COVID-19 Pandemic Prompts a Paradigm Shift in Global Emergency Medicine: Multidirectional Education and Remote Collaboration

Clinical Care and Public Health Advances in Technology

Technologic developments, including rapid point-of-care testing, telemedicine, mobile health technology, and low-cost medical devices, have allowed increasing numbers of people, particularly in low- and middle-income countries (LMICs), to access previously inaccessible and potentially lifesaving medical care. These innovations can provide diagnostic and therapeutic care in a cost-effective, timely, and sustainable way, improving health care delivery for millions of people living in regions lacking adequate health care infrastructure. Many of these developments supplement clinical diagnosis, improve treatment adherence, and increase dissemination of both emergency and general health information.^{14, 19-22}

Telemedicine can transcend geopolitical boundaries to improve the health of individuals living in even the most distant global communities.^{14, 19} Where the technology exists to support telehealth programs, they can fill in gaps due to lack of local specialist services, overly urban-concentrated generalist providers, and supplement public and medical health functions of overwhelmed health systems by reducing operational costs and enhancing organizational efficiencies.^{14, 19} The COVID-19 pandemic, in particular, has seen a rapid acceleration of the use of telemedicine visits, reducing patient and provider exposures to the virus while ascertaining who would benefit from an in-person evaluation.^{23, 24} Across the globe, in health care systems as diverse as China, Italy, India, the United States, and South Africa, virtual health care visits are allowing overwhelmed health care systems to provide ongoing medical care in a relatively expedient fashion.^{23, 24} GH providers are able to communicate and learn from one another through such technologically advanced platforms. The paradigm has shifted to bidirectional learning where high-income countries (HICs) may provide advice on infection control strategies while LMICs discuss their innovative strategies for COVID-19 containment and prevention such as dissemination of public health information through social media and the use of robotics to clinically assess patients.

With over 85% of the world’s population now covered by a commercial wireless signal and the ubiquitous presence of mobile cellular phones, mobile phones for health (mHealth) is another increasingly relevant technologic development.^{18, 25} mHealth applications use mobile technology to achieve health goals such as improving clinic attendance or medication adherence, enhancing community mobilization initiatives such as immunization campaigns, and bolstering the efforts of public health operations like those aimed at preventing drunk driving or promoting smoking cessation.^{18, 25} Point-of-care diagnostics represent another example of a cost-effective technologic advance that is strengthening the diagnosis and management of both infectious diseases and noncommunicable diseases like diabetes and heart disease that represent increasingly large fractions of the burden of disease in LMICs.^{20, 21}

These technologic innovations need to be implemented in a sustainable and low-cost fashion within LMICs instead of being exclusively donated from HICs. Local development and manufacturing of rapid diagnostics or medical devices can support prolonged use and maintenance of devices with the added benefit of supporting local economies and creating new job opportunities.^{26, 27}

Educational Advances in Technology

Other advances in technology have focused on promoting accessible and affordable means to exchange information and promote education. Distance and e-learning is a growing topic in limited-resource environments.¹³ In a 2001 bulletin, the WHO outlined advantages of distance learning in medical education including cost-effectiveness and wider dissemination of high-quality materials.²⁸ This same bulletin highlighted potential limitations including lack of access to technology (particularly high-bandwidth connections) and the need for ongoing quality assurance and rigorous assessment. This is especially true in remote regions and remain a challenge today as addressed in the “Remaining Challenges” section of the paper. Over the past 20 years, advances in technology and innovative collaborations have allowed for increased sharing of educational materials, training platforms, and mobile applications. In many instances, remote education programs are as effective as in-person teaching across disciplines.^29-31 The COVID-19 pandemic has highlighted the importance of these tools in allowing for ongoing collaboration and capacity building despite physical distancing and travel embargos. Several platforms for remote collaboration in education are discussed below with brief mention of limitations and pitfalls.

Carbon Footprint

Social distancing and decreased international travel in response to the COVID-19 pandemic and global restrictions on movements and border crossings have highlighted the effects of human activity on the climate. Air quality has improved in urban settings across the world with significant improvements in air pollution in settings as diverse as New York City and multiple Chinese cities.^{46, 47} These changes may be short-lived depending on how and when countries return to on-site and in-person business activities.

