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 Table of Contents  
ORIGINAL RESEARCH ARTICLE
Year : 2017  |  Volume : 30  |  Issue : 3  |  Page : 203-210

Developing and implementing a global emergency medicine course: Lessons learned from Rwanda


1 George Washington University, School of Medicine, Washington, DC, USA
2 Emergency Department, Centre Hospitalier Universitaire de Kigali, University of , Kigali, Rwanda

Date of Web Publication18-Apr-2018

Correspondence Address:
Giles N Cattermole
Emergency Department, Princess Royal University Hospital, Orpington BR6 6EL
Rwanda
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/efh.EfH_72_17

  Abstract 

Background: There is a growing demand by medical trainees for meaningful, short-term global emergency medicine (EM) experiences. EM programs in high-income countries (HICs) have forged opportunities for their trainees to access this experience in low-and middle-income countries (LMICs). However, few programs in LMICs have created and managed such courses. As more LMICs establish EM programs, these settings are ideal for developing courses beneficial for all participants. We describe our experience of creating and implementing a short-term global EM course in Rwanda. Objectives: The objectives of this study were to (1) provide EM trainees from HICs with an opportunity to observe global clinical practice and to learn from local experts, (2) provide EM trainees from an LMIC with an opportunity to share their expert knowledge and skills with HIC trainees, (3) create a sustainable model for a short-term global EM course in an LMIC context. Methods: A global EM curriculum and course were developed in Rwanda, entitled EM in the Tropics Emergency Medicine in the Tropics (EMIT). The following topics were covered: EM systems development, public health, trauma/triage, pediatrics, disaster management, and tropical EM. A one-and two-week course program was created and implemented. Results: EMIT participants rotated through pediatric and adult EDs, Intensive Care Unit, trauma surgery, internal medicine, emergency medical services, and ultrasound training. Activities included bedside teaching, case presentations, ultrasound practice, group lectures, simulation and skills workshops, and a rotation to a district hospital. A total of 11 participants attended: six for both weeks and five for 1 week. The course raised $5000 USD, which was dedicated in full to sponsoring local EM residents to attend international conferences. Discussion: The EMIT course in Rwanda achieved its objectives of teaching and learning between all participants. Benefits of this in-person experience for both visiting and local participants are clear in clinical, intercultural, and professional ways. Conclusion: Our experience of developing and implementing EMIT in Rwanda demonstrates that EM programs in LMICs can provide short-term global EM courses that are not only beneficial to all participants, but also logistically and financially sustainable.

Keywords: Eastern Africa, emergency medicine, global health, medical education, Rwanda


How to cite this article:
Yi S, Umuhire OF, Uwamahoro D, Guptill M, Cattermole GN. Developing and implementing a global emergency medicine course: Lessons learned from Rwanda. Educ Health 2017;30:203-10

How to cite this URL:
Yi S, Umuhire OF, Uwamahoro D, Guptill M, Cattermole GN. Developing and implementing a global emergency medicine course: Lessons learned from Rwanda. Educ Health [serial online] 2017 [cited 2019 Jan 19];30:203-10. Available from: http://www.educationforhealth.net/text.asp?2017/30/3/203/229515


  Background Top


There has been a surge in the number of global emergency medicine (EM) electives, clinical training, and research opportunities for medical resident trainees.[1],[2],[3] Recent literature also documents advancements in EM in a broad range of low-and middle-income countries (LMICs), where many formal EM residency programs have been started.[4] Global EM electives and fellowships provide opportunities for medical residents from high-income countries (HICs) to engage with the international community during that dedicated training period. However, short-term, contextually appropriate global EM learning experiences for medical trainees are still limited. To date, there is no global EM course that has been developed and implemented by individuals in an LMIC, based on our knowledge, literature search, and query of professional EM societies. While some LMIC programs have organized EM conferences or hosted participants in a course controlled by universities from HICs, no EM course has been created by LMICs themselves. Many factors, such as time diverted from formal training or employment, lack of program sustainability, or lack of funding to travel or host trainees, present barriers to establishing and participating in global EM courses.

