Global Emergency Medicine Committee

Location: Dunedin Public Hospital, South Island, New Zealand.

When: 2009

Type of experience: Six Month Registrar Post. Intensive Care Medicine and Aero-Medical Retrieval Medicine

Training recognised? Yes, my post was prospectively approved by Mersey Deanery, CEM and PMETB for six months out of programme training to complete my competencies in Intensive Care Medicine and Anaesthesia as an Emergency Medicine Trainee (This post was recognised for specialist training by the Australasian Colleges.)

Contact details: lauramcgregor@doctors.org.uk

In 2009 I completed six months out of programme training in Intensive Care and Aero-Medical Retrieval Medicine based in the Intensive Care Unit at Dunedin Public Hospital (DPH) and on the Otago Regional Rescue Helicopter.

DPH is a 350-bed tertiary level teaching hospital with a 10 bedded ICU plus Cardiothoracic and Neurosurgical specialities. In ICU, I worked alongside 5 other Registrars in a post recognised for specialist training by the Australasian Colleges.

In addition to this I worked on the Otago Rescue Helicopter – A 24/7 Aero-medical service providing medical attendance for primary helicopter missions and inter-hospital ICU patient transfers by air and ground. The team includes 3 dedicated pilots and 2 highly experienced paramedics permanently assigned to the rescue base. Added to this are the specially trained consultants, registrars (of which I was one) and nurses of DPH Intensive Care Unit.

Since 1998 the Otago Rescue Helicopter Trust has provided a dedicated intensive care rescue helicopter service for the entire population of the lower South Island of New Zealand.

How I did it – who to contact, and what order to do it in

I was fortunate in that my Educational Supervisor in my Emergency Medicine training post in Mersey Deanery had completed this same post several years prior as part of his registrar training and was still in contact with the team in Dunedin. He gave me the email contact details for Dr Mike Hunter the Clinical Director of Dunedin ICU whom I contacted in the first instance to find out more about the post and the application process.

It took approximately one year to organise my OOPT. The post commenced in June 2009 and so I requested to discuss this with the Head of School at my training review ARCP in July 2008 so that the departments that would be lacking a trainee from June to July and August to December respectively in 2009 both had plenty of time to make adjustments. Following this I set about completing numerous forms for the Training Programme Director and Deanery and The College of Emergency Medicine (as I was determined to have prospective training approval) as well as the GMC/PMETB and the New Zealand Medical Council. It was only once I had been accepted by both Dunedin Hospital and by the New Zealand Medical Council that I was actually able to apply for my Visa as this is very specific in terms of your exact post and the exact dates you will be working. That was a further laborious process but did not require CXR etc as I have heard some colleagues required to work in Australia.

At this stage I felt happy to book flights and arrange accommodation through the hospital and I looked into other things like car hire and bank accounts etc in New Zealand. I was able to rent out my home in Liverpool to some friends who were already my housemates and I made other allowances for bills, home insurance etc. At the time I did not have a partner or children or pets so that made life a little simpler.

I had to arrange medical indemnity whilst I was resident in New Zealand and so I temporarily halted my indemnity here in the UK. Other things like arranging for your pay to be halted in the UK whilst you are away can be tricky to arrange with local payroll, this led to some difficulties for me on my return to the UK.

Despite the time required and the seemingly endless forms to complete – it was ALL completely worthwhile and the inconvenience at the time of preparation is FAR outweighed by the experiences I gained from my OOPT.

What I had to do to prepare

I revised the Oxford Handbook of Intensive Care! I was at ST4 level and so was relatively clinically competent at this time and had already finished my MCEM.

I knew that I would be completing a training course on my arrival to Dunedin in order to be able to be a team member on the Rescue Helicopter so there was little else I could do to prepare for this from home in Liverpool. I do remember completing the “ISAC” – Incident Scene Assessment Course with Cheshire Fire and Rescue, this was helpful in dealing with roadside emergencies.

What I learnt when I was out there – specific educational skills

In the first week I completed the Otago Aero-medical Evacuation Course. This encompassed in-flight physiology, the management of in-flight emergencies (medical, surgical, trauma, obstetrics, paediatrics), practical transfer skills and in-flight emergency drills at Taieri airfield.

As a registrar I was then able to begin undertaking primary and retrieval missions as the sole doctor with nurse and/or paramedic support. Thereafter, I regularly undertook the transfer, retrieval and primary rescue of both adults and children, with direct advice form the consultant in ICU –but at the other end of the telephone.

