From Manitoba to New Delhi — Glimpses of Emergency Care Around the World

'"When you travel, remember that a foreign country is not designed to make you comfortable. It is designed to make its own people comfortable."
 — Clifton Fadiman              

Everyone loves the idea of traveling the world and seeing how others live; we physicians are no different. I'm fortunate to have had my share of travel to far-flung places as an emergency physician and inventor, finding innovation, cautionary tales and inspiration in each one.

Canada
Being born and educated in Manitoba, I first practiced emergency medicine in Canadian hospitals within the single payer system operated by the provinces. As an emergency department physician, you were either a hospital employee or an independent contractor billing the health system on a fee-for-service basis. As an independent contractor, I kept a list of my professional service charges for each shift and at the end of the month submitted them to the Manitoba health insurance office as a single bulk package — in hard copy without the aid of coders or billing employees. Each charge was quite simple, including little more than physician ID, patient ID, date of service and service code.

I was shocked when I moved to the U.S. to discover billing companies often employ more people than the physician groups they serve. The complexity of the billing process and the U.S. healthcare system with its multitude of payers and products amazed me.  

In Canada, the single-payer system streamlines admission to the ED because there is no need for an insurance/registration step in addition to triage. Canadian 'physicians certainly order fewer tests than their U.S. counterparts partly because of limited resources but also because Canadian medical education places great emphasis on clinical assessment and frowns on the overuse of diagnostic studies. Canadian healthcare spending per capita is significantly lower than in the U.S., so there are fewer hospitals in a given city and EDs are more spartan. Tight budgets cause many of the EDs in Winnipeg, Manitoba to close at midnight, leaving only one central  ED open 24 hours in a city of 600,000.  

Israel
Renowned for their advanced level of trauma care, Israeli EDs are studied by trauma experts from around the world. In 2011, I toured the Rabin Medical Center ED in Tel Aviv with the Texas-Israel Chamber of Commerce as part of a delegation to promote business between the two countries in the life science sector.

The Rabin Center ED receives mass casualties from rocket attacks, terrorist explosions and military clashes that occur in close proximity to Tel Aviv. The medical director, Pini Halpern, MD, described scenarios where 50 or more trauma patients arrive at the ED door simultaneously. They discovered one essential element in preparing for mass casualties is to position as many wheelchairs and stretchers as possible in front of their ambulance bay doors. These doors measure 40 feet across, allowing efficient entry of multiple victims to the ED. 

Through these bay doors, only a few steps and a straight shot led to a large open surgical suite with half a dozen complete pods for laparotomies, thoracotomies and other major procedures. Less critical patients flow past the surgical suite toward the other medical and surgical areas at the back of the department, veering right or left depending on acuity level.

During my project to adapt our emergency physician template system for the Rabin Center, surprising differences became apparent between U.S. and Israeli documentation. Israeli physicians generally chart bilingually with the history and physical exam in Hebrew, while the orders, medications and diagnoses are recorded in English. This resulted in a template that resembled a checkerboard of the two languages, rendered even more curious given that Hebrew reads right to left and therefore a bi-column template is charted from the center of the page outward.  

India
The patient mix in a private Indian ED is much different than in a typical American ED. Minor complaints such as sore throats and sprained ankles are rare; in fact, patients usually don't come to the ED unless they are gravely ill. 

In 2012, I spent several days in India, modifying our template system for use by doctors and nurses in the ED of a private hospital in Noida, a rapidly growing urban area east of Delhi. Reviewing the daily log, I was astonished by the high acuity and the admission rate exceeding 70 percent.

Indian hospitals operate on a pure point-of-service basis. Insured patients represent only about 20 percent of visits with mostly cash transactions. The main lobby of the Noida hospital was crowded with family members waiting in lines to pay at long banks of cash registers. Indians consider it shameful to leave any debt unpaid; my Indian colleagues told me an Indian would rather die than not pay a bill. In fact, the collection rate for the Noida ED is around 95 percent, compared to a typical U.S. rate of 30 percent.  

Designing templates for Indian hospitals also presented surprising cultural differences. For example, on the template where clinicians indicate where a body is taken in the event of death, 'taken to morgue" is a standard choice. But few morgues exist in Indian hospitals, because normally the family takes the patient's body home to bury or cremate, according to their religious tradition.

Hundreds of differences, one striking similarity
When traveling abroad, most tourists try not to include a visit to the ED in their itinerary. But I have found working with emergency physicians and understanding their departments provides a fascinating glimpse into a nation's character. The one constant that has always impressed me is the sincerity and dedication of emergency physicians and nurses around the world — whether it is Manitoba, Tel Aviv or New Delhi.

Dr. Langdon is a board-certified emergency physician and co-founder of T-System Inc. Having stepped back from day-to-day operations of the company, he serves on the T-System board of directors and assists with trial implementations in countries across the globe. Langdon is an active member of the North Texas Angel Network, providing investment and guidance to early-stage entrepreneurs. Additionally, he is an active member of the Life Science Angels, Health Tech Capital of California and director for several early stage companies developing innovative healthcare technology products. Langdon received his MD from the University of Manitoba.

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