While rarely acknowledged, air travel to support GH projects results in harmful CO₂ emissions which contribute to the climate crisis and worsen GH outcomes.⁴⁸ An informal survey of eight GEM providers found total emissions of up to 76 metric tons of carbon dioxide for the academic year of 2018. To illustrate, these emissions equate to 16 passenger vehicles driven for 1 year or 176 barrels of oil consumed.⁴⁹

According to World Bank estimates, by 2050, there will be 143 million people from Latin America, sub-Saharan Africa, and southeast Asia displaced secondary to the effects of climate change.^{50, 51} This illustrates that the effects of climate change will more profoundly impact LMICs compared to HICs. While the airline industry had been overall expanding exponentially before the pandemic, only 5% to 10% of the global population partake yearly, with travelers typically originating from HICs. Prior to current restrictions, however, the percentage of the global population traveling by air was steadily increasing with resultant exponential growth in air travel emissions.

The COVID-19 pandemic caused a shift in many GH providers’ ability to advance GH objectives through on-the-ground work. Transition to the remote methods described above proliferated as a means to continue to support research, clinical, and training programs abroad.⁵ Quarantine considerations and the back and forth of international flights are not reasonable when evaluating the risk–benefits analysis in regard to virus transmission and time considerations, but this pause presents the opportunity to reflect on the environmental implications of the prior status quo.

Examples of Remote Learning

As the COVID-19 pandemic continues to spread around the globe, there has been a significant impact on education and training, and remote learning is evolving rapidly. With many institutions and individuals unable to travel freely to and from different regions of the world, many efforts have transitioned to online. GEM trainees have traditionally participated in field projects that include advancement of the specialty of EM in specific countries, hands-on ultrasound training, and participation in conferences and meetings including the WHO Basic Emergency Care (BEC) course, among other activities. Thanks to advances in technology and online tools highlighted above, some components of GEM can continue to be supported remotely. While portions of this shift started prior to recent travel constraints, it has gained steam during this pandemic. Examples of prepandemic remote learning include edX’s “Practitioner's Guide to Global Health,” a free online course that prepares trainees for international work and learning experiences.⁵² Although developed for undergraduate medical trainees, anyone can access the International Emergency Medicine Education Project (iem-student.org), which has a growing body of educational content and global EM tools.⁵³

Tele-ultrasound programs are an important example of remote learning established prior to the COVID-19 pandemic which are receiving ever-increasing consideration.⁵⁴ The ability to support global emergency ultrasound development continues to exist in areas where there were baseline relationships, existing ultrasound equipment, and connectivity to allow for remote communication and ongoing learning even where trainers and trainees are at a distance. This may include feedback during real-time ultrasound scanning via several evolving ultrasound platforms that allow for this, or asynchronous image review during sessions on video conference platforms. This technology has been used to rule out life-threatening conditions like pneumothorax and continues to be expanded in prehospital, military, and expedition settings as well.⁹² The feasibility of remote ultrasound has been increased in low resource setting due to increasingly portable ultrasounds that can run for a long time using battery power or even solar power.⁹³ Establishing remote support for a new ultrasound training program is more challenging but still possible, depending on what ultrasound equipment, educational platform, and Internet capacity is available to support real-time feedback on probe manipulation and image acquisition tips and tricks.

There has also been a growing trend toward incorporation of other trainees in weekly didactic conferences overall. EM trainees in Pakistan and Mozambique have joined EM residents in the United States and regional experts to discuss the management of common emergencies with a focus toward resource limited settings as well as to discuss COVID-19–specific topics via video teleconferencing. Similarly, GH journal clubs and paper discussions have now shifted to video teleconferencing programs.⁵⁵

In addition to the FOAMed resources that are popular around the world, there are increasing resources available for online training specific to trainees in LMICs. EM:RAP, a popular EM education podcast, has expanded its global efforts with new nonprofit EM:RAP GO. EM:RAP GO provides free access to EMRAP-branded educational material to trainees around the world.⁵⁶ FoEM (Foundations of Emergency Medicine) and Rosh Review have also partnered to make other online education platforms in EM accessible to trainees in the United States and globally.⁵⁷

Furthermore, there has been a rise of online education series on specific topics in EM, with toxicology education as a leader in this field. The American College of Medical Toxicology (ACMT) supported the Global Educational Toxicology Uniting Project (GETUP) in 2017 to advance toxicology education among practitioners around the world, which has shown improvement in toxicologic knowledge.⁵⁸ In response to the COVID-19 pandemic, ACMT also started to offer free toxicology-based webinars every week through their website⁵⁹ (Table 1).