There are many potential benefits for both visiting and local participants in global EM courses. In-person exchanges facilitate positive teaching and learning opportunities for both groups. While a short global EM course cannot be as extensive as a fellowship program, it can provide a glimpse into the broad categories and realities that those training programs would explore. Perhaps most importantly, it is possible for LMIC programs to create a financially sustainable model for hosting these courses, as visitors from HICs are often able to pay for learning experiences abroad. The proceeds from the course can in turn serve as scholarships for the local trainees to attend international conferences and other opportunities that would otherwise be financially prohibitive. This financial advantage for programs in LMICs deserves emphasis, as the benefits for investing in implementing a global EM course are not only culturally and educationally enriching, but also innovatively re-investing in local trainees. Thus, there is potential for EM programs in LMICs to structure a financially sustainable global EM course and facilitate meaningful, short-term learning experiences.

One similar program has been identified with the proposed curricular and programmatic model: Tropical Medicine in Practice (TMIP) course, based in Blantyre, Malawi.[5] It offers experiences in hospital wards and admission facilities, seminars and lectures held by local experts, and academic exposure to journal clubs and teaching sessions. Based at Queen Elizabeth Central Hospital, the course is offered for 2 and 4 weeks (£550 and £900 GBP, respectively), and reports having capacity to host 16 participants yearly. However, this course focuses on tropical medicine and not on EM. Inspired by TMIP, we developed and implemented a similar global EM course in Rwanda: Emergency Medicine in the Tropics (EMIT).

Aims

The aims of this study were:

  1. To provide EM trainees from HICs with an opportunity to observe global clinical settings (emergency care in an LMIC) and to learn from local experts on EM, trauma, and critical care
  2. To provide EM trainees from an LMIC with an opportunity to share their expert knowledge and skills with HIC trainees
  3. To create a sustainable model for a short-term global EM course in an LMIC context.



  Methods Top


Emergency Medicine in the Tropics course setting

Rwanda is a landlocked, densely populated country in East Africa, with over 67% of the population aged less than 20 years.[6] The capital is Kigali, which hosts nearly one million people, or approximately 10% of the nation's total population of 10.1 million. The Rwandan health system was devastated after the genocide of 1994. Tremendous progress has been achieved since, however the health sector is still in significant need of resources: physicians and other health practitioners, as well as equipment and greater health infrastructures.[7]

The CHUK is Rwanda's tertiary referral hospital and the University of Rwanda's clinical teaching hospital. CHUK serves as the trauma center to most of the Kigali population and as referral hospital to 2/3rd of the 44 district hospitals nationwide. Many emergency patients are transferred to the emergency department (ED) from district hospitals when they are unable to receive the necessary and appropriate care. Patients can also be brought to the ED at CHUK directly by Service d'Aide Médicale Urgente, which is the national emergency medical sciences (EMS). Blunt major trauma patients form a significant proportion of the case-mix, together with critically-ill medical patients (e.g., sepsis, malaria, diabetic ketoacidosis, hypertension/stroke, tuberculosis [TB], and HIV).[8],[9]

In the ED, the resuscitation room also functions as an Intensive Care Unit (ICU), with capacity to provide for up to four ventilated patients. Patients often remain in the ED for a few days pending admission, and there are usually 30–40 patients in the department. The department has two ultrasound machines. Focused Assessment with Sonography in Trauma (FAST), Focused Assessment with Sonography for HIV-associated TB (FASH), Rapid Ultrasound for Shock and Hypotension (RUSH), deep vein thrombosis, and lung and cardiac scans are routine procedures in the ED. The hospital offers imaging services including X-rays and computed tomography (CT) scans. Specialized consults are available, including acute care surgery, neurosurgery, orthopedics, and internal medicine.

Rwanda currently has 19 EM residents, in years 1–3 of a 4-year training program. They rotate through different hospitals and other acute specialties, and each month, there are about 10 attached to the ED in CHUK. There are four full-time foreign faculties practicing and teaching in Rwanda as part of the Human Resources for Health (HRH), which is a 7-year national program intended to build the education infrastructure and workforce to create a high-quality health-care system in Rwanda. However, the presence of foreign faculty at CHUK is not unique in that many teaching or tertiary hospitals in LMICs already have partnership with foreign universities, nongovernmental organizations, or charities that provide foreign physicians for varying periods of time.

Emergency Medicine in the Tropics course objectives

  1. To teach about opportunities and challenges specific to a LMIC context through didactic lecture series from residents and faculty with local expertise
  2. To provide clinical exposure to emergency care in an LMIC through ward rounds, bedside teaching, and dedicated clinical shadowing time.


