medication-related over-diuresis).
Dr. Barrett is associate professor of emergency medicine at Vanderbilt University Medical Center in Nashville, Tennessee.
One of the reasons I chose emergency medicine is because I love the spontaneity our specialty offers. No shift is exactly the same. Anything can happen at any given time. Unfortunately, that spontaneity can put you in situations that you might never expect.
I was working a shift in our rapid care area for low-acuity patients when I met a young man in his 20s who presented with the chief complaint of rash. His rash had started three days prior, and he had completed a course of amoxicillin for pharyngitis a week earlier. He denied fever, chills, recent travel, and exposure to known sick contacts. The rash started on his neck, spreading to his torso and extremities. He had no significant past medical or surgical history. He reported using amphetamines and cocaine recreationally. On exam, the patient was well-appearing. He had a diffuse erythematous palpable morbilliform rash involving his face, torso, and extremities, sparing his palms and soles.
His history and exam prompted me to think that he had a simple drug reaction secondary to the amoxicillin. Drug reaction with eosinophilia and systemic symptoms (DRESS) syndrome were also on my differential, but the patient was well appearing with no history concerning for systemic involvement. My initial gut reaction was to discharge him home with expectant management. Yet something about his story did not sit well with me.
I decided to consult dermatology to get recommendations on workup and management. After my consultation, their initial thought was that his presentation was likely due to a drug eruption. They recommended that I obtain a complete blood count, basic metabolic panel, liver function tests, HIV test, and urinalysis. Results were coming in, and my concern began to diminish. I was on the verge of printing his discharge paperwork when I got a call that changed everything.
“Doctor, your patient’s HIV test is positive,” said the lab tech over the phone. I was stunned; I assumed the test would be negative. An attending once told me to never order a study unless you have a plan for what to do with the result. That day, I did not have a plan for this HIV result. More specifically, I did not have an idea for how I was going to share the unexpected news with him.
I took the patient out of our crowded rapid care area to a private room. I sat him down in a chair and looked into his eyes and told him his HIV test was positive. The look on his face was something I will never forget. The moment after sharing the news felt like an eternity. I watched the stages of grief unfold before my eyes as the patient tried to wrap his mind around this diagnosis. I tried to console the patient and inform him that he could live a long life with proper HIV treatment. Yet I felt my words fell on deaf ears. The hardest part about medicine is being able to bear witness to suffering.
After spending some time trying to coordinate this patient’s follow-up, I walked back into the room to find it completely empty. He eloped. I can only imagine what was racing through his mind as he secretly walked out of the emergency department. I made frantic attempts to reach him by phone to no avail.
He left the emergency department with a result he was not expecting. I left the emergency department that day remembering to always expect the unexpected.
Q. How are finances different for emergency physicians compared to other specialties?
A. I am looking forward to seeing many of you this October at ACEP19, where I will be speaking about personal finance for the early-career emergency physician. As I reflected on this opportunity to engage with so many emergency physicians, l began to think about all of the financial advantages we enjoy compared to our colleagues in other specialties.
Like most of you, when I chose to pursue residency training in emergency medicine 17 years ago, I was motivated primarily by my interest in diagnosing and treating acute medical issues. I wanted to be there to help on the worst day of people’s lives and be one of the white knights of medicine who would take care of anyone, anywhere, anytime. It was a place where my “unique set of skills” (often derided as ADHD or a thirst for adrenaline) was an attribute, not a liability. The last thing I ever wanted was a job where I knew what I would be doing all day long before I ever pulled out of the driveway. Like most medical students, I didn’t pay nearly enough attention to the future income prospects and lifestyle associated with my specialty choice. Today, I would like to review six financial advantages emergency physicians enjoy.
1. Emergency physicians have one of the highest hourly rates in medicine. While emergency medicine generally shows up somewhere in the middle on salary surveys of the various medical specialties, what is not taken into account is the number of hours worked. While many specialists make more money than we do, they also work two or even three times as many hours to earn that money. On an hourly basis, our compensation is at or near the top of the list. This can be easily demonstrated by comparing surveys of hours worked among the various specialties to salary surveys. In the 2018 Medscape Physician Compensation Report, emergency medicine was ranked 13th of 29 specialties, with an average income of $350,000. However, if you look at hours worked for the 12 highest-paying specialties using a 2011 Journal of the American Medical Association study, you will see those specialists worked an average of 216 to 1,183 more hours per year than the average emergency physician. Emergency physicians generally earn a total compensation of more than $200 per hour and sometimes more than $300 per hour.
2. Most emergency medicine training programs are three years long. The length of training for most specialties is longer, sometimes much longer. If you consider the other specialties that train for only three years (ie, family practice, internal medicine, and pediatrics), all of them are paid less than emergency physicians, both on an hourly and an annual basis. In fact, a typical community emergency physician makes more than many specialists who trained for four to six years! This opportunity to begin earning an income earlier in our careers decreases the total size of our student loan burdens and allows our savings to begin compounding earlier. Our hourly rate per year of training is so much higher than all of the other specialties that it might even make up for all of those shifts when you don’t have time to eat, drink, or use the restroom.
