After the busy holiday season settled down in my final year of emergency medicine residency there was discussion about a new virus emerging from Wuhan, China.  Feeling so far away from the United States it did not seem like a big deal, and I didn’t think about how much this would impact my near future.   I remember jokingly practicing donning and doffing PPE with our nursing educator while on shift in February 2020.  I never imagined having to wear a mask in public for the next 2 years let alone an N95 to work every day. But my residency all came to a crashing halt when I first faced this virus.  Outside of a tiny negative pressure room in the high acuity area of the emergency department I donned a gown, n95 mask, gloves, and face shield.  I entered the room and remember being struck with fear.  Is my patient going to die?   How contagious was this?  Am I going to bring this virus home with me?  Am I going to get sick?  It’s daunting facing the unknown, but that is what makes medicine and especially global emergency medicine so unique.  Initially the ED slowed to a snail’s pace as the community stayed home. I called it “coronacation” as we closed sections of the ED at night. But as COVID-19 started to spread and we got busier than I had ever expected. Our residency graduation was cancelled and I entered fellowship, without the promise of doing the most vital opportunity of it, traveling. 

Over the first 6 months of fellowship, we continued to make travel plans for them all to be cancelled when traveling internationally was near impossible.  December 18^th 2020 was a life changing moment; I got my first COVID-19 vaccine.  It felt like I could see a light at the end of the tunnel.  In the Spring of 2021, and 4 COVID tests later, I was able to travel to Uganda.  It was a short trip, but it felt great to make up for lost time in my fellowship. I was mostly ecstatic that I didn’t get stuck quarantining in a hotel in Uganda.  With a vaccine and the world being more open to traveling, I felt like more of a global health fellow.

I had my eye’s set on Malawai ever since my first trip to Uganda in March 2019.  Our first global health fellow, Dr. Carly Brady, had made the long move with her family to Blantyre, Malawi and helped to develop the countries first emergency medicine residency program. I’ve unintentionally been following behind Carly for most of my medical training.  When I was a 1^st year medical student at Marshall University she was a 4^th year heading to Palmetto Health (now Prisma) Richland for her Residency in EM.  I don’t think it was a coincidence that I also matched at Palmetto Health. Although we were never residents together, I remember working with her as a fellow.  Dr. Brady, is a small chaotic ball of energy, with a passion for emergency medicine and global health that is inspiring to all who she comes in contact with.  It was only natural after being her shadow in medical school, residency, and fellowship that we finally get to work together in Malawi. 

In September 2021, Malawi finally lifted their international travel ban and I was off.  Malawi was a true emergency medicine experience.  I worked as a visiting emergency medicine consultant with Carly.  The country, thanks to a large effort from Carly, has started their first ever Emergency Medicine Residency.  I was able to work in an emergency department with EM residents in Africa.  The acuity is high and resources are low.  We can easily get basic labs  and imaging such as XR, CBC, Malaria testing,  and a urinalysis, but to get electrolytes, BUN, creatinine, LFTs, ABG and a CT scan can be a much more difficult task.  On my previous trips, there was not much emergency medicine and I felt like more of a primary care physician than an ER doc. In Malawi I was able to use my specialty to directly impact patient care.  In addition, I got to teach residents, interns, medical officers, and clinical officers. 

One of the best parts of Emergency Medicine is that the principles are the same from Malawi to the United States.  There was an older lady who presented in the chaotic evening at the Adult Emergency and Trauma Center (AETC) in Queen Elizabeth Central Hospital.   Chief complaint of: dizziness, every EM docs favorite complaint (sarcasm.)   It was pretty clear why the patient was so dizzy, her heart rate varied from the mid 30s-40s and her blood pressure was in the 80s systolic.  Getting an EKG at the AETC is possible, but there is no EKG paper to print on.  So I hooked up the EKG machine and took screenshots of the EKG monitor and tried to read what her underlying rhythm was.  Initially it looked like a 3^rd degree AV block, but was difficult to tell from the 5 pictures I took of a moving EKG machine.  We also struggled with IV access, a common problem in the United States as well.  Dr. Brady and her residents struggled with a central line while the nurse was finally able to establish peripheral access.  We were able to start some peripheral epinephrine to temporize the patient and try to figure out what her rhythm was.  Fortunately, we were able to get a cardiology consultation, who though it could have been a 3^rd degree block, but also wasn’t completely sure.  A 3^rd degree AV block isn’t great news in the US, but patients can at least get a pacemaker placed.  In Malawi, without a cath lab or cardiac enzymes, her prognosis was grim.  She was admitted to a “step-down” unit, or one level below the ICU.  The next morning during morning report we found that on further investigation of her health passport, a small book that patient’s have which reports their past medical history, she had been placed on increasing doses of metoprolol for her hypertension.  This women’s bradycardia and hypotension was due to an iatrogenic beta blocker overdose.  She was eventually transitioned off her epinephrine drip and was able to go home.  The next week during the resident’s academic day, I lead a journal club discussing a clinical trial of beta blocker overdose treatment that we had discussed during my residency journal club.   We discussed improvements that we could have done with this patient and how we could have managed her better. It was nice to practice emergency medicine during my global health fellowship.  It was nice to see how emergency medicine can be translated across international borders.   The experience with Dr. Brady at the AETC is one I won’t forget, and I plan on returning for a longer trip this spring.

COVID has been a large obstacle during my fellowship, but as the world becomes more connected, it really matters to the world what happens in a city you’ve never heard of in China.  If anything, COVID, has taught the world is that global health is important and matters.  Until he next pandemic…

-Amanda Stratton, MD

Prisma Midlands Global EM Fellow