Years ago a colleague I hadn’t seen in a long time asked me at a conference “What the hell are you doing in Bendigo? From his lofty position in an outer urban Melbourne ED he couldn’t see what I could be doing in a regional hospital. Well, my rant about the opportunities out there in regional hospitals is not the topic of this blogpost but I was amused this year to be asked by so many people “What the hell are you doing in Mongolia?” when it was connections made in Bendigo that took me there.
Years ago, legend has it, an Australian anaesthetist visited Mongolia and offered some assistance with the beginnings of their anesthesiology training program. From that grew a 14 year relationship between the Mongolian Society of Anesthesiologists and some Australian anesthetists that, in the past few years, has spawned the Immediate Emergency Care Course, teaching fundamentals of emergency medicine in regional hospitals across Mongolia to regional and rural doctors.
We missed out on our SMACCs
In June this year, while lots of you were off in Chicago at SMACC, three Bendigo Emergency Physicians (Simon Smith, Wolfgang Merl and me), joined a small team (Robyn Parker from Maroondah, Rob Melvin from Northern/Alfred, Pete Jordan from The Northern, Ben Delaney and Luigi Marino from Western and Ingrid Yuile, an ultrasonographer and ultrasound educator from Ultrasound Training Solutions) and flew to Mongolia to teach the course. It was my first year on a team that has seen a lot of faces over the years.
Anesthesiologists have taken the lead in the development of the fledgling EM system in Mongolia, just as they helped to deliver Mongolian Intensive Care into the world. I find it fascinating that while in Australia, the UK and the US early EM governance and leadership was frequently from interested surgeons and internal medicine docs, gradually drifting across to form part of the triad of critical care with anaesthetics and ICU, in Mongolia they have skipped straight to where we are now, with critical care developing as a movement, thanks to the foresight of some passionate people in the MSA.
Is Mongolia ready for EM?
We got asked this a lot back home. The best answer I can give is that if a country is seeking out people to come and teach a subject, that country must be ready for it. The EM landscape seems to have been changing fast over the three years that the IEC course has been going. When it started it was common to find a single ECG machine in a hospital that no one knew how to use, or a single broken defibrillator, donated by an overseas visitor years before. There was little to no meaningful EMS/Ambulance service and transport was very difficult outside the capital.
On this visit we found a well functioning EMS service in UB and the beginnings of one in Khovd. Number 1 Hospital in UB has recently opened its new Emergency Department (a two bed resus room, two consultation spaces and a four bed Short Stay/observation ward), the Medical University of UB, which has traditionally taught mostly public health and chronic disease management, has started to give some lectures in Emergency Medicine and the first EM residency has begun at Number 1 Hospital with 12 EM residents.
Mongolia still faces some big challenges in provision of EM care. Less than half the population live in the capital and the rest are spread around small regional towns or living a nomadic or semi-nomadic life on the steppe or surrounding hills.
Transport is pretty hard going at times, with a lot of people living along two-wheel track 4WD routes, far from paved roads or services. Medical care is still heavily influenced by the years of Russian occupation (everyone gets a shot of IV Vitamin C as a general tonic for example).
Challenges for us
We were pretty challenged too. The rapid development of EM in Mongolia means it is hard to know, from year to year, where you are going to need to pitch your talks. This is made worse by trying to deliver the course in regional hospitals, which vary greatly in equipment, modernisation, staff and so on. The hardest thing for me was needing to actually write a talk. In Australia as long as I have a few slides to give people something to look at I am pretty happy just speaking off the cuff, adapting my lecture to the audience, cracking a few gags, walking around a bit. Not OK when you are speaking though an interpreter who is actually a doc who happens to speak English and has enough courage to do so in front of their peers.
All our slides needed to be translated ahead of time into Mongolian and we had no idea until we got there who would be doing the translating or how confident they would be. In the end we were fantastically lucky with some really wonderful interpreting which did free up our teaching style a great deal.
Oh, and you need to be comfortable with a diet of mutton, cheese, warm beer and vodka which was fine by me.
I really like using ultrasound in ED. Even more than using it, I really really like getting one of my much more capable registrars to use it while I “supervise” them. But to be honest, if point of care ultrasound disappeared from the Australian EM landscape tomorrow, I am not completely sure that it would make that much difference. I reckon I get a positive FAST that sends a blunt trauma patient to laparotomy perhaps twice a year. The AAA scan, lung US, bedside ECHO are all great but exactly how much they add to a good clinical assessment I’m not really sure. And it is not exactly hard for us to get an Xray, CT or formal US scan for the most part.
In Mongolia, POCUS really seemed to come into its own. In Khovd hospital (the Aimag or regional referral hospital where our group was teaching) there is no portable Xray, and only 1 CT scanner for the hospital. In the smaller village based Soum hospitals that feed Khovd Hospital there is no Xray at all. Small ultrsound machines seem to pop up everywhere though. The ability to rule out traumatic pneumothorax, diagnose a haematoperitoneum that will mandate a 2 hour 4WD transfer, or identify lobar pneumonia in these settings makes POCUS truly valuable and the hunger with which it was taken up by the Mongolian Docs seemed a pretty good testament to its worth.
We have to give a big plug to Sonosite Australia and to Ultrasound Training Solutions who let us take a Sonosite Edge with us and I have to give a huge plug to my fellow team member Ingrid Yuile who really made this aspect of the course what it was.
We taught for three days, covering ALS, BLS, paediatric life support, the Trauma Primary Survey, ICC insertion, Difficult and Surgical Airway skills, basic neurotrauma diagnosis and management and bedside ultrasound use. We drank lots of warm beer, sang some pretty extraordinary karaoke, ate a lot of mutton, were taken wonderful care of and might have perhaps left behind some useful education.