3. Our pathway to our peak level of earnings is very rapid. In most careers, even within medicine, it can take decades to reach your peak earning potential. Not so in emergency medicine, where we usually reach peak earnings within two years of graduation from residency, even in a group with a sweat-equity buy-in. ln fact, due to a willingness to work more shifts and more undesirable shifts, young emergency physicians often make more than their older colleagues. Early peak earnings, especially when combined with financial literacy and discipline, help us to “take care of business” early on in our careers, paying off our student loans and mortgages and rapidly building a retirement nest egg.
4. More so than most specialties in the house of medicine, we are an interchangeable cog in the machine. While this has its downsides, such as the risk of small physician-owned groups being replaced by larger groups, the rare skill set of the competent board-certified, residency-trained emergency physician ensures the doc will only be without work for as long as it takes to get emergency credentialing (and perhaps a new state license). We have the ability to adjust very rapidly to a new department, even in the age of the electronic medical record. While no one job is all that secure, our ability to find a high-paying job somewhere is fairly certain.
5. One of the biggest downsides of emergency medicine is that it really isn’t a “lifestyle” specialty. Only about a quarter of our shifts are worked during banker’s hours. The rest are worked in the evening, at night, on weekends, and on holidays. However, this setup allows for a very unique opportunity; we have a lot of time off during regular business hours. While many emergency physicians use this time to recover for their next shift, take care of family responsibilities, engage in academic activities, and pursue hobbies (ski slopes, mountain bike trails, and lakes always seem deserted on weekday mornings), we also have the opportunity to engage in entrepreneurial pursuits. It is tough to start and run a business entirely on weekends and in the evenings, but it is relatively easy to do so during the day and then practice medicine in the evenings when most ED shifts are worked. Time off during the day also allows us to be able to competently care for our own investment portfolios and rental properties, saving thousands in advisory and management fees. By late career, many physicians are paying a month’s salary each year just for investment management simply because they do not have the time that we have.
6. The flexibility of shift work provides for numerous burnout-reducing measures to be taken. While emergency medicine is traditionally ranked high on the percentage of doctors with burnout symptoms, when the severity of an individual’s burnout is measured, we actually rank fairly low. In few other specialties is it as easy to cut back to three-quarter time or half-time to go on the “parenting track,” do medical missionary work, or take a sabbatical.
Some groups have found innovative ways to reduce the effect of burnout-inducing night shifts on the group. Hiring a couple of nocturnists (and paying them well) can dramatically reduce shift-work sleep disorder. Innovative groups come up with solutions to ensure nobody is working shifts they do not wish to work. In my group, we have a large shift differential between day, evening, and night shifts. We simply let “the market” decide what each shift is worth. For us, it turns out a night shift is worth about 50 percent more than a day shift. The younger docs with high student loan burdens and new mortgages often volunteer to work all or mostly nights, and the older docs with fewer financial worries tend to work the day and evening shifts. If more docs start wanting to work day (or night) shifts, we simply adjust the differential until everybody is working exactly the shifts they want and being paid accordingly. This common-sense solution boosts career satisfaction, increases longevity, and builds a collegial sense of teamwork in the group.
Emergency medicine has significant financial advantages over other specialties. Take advantage in order to improve your career and financial situation.
Scenic view of the city market in Erbil. Left to right: Dr. Greg Jacobs; John Miller; and Dr. Balentine. Credit: Bryan Balentine
Of your top 10 international travel destinations, where does Kurdistan rank? It wasn’t initially on my list at all. After all, who would want to spend their own money to travel to a war-torn country with Islamic extremists just waiting to harm someone from the United States? At least that is what I surmised after following years of international news. Trying to understand the complexity of the Islamic State of Iraq and Syria (ISIS), Syria, Syrian rebels, Turkey, Russia, and the United States, all with their own agendas fighting in a very concentrated area of the world, is a challenge when only familiar with the U.S. perspective.
In the middle of all this enter John Miller and One Vision International. Even while the war was active against ISIS in northern Iraq, he would travel, usually alone, and coordinate humanitarian-aid shipments of water filters, coats for the cold winters, shoes, children’s clothes, wheelchairs, and crutches to help everyone displaced from the war. Through these experiences, he witnessed the need for a medical mission trip.
I traveled with John and One Vision International multiple times to Haiti and the Dominican Republic. On some of these trips, one of my best friends from residency, Greg Jacobs, DO, came along. When John approached me about a trip to Kurdistan in northern Iraq, I said no multiple times for the reasons listed above. After each of his trips, he would provide me with an update, and I learned more and more about the kind and welcoming people there who were in need. After multiple invitations and a retreating ISIS, I finally said yes in mid-2018, and we started planning. One conversation later, Greg was on board.
Dr. Balentine teaching peripheral IV access with ultrasound to attendings and residents. Credit: Bryan Balentine
Day 1: We visited a military base and treated 100 soldiers for various medical problems. Several of these individuals had fought against ISIS in the recent past. They were extremely kind and appreciative of our time and efforts. We joined them in the “mess hall” and ate good-quality food, better than expected, on the typical metal tray often seen on television.