Emergency Medicine in the Tropics curriculum development

The EMIT curriculum design first identified the two course objectives to guide participants' learning experience. Curriculum development was consistent with global EM fellowship programs in the United States.[4],[10],[11] Sample syllabi from these global EM programs (examples of curricular components in [Appendix 1]) were adapted to what could be meaningfully and appropriately offered in our context and given the short time frame. Through months-long series of discussions between local faculty and staff in the EM and consulting departments, the EMIT curriculum was developed to cover the following key topic areas (sample lecture topic examples are included in [Appendix 2]):

  1. EMS/pre-hospital systems' teaching and development:


    1. The purpose of lectures on Rwanda's EM and EMS program was to demonstrate how this system has developed in response to the culture, historical context, and health-care structures. Simply transplanting a US-type EM system ignores the medical culture and care delivery approach in Rwanda and would likely not succeed.


  2. Trauma and triage (including injury prevention):


    1. Various trauma, triage, and critical care protocols have been adapted to LMICs. Both the Primary Trauma Care PTC course [12] and BASIC Developing Healthcare Systems (DHS) (Basic Assessment and Support in Intensive Care-DHS) BASIC- DHS course [13] consist of lectures, skill stations, and workshops that teach nonspecialists a systematic approach to managing severely injured patients.[14] The EMIT course provided a day of PTC training and introduced BASIC DHS training.


  3. International public health:


    1. Basic public health concepts are important to practicing in international health, health policy, and administration. Through group discussions, participants learned population-based emergency care challenges, developed strategies for international health systems' interventions, and recognized the value of assessing needs and measuring the impact of interventions.


  4. Disaster response and preparedness:


    1. A half-day simulation titled, “Dealing with Uncertainty: An Interactive Humanitarian Relief Scenario,” covered challenges and strategies for humanitarian emergencies. Disaster management principles and techniques necessary for assuming a leadership role were introduced for effective medical response to disasters. The history and role of humanitarian aid were also covered briefly to contextualize the simulation challenges.


  5. EM in the tropics


    1. The course also covered specific clinical areas such as sepsis, USCOM, and hemodynamics, as management may differ in contexts with variable resources. Ward rounds and bedside teaching activities were conducive to introducing, reviewing, and practicing these context-appropriate concepts. Examples of journal club discussions provided based on applicability to the CHUK clinical setting include: CRASH-2,[15] CT rules in Traumatic Brain Injury,[16] CT before Lumbar Puncture,[17] and the FEAST trial.[18]


  6. Point-of-care ultrasound


    1. In this resource-limited setting, ultrasound has evolved from necessary to indispensable. EMIT was rich in lectures and hands-on ultrasound and its multiple applications in EM and critical care: e-FAST, ultrasound-guided procedures, RUSH, FASH, etc.


  7. Pediatrics:


    1. Pediatric emergency care was included in EMIT, especially in relation to the Emergency Triage Assessment and Treatment (ETAT+) course.[19]


  8. Touristic and social opportunities


    1. To learn more about Rwanda's history, visiting participants also visited memorial sites of the 1994 Genocide in Rwanda: Nyamata Genocide Memorial Centre and Kigali Genocide Memorial. Rwandan residents guided EMIT participants through the memorial sites and shared their personal experiences
    2. Various events and dinners were also organized to provide an informal environment to gather all participants.


For each curricular category, various modes of education delivery were pursued according to the learning theories and Continuing Medical Education program planning framework proposed by Davis et al.[20] Assigned readings and electronic resources were availed to participants before and during the course to enhance in-person teachings both in the classroom and in the clinical setting. In the classroom, case-based learning, formal didactic lectures, directed seminars, interactive small group discussions, journal clubs, and simulation laboratory/skill workshops were utilized. In the clinical setting, departmental rounds, bedside teaching, and hands-on ultrasound practice with faculty and resident guidance were integrated into the curriculum.

Funding

No initial funding was acquired. The requested fee for the course was $450 USD for the 1-week course and $800 USD for the 2-week course (a booking deposit was implemented to ensure commitment and anticipate the number of participants). This initial funding was also helpful for budgeting other logistical costs, such as printing and food. Accommodation, meals, and transport within Kigali were not included. However, there are many affordable budget options near CHUK. Ultimately, no external funding was utilized for the EMIT course, and the expected fees from participants covered the budget.


