One concept that will likely run through this conference is the concept of Ubuntu. A person with Ubuntu is welcoming, hospitable, warm and generous, willing to share. Such people are open and available to others, willing to be vulnerable, affirming of others, do not feel threatened that others are able and good, for they have a proper self-assurance that comes from knowing that they belong in a greater whole – Desmond Tutu
The Rwandan Minister of Health Dr Diane Gashumba @DianeGashumba welcomed & opened the conference and spoke about breaking the barriers in emergency medicine & discussing concrete solutions to huge barriers to emergency care. It is fantastic to see the minister of health has such a great understanding of the importance of emergency care. Emergency Care forms part of multiple Rwandan policies as a priority area for development 2050. It is fantastic to see that the minister of health is a paediatrician, so she truly understands how critical emergency care is for the healthcare system and is reflected in her stressing the importance of healthcare worker wellbeing.
Introductions were also made by Gabin Mbanjumucyo, to the first group of Rwandan Emergency Physicians to qualify: Bernard Nsengiyumva, Chantal Uwamohoro, Ernest Nahayo, Oliver Felix Umihire and Ezechiel Nteziryayo.
Book: “Oxford AFEM Handbook of Acute and Emergency Care”
The new and exciting 2nd edition of this incredibly helpful handbook was launched at the event by the editors Prof Lee Wallis, Dr Keegan Checkett and Prof Teri Reynolds. The first edition was published in 2013 and was disseminated into the hands of frontline workers across Africa. The book was available to be bought at the conference and hopefully will be available to be bought online soon, keep an eye out for it on www.afem.info They are also looking for sponsors to help get more copies of the 2018 version printed and distributed.
Book/Resource/Training Course: “Basic Emergency Care: Approach to the acutely ill and injured”
Book/Resource/Training Course: “Emergency Unit management in low-resource settings”
A new WHO Training Course that is KEY in low resource settings was also launched. In Africa when an EM Physician or EM Nurse qualifies we suddenly have to step in and start or run a unit, often alone! We just aren’t trained for that. The entire course will become freely available soon as a #FOAMed resource. The slide–set, facilitator guide and student guide will become open access, as soon as peer review processes and refinement are complete(manyattendees of the conference are also involved in this process, African Solutions to African problems!) It helps that this resource is being published by the WHO because the credibility of the name can be used to advocate to your political decision-makers in ministries/departments of health.
Defining and building EM – using a moving target: James Ducharme (Canada & President of IFEM)
James is the current president of IFEM. He led with the comment,“EM is the poorest defined speciality ever developed”. Why did EM start?EM filled a gap – a lack of organised trauma systems(US and Canada). But gaps are different in Africa – therefore the definition of EM varies: a shifting scale of definition.
Training programmes do not teach residents/prepare them for what they actually are going to do: social issues, geriatrics, chronic pain, drug seeking, centre of last resort. Building blocks for EM systems are different in each country/setting – depending on the specific needs of the community and availability of resources. The basic building blocks are similar though. External experts are unable to define building blocks required.
We should constantly state what we will NOT provide; we often advocate for all patients in the EC(including those not requiring emergency care), leading to us failing those who actually require EC. We have adopted maladaptive behaviours(because of failures in other systems) to the detriment of our patients. We should define emergency care in our setting and be the advocate for patients requiring emergency care. We have become the safety net for the health system. Instead, we have to ask our health care managers,“What are YOU doing about these non-emergency issues?”
Who we are, where we are going: The identity (r)evolution of emergency care in Africa – Dr Heike Geduld @heikegeduld (South Africa President of AFEM)
The current fearless leader of AFEM, who will be, after this conference, handing over the reigns to Dr Ben Wachira from Kenya.[Personal note from Kat: Heike is one of my biggest role-models & I hope that one day I am 5% of what a phenomenally wise & inspiring person that she is].
So how/where did AFEM start? In 2009 AFEM started as a lunch-break meeting at another conference and the agenda/programme of the meeting was only the words“African Emergency Care.” Look how far they have come!
So what is AFEM? Heike mentions how it doesn’t feel like a society;“we don’t really know what it is.” Then how is it doing so much?“We are the sum of thousands of interconnected stories of EC across Africa, we are a community, the spirit of Ubuntu, a network of people constantly evolving organically in response to the needs of the community.
‘Servant Leadership’: which I love: it values diverse opinions, cultivates a culture of trust, develops leadership in others, encourages and, thinks about others.