Translation of Skills

Expertise and experience obtained during GEM subspecialty training can be repurposed to the domestic environment during times of crisis. As many hospitals and cities in the United States began to set up field hospitals to handle the surge in COVID-19 patients, GEM physicians shared their experience working in disaster zones and low-resource settings. The COVID-19 pandemic required the type of rapid scale-up of clinical services that GEM physicians are accustomed to dealing with from experience in humanitarian work where plans and operations are developed in anticipation of patient surges.^60-62

Task shifting is a familiar concept in GEM that is practiced in settings with an acute shortage of the traditional providers for a role.^{63, 64} Experience gained by just-in-time and focused additional training in humanitarian and low-resource settings can be applied to the domestic environment for triage and surge management.⁶⁵ Many health systems in the United States have redeployed GEM staff to new roles to support the growing crisis, at times using guidelines developed in the field.

Early in the pandemic surge there was inadequate access to testing and a rapidly evolving case definition that created diagnostic uncertainty that was uncomfortable for many United States–trained providers.⁶⁶ However, as GEM providers are accustomed to resource limitations with concomitant diagnostic uncertainty in their global practice settings, they have been able to apply that experience to developing fluid diagnostic and clinical treatment guidelines that are adaptable in the face of resource variability.⁶⁷ Triaging patients in a crisis setting based on resource availability is also an area where GEM has advanced research and practice.^68-70

It is important to also note that although GEM providers are well prepared for task shifting at their home institutions due to their experiences abroad, the pandemic provides an opportunity to change our notions of where expertise lies. Colleagues in resource-constrained settings have experience with infectious disease outbreaks of the Middle East respiratory syndrome in 2015 and the severe acute respiratory syndrome in 2002.⁹⁰ The GH model currently over emphasizes a unidirectional flow of technical assistance and capacity building from HICs to LMICs. COVID-19 provides an opportunity to reverse this trend and move toward a more democratic sharing of global emergency care knowledge in where LMICs share their pandemic experiences and expertise with HICs.

The COVID-19 crisis has created unprecedented levels of stress for health care providers for several reasons: practicing in a high-risk setting with high morbidity and mortality, making difficult triage decisions based on resource availability, and feeling isolated from family and friends.^{71, 72} These are commonly encountered scenarios in GEM and much work has been performed to better understand these situations, the impact they have on providers, and mitigation strategies.^{73, 74} Applying this experience and guidance to domestic providers facing this crisis/surge may help support the mental well-being of our providers working in settings of high COVID-19 transmission.

Faculty Inclusion

A potential silver lining of pandemic-related changes relates to faculty inclusion. While previously faculty facing family or administrative responsibilities, enrolled in coursework, or experiencing health issues or financial constraints have been limited in their ability to travel to support GEM projects, via the strategies discussed here, these faculty are increasingly able to share their expertise by participating in webinar series, asynchronous or synchronous educational activities, or research support over video conferencing. Additionally, ministries of health, local NGOs, and universities can more readily mentor GEM fellows and students in implementation of research programs.

Research Innovations and Challenges

The COVID-19 pandemic has resulted in a worldwide disruption of EM-related research activities, as the result of multiple factors, including research effort shifting to prioritize clinical activity, quarantined staff, changes to research infrastructure, closed sites, and limited travel.⁷⁵ While these barriers are not a new phenomenon among GEM researchers,⁷⁶ the COVID-19 pandemic has only increased the challenge of conducting research internationally. Innovation of conventional research practices is needed to overcome these additional barriers and to accommodate safe and efficient scholarly projects and studies. Solutions to these challenges, proposed by Levine et al. in 2016, ⁷⁶ are clearly more pertinent now than ever and can be used as a framework for research development (Table 2). Examples of these solutions include: prioritizing more significant leadership roles for local researchers (even if less experienced in research, remote support can help with further capacity building in this regard), use of remote/virtual research (i.e., surveys, mHealth, training of research assistants), retrospective chart reviews/systematic reviews without patient contact, analysis of existing databases, and dissemination of results online.^{75, 76} Overall, greater inclusion of local partners in establishing and leading research agendas will improve the relevance and success of contextually appropriate research efforts.⁷⁷ This can serve to further local research infrastructure building and allow for productive research partnerships despite travel limitations.