  Results Top


Emergency Medicine in the Tropics Implementation

Emergency Medicine in the Tropics Participants

A total of 11 visiting participants attended the course: 6 for both weeks and 5 for only one week. They originated from a total of six countries: the US, the UK, Australia, Ireland, Norway, and the Netherlands. Out of the 11 participants, one was a final year medical student, 6 were residents in training, and 4 were practicing EM physicians. The mean clinical years of practice was 5.4 years and the median was 3 years; with 27% male (n = 3) and 73% female participants (n = 8). Only one had previous experience attending a global EM course. Participants had learned about the course through a conference announcement, Facebook post, online search, or word of mouth.

There were a total of 14 EM residents training in Rwanda at the time of the EMIT course: eight in postgraduate year (PGY)-1 and six in PGY-2. They all contributed to implementing the EMIT course, facilitating learning activities such as the ultrasound training, leading morning departmental rounds and bedside teaching in the wards, and both attending and delivering lectures.

Emergency Medicine in the Tropics course

During the 8 days in CHUK, participants rotated through half days in each of: ED/resuscitation and critical care room, general ICU, trauma surgery, internal medicine ward, pediatric ED/ICU, EMS, and point-of-care ultrasound trainings. Activities included morning departmental rounds, bedside teaching in the wards, morning case presentations of patients observed in the wards, hands-on ultrasound practice, case-based learning, formal didactic lectures, directed seminars, interactive small group discussions, simulation laboratory and skill workshops, journal clubs, and assigned readings/electronic resources ([Appendix 3] for full timetable of the 2 weeks).

Emergency Medicine in the Tropics curriculum evaluation through participant feedback

Informal surveys were administered for feedback from the course participants regarding their experience in Rwanda through EMIT. Seven of the 11 visiting participants returned the surveys. Responses to questions on the content and structure of the course were strongly positive based on a 4-point Likert-type scale (range from 3.4 to 3.9, with 1 = strongly disagree and 4 = strongly agree).

Free-response course feedback was also collected and analyzed. The feedback centered around themes of interactive learning both in the clinical and personal contexts. In particular, responses from participants found the following elements to have helped learning: “hands-on clinical cases,” “seeing real patients,” “excellent teaching from residents in ED,” and “gaining Rwandan residents' perspectives.” All visiting participants reported the local EM residents as an invaluable component of the learning experience, especially captured in this summary: “combination of all sessions with residents was probably the biggest strength; I learned a huge amount from them and am so impressed with the way they manage to work in such difficult environments.”

Feedback for improving the course centered around expanding course topics and reorganizing the course schedule. Responses included: “even wider topic range” (such as pediatric, ICU, head trauma, infectious disease, and maternal/fetal management), “more discussions about differences in the management of patients in this setting (vs. in a high-income country),” and “offer option for longer duration.” All respondents strongly agreed that “this course was worth the overall time and expense of travel and attendance.”

The free-response section of the informal surveys was also administered to the local EM residents. The responses displayed several themes focused on the value of interacting with the international visiting participants and an appreciation for the Rwandans' own training and expertise: “I really valued sharing different thoughts from different people across the world,” “the face-to-face time (with visiting participants) was most helpful,” “people appreciated how good we are doing ultrasound,” “it was good to see how people are good at different things, especially for us in our low-resource settings.” Regarding suggestions for improving the course, local residents requested gaining feedback for teaching and expanding the number and variety of participants (i.e., from other African countries).

A sustainable model for Emergency Medicine in the Tropics

The course raised $6500 USD in participant fees and cost $1500 to run. Costs included printing, transport, food, and speakers' honoraria. At the time of this manuscript's publication, the profits gained from this course have been invested directly into funding Rwandan residents' active participation in regional and international conferences to advance their personal learning and professional careers.

The organizers of the EMIT course included a combination of the Rwandan EM residents, Rwandan attending physicians, and instructors from other specialties (i.e., surgery, obstetrics/gynecology, and pediatrics), and a few foreign HRH faculty. Given the growing presence of the African Federation of EM AFEM and regional leadership interested in bolstering African EM education, other practitioners were able to further contribute their time and expertise to this EMIT course without additional cost to the Rwandan EMIT organizers. In particular, international colleagues from the US, the UK, and South Africa were also invited to attend EMIT, but with the understanding that they would fund their own travels to the course in Rwanda. Four speakers were able to attend the course and provide lectures on their respective areas of expertise in global EM.