‘Agency’: Is our capacity to act independently and make our own choices. We need to claim our identity as African emergency care providers to increase our sense of agency.
‘Revolution’: In thinking about what AFEM is and does and what African Emergency Care wants to achieve, we need to think about what we CANNOT do. There are 40 countries in this room, the majority are clinicians, and our view of health is limited by our fairly clinical viewpoint. If we want to make bigger change, on a bigger level, we need to open our minds to broader viewpoints. Think about emergency care system development in conjunction with social welfare experts, politicians, engineers, epidemiologists, patients and multiple spheres of knowledge. How do we bring these other people in? We cannot do this alone, we need to pull in stories of emergency care from non-emergency care people.
Unpacking the essential elements of emergency nursing in Africa: Petra Brysiewicz (South Africa) @petrabrysiewicz
Petra Brysiewicz is a professor in the School of Nursing & Public Health, University of KwaZulu-Natal, Durban, South Africa. She has worked with research and education of health professionals in South Africa and Africa for 20 years, predominately in the area of acute/emergency care.
Successful emergency nursing programmes rely on six essential elements.
Recognise nurses impact:
Nurses are well positioned for theemergency centre(biggest group of health professionals). They are incredibly trusted by communities; nurse practitioners are well trusted by patients. Evidence suggests that nurse practitioners outscore other health providers with regards to quality of care and patient satisfaction. Trauma nurse practitioners – evidence that they decrease LOS, patient satisfaction, and complications.
Essential knowledge and skills:
Great strides were made with regards to nursing education challenges and solutions in Sub– Saharan Africa however, strategic leadership and mentors are required.
Self–assessment survey of nurses in Kwazulu Natal: only 52% competent to perform CPR, 64% to assess GCS,42% to administer drugs in cardiac arrest.
Outdated and static curriculum and a mismatch between needs and curricula becoming a barrier to effective education.
New type of learners – with different needs and strengths – Curricula should be dynamic and adaptive.
Research and Scholarship:
Researchophobia – research need to be demystified.
PHD vs doctor of nursing practice(practice scholar vs research scholar) – new PhD in practice, instead of research – great for nursing leaders in Africa.
Qualitative research undervalued: evidence that inform recommendations.
Career pathing and role models
Blue skies thinking – no limits(old ways don’t open new doors)
Make nurses visible:
Nurses“operate under the radar”– they are trained to be silent; The public and media unaware of the importance of nursing; traditional subservience still common; The media ignores nurses – don’t really understands what nurses do – a good example is the Thailand Cave Rescue – very little emphasis on the nurse that was part of the team.
These 6 elements play an important role in a successful nursing programme.
Medical education during the digital era – Prof Stephen Rulisa (Rwanda)
Things have changed & suddenly educators were caught unaware! The world of IT is changing faster than the teachers’ ability to change. As educators we need to catch up to ensure to try and keep up with the learners! Get your material onto facebook! The students can be found“inside of the book of faces more than the books of the university!“
Interesting move at Prof Rulisa’s university: Teachers who are not uploading their teaching onto the university IT sharing platform lose points on their performance reviews! Forcing“old school” educators to catch up with the times!
Teaching procedures in EM: 7 steps to success: Mindi Guptill
Traditionally in medical school we all have heard“see one, do one, teach one”. This was the mantra that was used but this mantra breaks down in emergency medicine. Mindi discussed a 7 step process for procedural teaching.
Conceptualisation(at home) – preparation to learn the procedure, indications, contraindications, patient counselling. We can do this but simply getting the student to read something, eg procedure textbook or FOAM resource such as LITFL
Visualisation(at home) – view the procedure in its entirety eg video
Verbalisation – instructor should talk-through entire procedure step by step, learner to narrate it back, this cements the correct sequence
Guided Practice – in a step-wise fashion, from sub-component practice to linkage practice. Do microskills, break up the procedures into smaller parts and teach components separately. Some microskills can be practiced at home!
Feedback – to facilitate perfect practice, do not let them do it wrong, stop them so they don’t get motor-imprinting of incorrect practice. Can also consider video for feedback.
Skill Mastery – repeat practice regularly, spaced repetition
Autonomy – do on real patient!
Simulation Education: Simple solutions for effective education: Dustin Smith
Three key messages:
skills acquired from simulation can be transferred to real patients
simulations do not have to be expensive to be effective
commitment from learners and a safe environment
Dunning-Kruger Effect: Students in the lower quadrant of performance often have a perception that they know a lot more than they do. Difficult to reset their goals.