Global EM researchers are ideally situated to use in-place research platforms and partnerships for studying COVID-19, even if not initially designed to focus on infectious disease or outbreak responses.⁷⁸ The constraints and opportunities of the pandemic can and should be used to strengthen the understanding of the importance of research undertaken in emergency care centers as a frontline interface with populations to define epidemiology and clinical disease states in COVID-19. GEM can take cues from other GH research consortia, such as the African Research Coalition for Health,⁷⁸ in regard to building multi-institutional research partnerships for strengthening GEM research agendas. GEM researchers should maintain methodologic rigor in the setting of the significant proliferation of research (both peer and non–peer reviewed) related to COVID-19. Additionally, in the process of reescalating research activities, investigators should “adhere to public health guidance, prioritize the health and safety of the workforce and participants and implement fair and transparent processes for decision making.”⁷⁹

Economic Implications

Technologic advances in health care delivery and education also potentially provide economic benefits. When used in carefully selected settings, telemedicine services can save costs over equivalent in-person care.^39-41 Point-of-care diagnostics such as rapid diagnostic tests and point-of-care ultrasound may reduce facility cost through rapid delivery of results.^{42, 43} Learning strategies previously discussed, including MOOCs and Free Open Access Medicine (FOAMed), not only enable information to reach a broader audience and permit ongoing information sharing during a global pandemic but also result in reduced spending by learners.^{44, 45} Previously, access to critical appraisals of current medical literature was only available through expensive subscriptions, while now FOAMed resources like Journalfeed and Emergency Medicine Literature of Note allow individuals to access equally high-quality material for free. However, and as noted by Nickson and Cadogan.³⁴ “An important limitation to the expansion of FOAM is the ‘cost of free’. At this time FOAM resources are created largely by altruistic, motivated individuals, in their own time and at their own cost” and this may be less scalable or sustainable.^{34, 36}

Remaining Challenges

Despite advances and availability of technology, there are still vast disparities in access worldwide. Although cellular coverage is on the rise, data from the World Bank still shows that 84 countries have less than one mobile cellular subscription per person. Additionally, in 87 countries, at least 50% of the population is not using the Internet. Finally, in 30 countries worldwide, more than 50% of people still do not have access to electricity.⁸⁰

Even when available, the quality, reliability, and bandwidth of the Internet connection still remain significant barriers in many areas.^{81, 82} In 2019, 50 years after its creation, only just over half of the world is using the Internet, and that half often has inconsistent access. Additionally, the growth of new Internet “users” has significantly slowed recently. Also, issues such as censorship, security, and ownership—particularly of medical information and research data—remain a substantial concern as robust regulations may not be in place and access to secure Internet servers remains low in many LMICs.^{80, 82, 83}

Virtual interactions can make the complexities of cultural and language differences more challenging, particularly as remote technologies themselves have created a unique “virtual culture.”⁸⁴ Although these technologies have in some ways allowed for the maintenance of partnerships when there is not an on-the-ground presence and have increased access to and exchange of knowledge or expertise, some investigations into these connections have found they may result in a feel of a lack of accountability and difficulty in fostering new and meaningful relationships.^85-87 Interoperability, program and device compatibilities, and differences in regulations and standards of care are among other concerns.^{88, 89}

Differences in time zones can also be a barrier for meetings and live conferences, particularly interactive educational sessions. Collaborations that exist among individuals that reside in time zones that are between 8 and 12 hours apart can often result in meetings and/or sessions that must be held on the extremes or outside of the “typical” workday, which may be challenging due to family, social, religious, and/or personal obligations outside of work.

As the COVID-19 pandemic moves the GH community toward consideration of new paradigms for continued work abroad it is also important to recognize that the tradition of concentrating technical assistance and capacity building in the global north needs urgent reconsideration. Although a recent 2019 Global Preparedness Index placed many HICs among those most ready to face infectious disease outbreaks,⁹⁰ the COVID-19 pandemic has challenged the notion that economic wealth and HIC status would translate to successful pandemic response. Instead, many resource-constrained nations have years of infectious disease outbreak experience and rapidly scaled up contact tracing and widespread testing according to WHO recommendations.⁹¹ Looking toward the future, technologic platforms that remove the barriers of travel can help us move toward more equitable GH delivery, one in which expertise in pandemic preparedness from LMICs is shared with HICs.