Day 2: John mentioned beforehand that his local hospital had requested Greg and I provide a lecture for their physicians. We would be speaking to their EM residents and attendings, with the goal of decreasing complications of central line placement by teaching them how to perform the procedure with ultrasound. The lecture also included peripheral IV placement with ultrasound to allow them to more successfully place peripheral IVs on patients with difficult anatomy.
In my limited experience, most international hospitals have ultrasound in the facility, but ED-provider utilization varies. Dr. Ben Smith from the University of Tennessee at Chattanooga graciously loaned me an excellent vascular access lecture. Greg and I tag-teamed the delivery and it was well-received.
Dr. Greg Jacobs teaching the FAST exam. Credit: Bryan Balentine
We met the emergency department director, Dr. Dilshad Al-Sheikh, who gave us a hospital tour, including the emergency department seeing 700 patients a day. We were pleasantly greeted by several staff physicians and learned of their EM residency training program. I was amazed at how they functioned with limited resources. CT scanner? Broken. A new GE machine had been donated but was still in several boxes upstairs. (I recently learned that a GE representative was scheduled to visit soon to install the scanner.)
Day 3: We returned to the same facility and conducted a hands-on ultrasound workshop. They had two donated high-quality portable machines that were almost right out of the box. Greg taught them the focused assessment with sonography in trauma (FAST) exam, and I focused on vascular access. It was so rewarding watching the faces of the residents and attendings light up as they quickly learned their new skills.
Later that evening, we were invited into the home of a lady John affectionately called “Mom” who fed us an amazing meal that had taken 10 hours to prepare. During our conversation, we discussed the recent war and learned of the many atrocities committed by ISIS in her country. As one resident recounted: “ISIS came in quickly to Sinjar region where a high concentration of Yazidis are located. They killed the men and took the women and children for use as sex slaves. Over 3,000 women are still missing. Some of the women who have escaped or have been “bought” back tell stories of multiple rapes and of being sold to many different men. They took them to Syria and other places as trophies. Those that could fled to Sinjar mountain, where many died of heat, thirst, and lack of food. Many women who could not escape committed suicide.” Our host relayed that Christians and Muslims had lived as neighbors for hundreds of years in Kurdistan. This obviously opened my eyes.
The trauma hospital in which Dr. Balentine worked with the ED attendings and residents. Credit: Bryan Balentine
Day 4: John connected with a local community leader coordinating an effort to rebuild several villages damaged by the recent war. The hour-and-a-half drive took us past other destroyed villages and minefields behind the previous battle lines. The emotional weight was undeniable. I wasn’t reading about this anymore—I was there, where the recent fighting had occurred.
After we arrived and treated another 100 patients, providing primary care services mostly for hypertension and diabetes, the local village invited us to share another amazing meal in traditional style, seated on the floor.
Day 5: Another community leader invited us to speak at their local community center about first aid. Where do you start with such a broad topic to the general public in Kurdistan? We decided to go with a Q&A session.
The first question: “What do I do when I come upon an auto accident, the driver is unconscious, and the car is on fire?” Greg and I responded with what anyone here would state. “Call 911,” only to learn their EMS response time is one hour.
Next question: “My friend and I are walking, and he accidentally steps on a mine which blows off part of his leg. What do I do?”
After several similar questions, we quickly realized that these were not hypothetical situations, but real scenarios they occasionally faced. Greg and I offered basic maneuvers and temporizing measures until the patient is transported to a medical facility.
Several rounds of appreciation followed our Q and A. Two local governmental leaders arrived and formally handed us each an award, which read, “Thank you for visiting Kurdistan—your second country.”
Members of the community center then performed and sang traditional songs for us, which included a traditional circle dance. I had a great time recording Greg as he was pulled to the front to join in. The video ended when they pulled me into the circle. Thankfully, they were gracious and only provided us with an abbreviated example of a dance that traditionally could go on for hours. I left the event drenched and ready for bed.
Day 6: John arranged for us to see the huge, sprawling indoor market and arguably the oldest continually inhabited city in the world. Another local family invited us to lunch after another hours-on-end meal prep. We felt like royalty.
So, what did I learn? Before my first medical mission trip in college, I had grand aspirations of how those people were going to benefit from my assistance as a premed student. Conversely, I returned home and began to unpack the truckload of emotions in how they positively impacted me.
Several trips and years later, I blazed another personal trail into a war-torn country as a boarded emergency physician. Despite possessing additional medical knowledge, I braced myself for the potential impact that they would have on me. Hundreds of patients, residents, teas, amazing meals, group photos, hugs, and a few tears later, I processed the emotional onion of this wonderful experience one layer at a time.
I went from watching my back to being treated like family and, occasionally, a celebrity. Love, kindness, and appreciation were freely given from a country and people I had not previously known. What started as a once-in-a-lifetime trip is now hopefully an annual experience. Thank you, Kurdistan, for opening my eyes to a larger, more complete worldview. I cannot wait to see you again!
Dr. Balentine is assistant system medical director of emergency/hospitalist medicine at St. Vincent’s Health System and facility medical director of emergency medicine at St. Vincent’s Blount in Oneonta, Alabama, and St. Clair in Pell City, Alabama.