Updates From the Southern Front

At the time of my last Guatemala update, about a year ago, IGSS (their national social security health system) had announced they would start the first EM program in the country, in partnership with USAC, the national (and by far largest) medical school.  The Ministry of Health shortly thereafter announced their own program at San Juan Hospital, the largest in Guatemala.  This was the epitome of many years of work in the country, drama, political land mines, lobbying, fighting, problem-solving, etc. If you've played chutes and ladders, you'll know what global health is like.  We were thrilled to finally have two programs but also apprehensive of what we knew would be a bumpy road.

For starters, because of previous frictions which originated from the organization of the first EM conference in 2017, the faculty at San Juan Hospital completely excluded us, to the point that we were never even introduced to their residents, in spite of our continuous offers of support.  But IGSS was happy to have us and we helped their program with interviews, resident selection, scheduling, descriptions and objectives of specific rotations and, in December 2018, orientation week.

After that honeymoon period, the real issues began.  Problems, I must say, we were anxiously awaiting after almost 3 years of work and politics.  Among them:

• Complete lack of emergency physicians to teach and supervise.  There is not one EM-trained physician in the whole country.  Our faculty team consists of a PD (Peds Intensivist) and 3 APDs (a surgeon, an OBGYN and a medical intensivist).  Additionally, USAC decided to only pay for the PD, which meant the rest were essentially volunteers.
   
• Exhausting clinical hours.  Our residents are currently working 8h shifts during the days + 36h shifts every 4 days.  No holidays, no vacation until their second year.  No sleeping quarters.  No easy rotations.  No duty hours.
   
• Overwhelming teaching burden.  Each resident is expected to give one lecture per week.
   
• 1 hour of daily conference as opposed to a 5h block once a week.
   
• Not enough trauma volume or pathology.
   
• As initially designed, the conference schedule wouldn't have come close to cover the complete curriculum in the 3 years duration of the program.
   
• Sporadic drops in morale, interpersonal conflicts, burnout and threats of dropping out.
   
• We were not approved to expand to 12 or even 8 spots as requested (remains 4/year).
   
• Still no US machine despite regular requests.

Now, if you know the stories behind the beginnings of EM in each country, you'll know that we're not doing too bad.  We are fortunate to have solid support from the main academic institution, healthcare systems, hospitals and the Guatemalan College of Physicians.  We are also fortunate to have so much external support from UPenn, UCLA/EMRAP, Stony Brook, colleagues in Costa Rica and Chile and our Global Health Section at WSU.  And finally, we are very fortunate to have had 9 brave Guatemalans who are passionate about our specialty and have decided to bet their professional careers on it.  Most other countries were not so lucky.  So yes, we're late to the party, but we are also starting the specialty from a relatively privileged position, almost guaranteeing the success of our endeavor.

Many of these challenges have been or are being overcome, and the future is bright.  The last couple of months have been increasingly productive and we have much to celebrate:

• Our partners at UCLA/EMRAP, Sara Crager and Ryan Ernst (a SGH grad!), have been working intensely to rewrite the conference schedule and have designed an amazing multi-format, comprehensive, flexible and interweaved 15-month curriculum and detailed conference schedule.  (Why 15 months? So that residents go over each topic twice before they graduate.)
   
• Thanks to support from EMRAP and the organizers of the acclaimed Conceptos conference series, the residents were able to attend their first EM conferences in Costa Rica (May) and Chile (September) for an opportunity to hear great speakers and meet fellow Latin American emergenciólogos.
   
• We got approval for our residents to rotate at the IGSS Trauma Hospital, where they will see more than enough trauma, and where there are no internists or pediatricians, which makes them very popular whenever an MI or a pediatric status epilepticus comes through the doors.  This helps us advance the professional prestige of our specialty and earn the respect of our colleagues.
   
• We recruited a fantastic new APD, Luis Aragon, a skilled young surgeon at the Trauma Hospital with a passion for medical education and simulation.
   
• We again filled both residency programs for a grand total of 17 EM residents now.
   
• For the first time ever, the National Medical Congress had an EM module, which we organized. It was extremely well attended.  Big milestone for our specialty!
   
• Although the San Juan residents were not allowed to attend their Module, we serendipitously got to meet two of them later that night.  We're happy to report they are as cool and passionate as any other EM resident and we've been in direct communication with all of them ever since.
   
• For orientation week this year, we have visiting faculty from UPenn, UCLA/EMRAP, Stony Brook and University of Chile.  And unlike last year, we are now accompanied by the San Juan Hospital residents.
   
• We organized a "Master Class" of EM, held at the College of Physicians and it was inaugurated by its President and Secretary.  The event sold out (150 people) and was very well received.  We also found a great new partner in EMS Guatemala, a private MedEd company that was in charge of the financing, logistics and execution of the event, while we organized the academic side.  They were top notch and we will definitely continue working with them.
   
• Our WSU International EM Fellowship program (soon to be rebranded Global and Urban Health) successfully recruited two fellows this year, Drs. Nora Berens and Andrew Leamon.  The former was the first US resident to rotate in Guatemala earlier this year and will be continuing her involvement longitudinally.

There are still many major issues and challenges, but I think it's safe to say our specialty is in Guate to stay.  We are now focusing all of our efforts to the training of excellent emergency doctors capable of continuing to pave the way and lead EM to the heights we know it's capable of reaching.  They are not just future EPS, they are the pioneers, the future teachers, administrators, ambassadors, organizers, researchers and advocates of our specialty and patients, and we are preparing them for all of this. 

Our involvement in Guatemala is not winding down any time soon, and in line with that, I am currently leading the translation of Rosh Review into Spanish.  We recruited a small army of volunteer translators and co-editors (60+ so far) to make this amazing resource available and free of charge to all EM residents in Latin America (and very affordable to everyone else).  There is really nothing like it in the Spanish speaking world and we know it will be a game changer.  I am also working with Richard Levitan to translate his EMRA Airway guide, another fantastic freebie that all Spanish-speaking residents will be able to take advantage of.

To finish, I'd like to thank Brian O'Neil, Dan Taylor and the MCES board for their support of our Global Health Section.  Global Health is by far the most expensive fellowship (2 years, cost of MPH + travel + international courses + language lessons, etc.) and its approval by the above reflects how much they support our efforts and share our mission. So, muchas gracias!

Daniel Ridelman, MD FACEP