International EM Resident Rotation: Columbia

For the months of February and March of 2017, Dr. Ellie Wallace (PGY3) and Dr. Konrad Karasek (PGY2) both travelled to the beautiful country of Colombia to work in the two Emergency Departments at local hospitals and experienced the incredible culture first-hand. Ellie traveled to Medellin, and rotated in Hospital Pablo Tobon Uribe (HPTU), a Level 1 Trauma Center, where she worked with one of the most prominent residency programs in Colombia. Konrad worked in Cali under the guidance of Dr. Virginia Zarama, at the Fundación Valle del Lilli (FVDL), ranked as one of the best hospitals in all of South America and is home to the newest residency program in the country.

Emergency Medicine is still a relatively new field in Colombia. There are only six Emergency Medicine residency training programs in the entire country, all of varying sizes and structures. While Ellie worked with a variety of resident and attending physicians in a large academic setting, Konrad worked with a smaller team, primarily working alongside one resident and a few medical interns. While Hospital Pablo Tobon Uribe was similar in size to residency programs you may see in the United States, Fundación Valle del Lilli is in its nascence, with its first cohort of only two residents. For this reason, at FVDL in Cali the EP’s greatest role is as a resuscitationist, treating the sickest of the sick. In contrast, cases seen in Medellin are of more variable acuities.

As foreign rotators, both Ellie and Konrad spent the majority of the time in the resuscitation bay – observing, helping, and learning from the sick medical and trauma patients that came into both hospitals on a daily basis. Patients at FVDL ranged from scooter accidents, gunshot victims, MVCs, strokes, and MIs. Patients at HPTU presented with fewer traumas, but were equally sick, with new onset heart failure, intracranial hemorrhage, patients requiring emergent dialysis, and cancer patients being transferred from other surrounding facilities.

Both were impressed by the capabilities at each hospital. The Trauma team at FVDL functioned in much the same way as the trauma teams of BMC, with the whole resuscitation team assembling every time a new patient presented. The hospital was equipped well enough to treat both medical and trauma patients just like any large U.S. academic center, and even had some capabilities that BMC doesn‘t have (e.g. ECMO!). As a private hospital serving mostly middle and upper middle-class patients, HPTU was similarly well equipped, in some ways with more resources than BMC, able to obtain rapid MRIs on every possible stroke patient. Yet they were also efficient and thoughtful regarding resource utilization, and all worked hard to make everything count. They reuse anything they can, including trauma dressings and isolation gowns that are usually disposable in the United States. By doing so, they are able to access advanced imaging and specialist consultations on more patients with less concern for cost to the system.

The educational programs at both sites was impressive. They utilize evidence-based medicine in treatment decision making, and manage patients conservatively with frequent testing and admissions. Ultrasound has also become much more prevalent in Colombia in the past 5-10 years. It is utilized in most resuscitations and on sicker patients. Academic teaching and presentations are highly valued, with frequent conferences and lectures. Both Ellie and Konrad learned just as much as they were able to teach. Patients were always treated thoughtfully, carefully, and with great respect.

Travel to a foreign country and working in a second language can be intimidating, but also exciting. On arrival, both visiting doctors began their rotations as observers, and as a result of the warm and welcoming host physicians both were able to integrate as members of the team. Educational exchange about the Colombian medical system was shared with the visitors while they shared their ultrasound knowledge and skills on patients with diagnostic uncertainty with the Colombian doctors. The personal relationships, cultural exchanges, and language immersion were the most rewarding aspects of the elective for both Ellie and Konrad. The true value of global health can be found in discussions of the strengths and limitations of a health care system different from our own, in thoughtful discussions with providers in other countries, and finding common ground in different environments. Through further rotations and global health experiences, there is hope to be able to bridge more boundaries and to truly discover how similar we all are.

Ellie Wallace and Konrad Karasek