  Discussion Top


The inaugural EMIT course in Rwanda achieved its objectives in terms of the teaching and learning facilitated between all participants. The benefits for both visiting and local participants in global EM courses are clear. There are teaching and learning opportunities for both groups that can only be facilitated through in-person exchanges. For visiting participants, they can observe different clinical pathologies and gain insight into the unique challenges of health-care provision in LMICs with more variability in resources. They can strengthen intercultural competency, foster personal growth, and access unique teaching experiences. Like-minded international colleagues also help facilitate enriching discussions and collaborations. For the local participants, they learn from their exposure to trainees of different backgrounds and health systems. As experts in their contexts, they have an immense opportunity to teach and share knowledge. While the informal free-response feedback collected from participants serves mainly to improve the quality of the EMIT course, there is future opportunity for assessing attendee's intercultural competency, public health knowledge, and clinical skills acquired through the course.

The financial model for a short global EM course such as EMIT is also compelling. The course requires minimal financial investment, as it only involves careful planning by the local course organizers such that the ED schedule can accommodate the rotating participation of EM residents and attending physicians in the course activities. Visitors from HICs are willing to pay for experiences and learning opportunities abroad. Resoundingly, participants from HICs responded that they felt the learning experience in situ was worth the cost of paying for the EMIT course and making appropriate time arrangements with their home institutions, especially with the knowledge that their financial contribution fueled this sustainable model. The profit from the course is dedicated to both regional and international educational opportunities for the local residents. A part of this year's profit already has been used to sponsor Rwandan EM residents to attend and present their research projects at the 2016 African Conference on EM. A substantial portion remains, and strengthening this EMIT course will only continue to help financially support local residents to pursue such learning opportunities that have been previously inaccessible for financial restraints.

The lessons learned from our process may serve as a model for other EM programs in LMICs to structure a short-term global EM course and ensure meaningful, enriching learning opportunities that are financially sustainable.

The growth of global EM fellowship programs in HIC and EM residency programs in LMICs reflects the increasing international demand for emergency medical care services, and the demand for additional education and training opportunities for those seeking career paths that are focused on responding to that need. The unique opportunity of EMIT to learn from Rwandans in Rwanda dampens ethical dilemmas on contextually appropriate global health learning experiences.[21],[22] Moreover, career paths in global EM can lead in many directions, as EM physicians are well suited to work in international settings where there is high value for the ability to treat a wide range of clinical problems, and a familiarity with prehospital and medical emergencies.[23],[24] However, opportunities to engage in short-term global EM courses are still limited, even though such courses in global EM can introduce to a broad range of subjects that may help shape those career considerations and meet the need for global EM physicians.[3]

Global EM courses help to define the knowledge and skill areas that can constitute a common base of knowledge and skills offered through such international learning opportunities. We do not propose this set of knowledge and skill areas as a standard, but rather as a resource for individual course designers in LMICs as they develop and refine their own curricula. Our goal is to stimulate further thought and discussion about the knowledge and skill areas that should be included in short-term global EM courses in LMIC settings.

The course has been implemented once, so it is not certain yet whether this model will continue to be successful. The future recruitment of global EM practitioners and experts for LMIC courses such as EMIT may be challenging, but the ultimate direction for such courses is for enough funding from HIC participants to be generated for EM physicians in LMICs to pursue and design their future courses. The EMIT course fills a particular role in the landscape of international education experiences: it intends to provide an introductory glimpse into EM in LMIC contexts. Developing specific competencies for participants, examining mindset or clinical practice changes, or developing scholarly opportunities [Appendix 1] are examples of next-level curriculum development and evaluation. Although visiting participants and local residents provided immediate informal feedback, the long-term effects of EMIT have not been assessed.

The lessons learned from designing, implementing, and sustaining EMIT in Rwanda may serve as a model for other EM programs in LMICs to provide short-term global EM courses that may facilitate meaningful learning opportunities for all participants and that are financially sustainable.

Summary points

  1. There are clinical and cultural insights that can only be shared through global EM experiences that are properly contextualized and facilitated by local EM practitioners. A short-term course may facilitate such brief yet enriching learning opportunities
  2. Hosting an EM course in an LMIC setting allows for professionals to meet and build a network of like-minded international colleagues
  3. Future opportunities for EM course development and evaluation are encouraged to be shared and refined through formal venues, as common knowledge and skill areas that should be included in short-term global EM courses in LMICs are not yet standardized
  4. The sustainable financial model for a short-term global EM course can be achieved through careful planning by local course organizers and a growing base of interested participants from HICs who can pay for such learning opportunities abroad and want to contribute to this model.


Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
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