Qatar: EM Under Construction

Published on January 31, 2013
A new post in resource-rich Qatar means unprecedented opportunities to develop the specialty.

Being an emergency physician, I have a fairly short attention span. I like things to happen with speed and hopefully some excitement! After nine years in Melbourne, Australia, developing an academic program and working with the clinical and research teams at The Alfred Hospital and Monash University, I needed some time out. The program is going well—lots of grants, good people and plenty of publications—but I just needed a new challenge.

Emergency Medicine isn’t the only thing developing in Qatar..Experts expect the Qatari construction market to grow by an average of 12.5% each year over the next decade, compared with an average of 1.7% growth in Europe over the same period.

So when the opportunity arose to spend some time in a very different environment, in a region where I had little experience and didn’t know what to expect, it was a no-brainer. I was asked to become the Chair in Emergency Medicine in Qatar, a place with financing, but lacking the guidance in how to develop emergency medicine.

Leaving a lot of half-finished projects in Melbourne has not been easy, but fortunately there are many talented people who will continue that work. Hopefully they will forgive me for my dalliance in the Middle East.

I had every reason to anticipate a rough entry into Doha. I arrived in the middle of summer’s sweltering heat, with Ramadan underway (people were fasting and grumpy and many services were shut down). On top of that I had all the normal administrative matters that I’d need to sort quickly if I was to get up and running. However, the entry into this new environment went more smoothly than expected. The organization has bent over backwards to assist and everyone has been very helpful. A month in, I have most of the important paperwork completed and can focus on the tasks at hand.

Qatar is literally ranked as the world’s richest country, as measured by adjusted per capita purchasing power. The Persian Gulf emirate’s wealth is relatively new, however, and recent growth has been rapid, both in infrastructure and population. The wealth is based mainly on gas, rather than oil, and the facilities for exporting large quantities of gas have only recently been developed. The current population is estimated at 1.8 million, however only about 300,000 of these citizens are actually Qatari. The rest are expatriate workers, employed to build a nation. This means that 75% of the population is male and most are under 40 years. Unfortunately, because of wealth and poor public health programs, the biggest killers for the local population are obesity-related diabetes, heart disease and trauma.

My first impression of the Hamad General Hospital ED (the only tertiary ED for the country) was that it was a chaotic construction site! The ED is under-going a renovation to temporarily improve patient flow before a major rebuild takes place in 2-3 years time, followed by an even more impressive rebuild in 8 years. Hopefully by the third rebuild, we will get it right. We are desperately seeking input from global authorities on ED design, such as Manny Hernandez. Predicting the model of care five years from now in a constantly changing environment is not possible; flexibility is the key. The ED is huge, seeing about 1500 patients per day. Fortunately, most injuries are minor and are seen in the Fast Track areas. In fact, it is not uncommon for a bus load of workers to arrive with minor ailments and injuries. The short stay model of care has taken off with more admissions going through short stay than inpatient beds. The “Short Stay” model has now expanded to a projected 72 hours length of stay, to account for deficiencies in inpatient processes. Although very efficient, this goes beyond the normal short-stay model.

The physical layout of the Qatari ED is much different than I would have expected, coming from a Western-style department. There are separate entrances and waiting areas for men and women–-and one dedicated to the local Qatari population. There is a strong Muslim influence and this extends to many practicalities such as a lack of eateries during the fasting times in Ramadan, prayer times and strict customs regarding male/female interactions. Doctors and nurses working in the ED come from all over the world many from countries dominated by other religions and cultures. This leads to many potential clashes in culture and unmet expectations. Whilst waiting for my medical examination I casually sat down in a vacant seat next to a woman who was also waiting. I couldn’t quite understand why everyone was staring at me, then I real- ized that the "male waiting area" was around the corner. Soon after, in my usual Australian manner, I went to shake hands with the nurses only to be quickly reprimanded for attempting to touch a woman. I am hoping that we can plan to develop the best-designed ED in the region while taking into account these and other cultural sensitivities.

Overcrowding has been a big issue in the ED, with up to 60 patients waiting each morning for admission. Fortunately, this has been a focus of improvement across the hospital over the last six months. The success of this program has been evident by the routine occurrence of no patients pending admission over the last month or two. Sustainability will be an issue, but the process improvements underway will go a long way to maintain the momentum. The main changes have been routine tracking and reporting of patients waiting for admission and ward discharge data to ensure that there is a hospital wide focus on the issue. Emphasising inpatient unit accountability for admission and discharge decisions in the ward has also been important.

There are a huge number of doctors working in the ED. Approximately 200 emergency doctors with varying levels of emergency training and experience from all over the world are working at Hamad General Hospital and associated “walk-in clinics.” At present we have one Qatari consultant in adult emergency medicine, although this is likely to change over the next few years. One of our immediate challenges will be to develop a coherent workforce strategy that will ensure a sustainable model for training new graduates and maintaining and up-grading skills of the present workforce. There is no mandated CME program specifically for emergency medicine and no Qatar board exam. There is a four- year Arab Board training program, which is beginning to deliver good graduates. The intention is to develop a three-year fellowship program in addi- tion to the Arab Board over the next couple years, resulting in a high level fellowship qualification. The fellowship program would cover the topics that are typically not well covered by basic board qualifications, including management, disaster medicine, research and teaching skills and elective subjects such as ultrasound and critical care.

At present we have one Qatari consultant in adult emergency medicine, although this is likely to change over the next few years. One of our immediate chal- lenges will be to develop a coherent, sustainable workforce strategy.

The case mix in the ED is different than any other ED I have worked in. The trauma cases are similar, although there is virtually no penetrating injury. Heat exhaustion and heat stroke are common, as the temperature during summer hovers around 45-50 C with high humidity. Amazingly, manual workers continue to work outside in these temperatures. Even more bizarre is the fact that many of the workers come from Nepal (a trifle colder than here). Meanwhile, I get heat exhaustion walking to the car. With the hot weather, renal colic is common, along with dehydration and electrolyte disturbanc- es. There are many minor injuries associated with manual labor. The older patient group has a high rate of diabetes, heart disease and renal failure associated with high obesity and smoking rates. There are also some very unusual diseases associated with the countries that guest workers come from. For example, Neurocysticercosis is common in the Nepalese workers, presenting as seizures. These are usually managed in the short stay area. I saw only a couple of these in 20 years of ED practice in Melbourne.

Prehospital care has been neglected in this country until recently. Over the last five years there has been a massive investment in para- medic training and development. In addition, the coordination, quality control programs and clinical practice guidelines have been massively upgraded. Despite this, most patients prefer to come by private vehicle, even when seriously ill.

The politics are very different here compared with most Western countries, in that there is a hereditary ruler with no elected government. One would expect that this would make government less responsive to the population than with a democracy, but that has not been the case in my experience. There is a perceived need by the Qatari government to keep the population satisfied with their health services--a desire to please that seems even stronger than in many de- mocracies. Political involvement in clinical planning seems as strong here as in Western democracies. The ruling family and Ministries are frequently seen in the hospitals and demand a lot from health administrators. Importantly, emergency medicine is seen as a high priority area and there is strong backing to take it to the highest level internationally.

Given the potential resources available and the political will, it seems inevitable that emergency medicine will improve in Qatar. Hopefully, eventually, Qatar will showcase the value of investing in this cornerstone of modern medicine. I am hoping that we can demonstrate just what a difference good emergency care can make to the way the healthcare system functions and ultimately to patient outcomes.

From the Fall 2012 issue of Emergency Physicians International

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