In addition I gained experience in anaesthesia when opportunities arose to attend emergency theatre, neurosurgery and cardiothoracic theatres. ICU registrars were encouraged to perform elective intubations and central venous line / arterial line insertions in theatre for elective postoperative admissions, as well as rapid sequence induction and emergency intubation of new patients in ICU/ED.

I did several presentations at hospital meetings and was granted study leave to attend the World Interactive Network of Critical Ultrasound Congress in Sydney.

When I returned to the UK I presented a poster entitled “Otago Rescue Helicopter, New Zealand: The Value of Out of Programme Training Opportunities for UK Emergency Medicine Trainees” at the College of Emergency Medicine Annual Conference 2010 and National Annual Conference of Pre-hospital & Critical Care Transfer 2010.

How I am different now and why it was worth it

Out of programme training opportunities for UK Emergency Medicine trainees can be viewed as non-essential or undesirable, perhaps due to trainee absence impacting on local service provision. However, the value of such training experience for the individual trainee should not be overlooked. By participating in the rescue, retrieval and ongoing ICU care of both adult and paediatric patients I gained multiple new skills, including confidence in performing independently with limited equipment in challenging prehospital environments. This was an invaluable and very enjoyable experience and did lead me to pursue further training in Prehospital Care later in my career.

Any downsides

None that I can think of to be honest!

Location: LAMB Hospital (Bangladesh)

When: 2010-2012

Type of experience: Working as a doctor for BMS World Mission

Training recognised? No

Contact details: James Hayton, hayton@doctors.org.uk

Between ST5 and ST6, I took 2 years Out Of Programme Experience (OOPE) to work for BMS World Mission at LAMB Hospital in Bangladesh with my wife (an O&G SpR). LAMB Hospital is an established Christian mission hospital in NW Bangladesh with an international reputation. I had previously worked with BMS World Mission in Thailand/Burma in 2007-8.

Planning OOPE can be difficult, long, and frustrating. However, I have found my time working in resource poor healthcare interesting, worthwhile, and developed my skills as a doctor far beyond what I could have achieved in UK practice alone.

Planning OOPE

1. 1. Finding a placement is probably both the initial and most important step. Although the need is clearly significant, we found getting a suitable post in a resource poor setting difficult. LAMB Hospital was personally recommended to me and we contacted them for vacancies. On a previous period of OOPE type work, we had let BMS World Mission find a placement. VSO, MSF, and many Christian mission organisations work this way. We started this process a year in advance which seemed about right for both for the deanery and the overseas placement. It helped to have a provisional placement and sending organisation in mind when approaching the deanery.
   2. Approval from the deanery. While I had a supportive deanery school, my wife had a very different experience in her specialty. Having a well researched credible plan helped. She had to be persistent and pressure office holders for definite answers and approvals in writing. We needed to start committing time and money to planning the OOPE at an early stage so we needed to be sure it would actually happen. This was not fully appreciated at deanery level. The Gold Guide was useful and having read it, we appeared to know more about the process than many in the deanery.
   3. Preparation for working overseas started as soon as we had the approval which was about 6 months before we left. We needed to make arrangements for our UK house, car, relationships, finances etc. With the help of BMS World Mission, we also made arrangements for travel, visas, travel/health insurance, occupational health, professional registration, overseas malpractice insurance etc. An organisation familiar with this, like BMS World Mission, was invaluable in the process. As we working for a longer period they also shared some of the costs. I attended a three month tropical medicine course in Liverpool in 2006. Although helpful, this is not essential.
   4. Preparation for arrival in the placement overseas. On the whole LAMB Hospital was well organised and supportive. However, we were surprised to find our accommodation was unfurnished and the clinical roles they had for us were different to what we expected. These initial surprises could have been avoided by asking the right questions. BMS World Mission expected us to learn some Bengali in a language school before starting clinical work. This was useful and probably better than trying to pick up language as we worked.

Working while on OOPE

Although it would have been wise to clarify what role I would be doing before I arrived, it was not a big problem. I had expected to take on more responsibility and practice more widely than I do in the UK and was comfortable doing this. We found it difficult to balance workload and rest in a new and challenging environment. A mentor from our own culture but with experience of the working environment may have been helpful.

I learned a number of new skills, while on OOPE, as well as developing others. I was working as an independent senior doctor (similar to consultant) in adult medicine with my own in-patients and out-patient clinics. Although I needed to rapidly adjust to the new spectrum of pathology, in time I was able to identify areas of practice the hospital could change and improve and enjoyed developing these services. In the second year of OOPE, I was given some management responsibility in the hospital.