Ebbinghaus Forgetting Curve: lose 40% in 20 minutes
Spaced Repetition – repeating training of a skill over time – better retention with every repeat.
NERDS approach to teach simulation
Nickel down – investment ensures engagement –“why do you think the baby passed out?”
Evidence –“what do you think the literature suggest around…”
Rules – lay down rules at the begging
Do – guided practice of skill
Stop – as soon as a mistake is made – and correct immediately
Feel safe to make mistakes: students need to feel safe and comfortable to make mistakes and learn. Introduction to session should include a discussion around this.
Psychological fidelity vs engineering fidelity (how well does this mannikin look like the real deal) High fidelity simulation not always better.
Breaking barriers in #MedEd: Better educator… better clinician: Janis Tupesis
Janis brought some insights on the changing paradigm in how we share information. We don’t need to remember Ransons Criteira anymore, we can ask Siri!Everyone is collating/crowdsourcing information.. governments, university. Allows you to connect to your peers and share what you are doing in real-time.
Shared social networks that focus on emergency care in Africa – clinical care, education, leadership & development
Shared online educational resources that are specific to emergency care in Africa
The use of tech to further develop implement locally applicable educational materials, clinical guidelines &research programs.
Postgraduate EM teaching in Botswana: Megan Cox
Megan is previous head of department in Botswana and led the programme that recently graduated 3 EM Physicians: They are all close to my[Kat] heart in Cape Town as they completed some of their specialist rotations in our programme. Botho, Sebakeng & Kago are fantastic EM Physicians and we are super proud of them! Megan worked for 4-6 years as the only specialist EM Physician in the country!
Lesson 1: EM education needs an EM culture: Needs an appropriate workplace, space, equipment, triage, guidelines, clinical EM educators, students need to see EM in action
Lesson 2:Everyone needs EM education. Megan spoke about the 3min“elevatorpitch” about EM that she gave to minister of health when she became ill and presented to the Emergency Centre!Clarify to everyone the EM role & expertise. Get EM education, introductions for all the hospital, engage prehospital providers, nursing and medical students(final year best to allow collation of knowledge from other departments)
Lesson 3: Don’t assume EM knowledge, start with basics but also don’t reinvent wheel! Don’t try create all your own guidelines from scratch! Other guidelines you can use www.emergencymedicinekenya.org / www.afem.africa/resources / EM Guidance www.emct.info/em-guidance.html/ FAME/FOAM / new WHO coursementioned above / AFEM handbook
Lesson 4: EM education is a team sport
Collaborative training – Involve other departments when you are the only EMP in country. Don’t try to do it all yourself!
Vary the modality of educational interventions: lectures case presentations, quizzes esp ECG, radiology, use PBL, praatical sessions, trial exams, watch videos, journal club(AFJE), sims, M&M meetings
Be careful of well-meaning international speakers who don’t understand the healthcare context. Need to guide & direct the content & discussionsregarding suitability of management, equipment knowledge, cultural appropriateness. Teaching on completely unobtainable interventions can make students despondent.
Lesson 5: EM Research is challenging(and you need lots of help!) [ Kat: new residency programmes can consider engaging www.authoraid.info ]
Lesson 6: The“soft skills” can be much more like“hard skills” in the African context. When a new EM Physician qualifies they are likely to be a head of department. Leadership, management of complaints, conflict resolutions, medical professionalism and recognition of diagnostic biases are critical.[Kat: The WHO course mentioned in the first talk will hopefully be a great resource for this]
No more snores from the back of the Room: Transform your classroom teaching for better student retention and attention: Amelia Pousson (USA)
Fascinating talk FULL of pearls of wisdom. Great framework adapted from learningscientists.org. Incredibly simplified take-home points below.
Find the love –Earn attention from the classroom with our own enthusiasm and motivation. It cost nothing to be enthusiastic. There are two types of learners: fixed mindset vs growth mindset.
Interleaving – Switch between ideas while teaching, we cant really focus beyond 15mins. Go back over the ideas again in different orders to strengthen your understanding
Concrete examples: Use specific examples to understand abstract ideas
If you know that a particular case/medical problem is hard to manage or badly managed: ask students to“collect” those cases & bring them to class. In business they use Harvard Business Review, some options in EM to use are JETemhttp://jetem.org/& CPChttps://westjem.com/cpc_em
Elaboration: Explain & describe ideas with many details