As needs arose, I started working in areas that I had not previously practiced (eg club foot surgery) and others that I had previously trained in but not done recently (eg anaesthesia). Although I was prepared to work flexibly, I believe I recognised when it was not in the patient’s best interest to stretch the boundaries of my competence.

Advantages of OOPE in a resource poor setting

1. 1. • Assisted a resource poor healthcare system better care for patients.
      • Gained and developed clinical and management skills far faster than is possible in the NHS.
      • Saw other healthcare systems in action and identified areas where the NHS could learn from these

Challenges of OOPE in a resource poor setting

1. 1. 1. Reluctance from deaneries to release trainees as the experience is undervalued or due to pressure to maintain rotas locally.
      2. Expense: Either from the delay in reaching CCT or direct financial costs.
      3. Administrative burden of organising OOPE

Suggestions for improving the OOPE experience

1. 1. Personal: Plan earlier and involve an experienced individual or organisation to help. Be prepared to ask the right questions and get clear answers.
   2. Deaneries: Recognise the benefits of this aspect of postgraduate medical education and clearly demonstrate this is considering enquiries and applications for OOPE.
   3. CEM: Clearly recognise and state the benefits of OOPE. Consider arrangements that actively support it (eg RCPCH/VSO fellowships).

Location: Children’s hospital, Westmead, Sydney

When: July 2009-2010

Type of experience: Fellowship in Paediatric EM

Training recognised? Yes – 6 months (at his request)

Contact details: Kevin Enright, kevje26@hotmail.com

It was one of the most enjoyable and educationally beneficial experiences of my career. I organised it myself, having decided that as a future Consultant in Paediatric Emergency Medicine I wanted to be as well trained and as experienced as possible. I wanted to be able to walk on to the shop floor on day one, knowing I could do the job. The fellowship gave me that.

I got my Deanery and the College to not count six months of the fellowship year (thereby giving me the benefit of an additional six months of experience that I otherwise would not have had from my time as a trainee) and the other six months of the fellowship was counted towards the mandatory second six months in PEM which is required of trainees sub-specialising in PEM.

Having decided that I wanted additional training and experience in PEM and that I wanted this outside the UK, I looked at options. I decided on Sydney and made contact with the hospital directly. Having researched the hospital website including information about their ED and their PEM Fellowship programme, I e-mailed the clinical lead. This set the ball rolling for a future telephone interview. The clinical lead forwarded detailed information about their fellowship programme. In the meantime, I had been liaising with my trainers, the College, the deanery and PMETB (whose functions in this regard have since been taken over by the GMC, as you will be aware).

The CHW Fellowship in Paediatric Emergency Medicine was a fantastic year. There are three fellows at any one time. They are either senior trainees in EM (as I was) or senior trainees in Paediatrics (either Australians planning to become PEM Consultants in Australia) or from overseas and planning to return to their countries to practice Paediatrics with an interest in PEM.

I did a one in three weekend on-call. I was on-call all weekend Friday afternoon until Monday morning with a Consultant at home but available for advice, plus one evening per week on-call. Mondays after a weekend on-call were non-clinical (admin) days. The weekdays consisted of one evening on-call, one day of admin duties (including teaching, training, meetings, audit, complaints, clinical governance, policy development and other departmental projects) and two to three day shifts in different clinical areas of the department. This meant superb clinical experience and clinical responsibility with the benefit of great teaching and support. It also meant at least one day of admin duties per week, based in the office area with the other fellows and consultants: therefore great experience of all the non clinical duties of a consultant. This is something my UK training would not have given me. It meant the transition to consultancy was so much easier than it might otherwise have been.

The range, complexity and volume of clinical cases at the hospital was incredible. I learned so much, particularly about acute Paediatrics and Paediatric major trauma. In addition, I was responsible for leading post-take ward rounds on the ED’s Observation Ward which provided extended care to a variety of Paediatric in-patient cases. Many of the ED’s acute admissions were cared for here.

During the year I taught regularly at the Sydney Clinical Skills & Simulation Centre. This was great experience in the principles of simulation and gave me an opportunity to learn how simulation training is delivered.

The fellowship provided additional experience I would otherwise never have had. I worked with great clinicians who were fun while very dedicated to their patients and their colleagues. I gained expertise in Paediatric trauma and the confidence to know that I would be well equipped to practice as a Consultant in Paediatric Emergency Medicine. But apart from anything else, I got to live in Sydney for a year. I loved it and made the most of every minute.

I don’t think there were any downsides to the experience.

Location: South Africa

When: 2011

Type of experience: Rural medicine

Training recognised? No

Contact details: Tim Nutbeam, timnutbeam@hotmail.com

I spent a year on an OOPE in a rural area of South Africa. I worked in a 450 bedded acute care hospital within a ‘township’ (informal settlement) of 650,000 people. Regular power and water cuts, public workers strikes and the difficulties related to poor governance and quality procedures made this placement an interesting challenge. I learnt a huge amount of Emergency Medicine and also vastly improved my practical and nontechnical skills.

How I did it – who to contact, and what order to do it in

Organising an Out of programme experience (OOPE) is undoubtedly challenging. Start early, an absolute minimum of a year will be required to organise an OOPE and gain deanery support – two years is more realistic. A good first step is to determine why you wish to do your OOPE. You may have personal and/or educational objectives. Once you have clear objectives you need to carefully consider the practicalities:

• Who will be travelling with you and do they have any special requirements?
• How will you communicate (does it need to be English speaking)?
• How will you fund the OOPE (does it need to be paid)?
• How safe does it need to be?
• Any other special requirements e.g. availability of healthcare / childcare etc?

With these clear in your mind, you will be in a position to identify geographical regions or even specific posts that fulfil your requirements. From this position you can start making tentative enquiries both with potential future employers and with your deanery. Getting early ‘buy in’ from your educational supervisor and / or members of the training committee certainly helps. From here your deanery will have a process to follow which normally involves some form filling and (potentially many) meetings.

You need to consider visas, permissions to work, proving the equivalence of your medical degree, professional registration etc. You are likely to need at least one visit to a notary and expect to spend a lot of time preparing and sending various documents: many preferred OOPE countries have a certain fondness for tedious bureaucracy. You also need to consider what will happen to your stuff: house / family / pets / car whilst you are away.

What I had to do to prepare

My original learning objectives had included increasing my exposure to penetrating trauma and burns. South Africa seemed the obvious choice – my original plan saw me working at the infamous Baragwanath hospital in Johanessburg. Even though I spent a short period of time in Jo’burg, lifestyle, family and the availability of paid work encouraged me to spend the majority of the year in the rural north-east of the country. I visited the hospital I would be working in (highly recommended!) about 8 months before starting there. As I had some insight as to the challenges I would be facing it allowed me to prepare. This involved diversification of ultrasound skills (as there was no access to CT) a few surgical skills courses (no surgical team out of hours, if your on duty in the ED you deal with it!), a brief burns and plastics placement and lots of advice from colleagues from EM and other specialities. I knew that I would be working independently so I established a network of “phone (or Skype) a friend” buddies in a variety of specialities who I could seek advice from – this proved invaluable!

What I learnt when I was out there – specific educational skills

I experienced the increased exposure to burns and penetrating trauma I had planned for! In addition I also learnt a huge amount of paediatrics, obstetrics and gynaecology (as well as infectious diseases of course)! My ultrasound skills definitely improved – though not in line with the standard Level 1,2, etc. I learnt how to (independently) repair tendons, graft wounds/ burns and perform caesarean sections, as wells as ‘put into practice’ the surgical management of penetrating chest trauma – surgical skills that I had not had much opportunity to apply during my EM training scheme. There was an opportunity to teach and train others, introduce new clinical pathways, and start a clinical Governance programme all of which I took advantage of and learnt from.

How I am different now and why it was worth it

I gained a lot of confidence in my own practical skills and complex decision making ability – covering a hospital at night, with responsibility for all the specialities is testing but rewarding. I learnt enough of the acute aspect of many specialities to temporise most situations. I now have the confidence to perform (potentially) life saving surgical interventions.

Any downsides

The hospital ran in a permanent mode of what we in the UK we would consider a major incident / disaster state – the resources available were far outweighed by the clinical need. I needed to make many difficult decisions some of which will be with me for a long time. My wife (an anaesthetist), provided invaluable clinical (and emotional!) support (if you choose to work in an austere environment, where you will get this support needs to be considered). It took me some time to adjust to EM back in the UK. The availability of diagnostics and therapeutics was overwhelming  – and often clearly not in my patients best interest! It was odd, asking (and getting) support and initially some patients presentations seemed farcical compared to the overwhelming need I had experienced in SA.