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What I did this summer: Stanford medical student works to improve emergency care in Cambodia

This summer, Stanford medical students contributed to projects in communities around the globe as part of the Medical Scholars Research Program. In this special back-to-school Q&A series, five students share their experiences developing preventive medicine strategies, gaining hands-on clinical experience and conducting field research.

As part of Stanford Emergency Medicine International (SEMI), School of Medicine faculty and students are actively involved in a variety of overseas projects aimed at advancing global emergency medical care through systems development, infrastructure expansion and educational innovations.

One such project is an ongoing initiative in Cambodia to develop video-based education modules for the management of common emergency complaints. SEMI co-directors Swaminatha Mahadevan, MD, and Matthew Strehlow, MD, have partnered with Center for Human Services, the non-profit arm of University Research Consortium, in Cambodia to develop these modules - but doing so requires learning more about the background of patients served by emergency departments at Cambodian hospitals and evaluating the effectiveness of current triage systems.

This summer, second year medical students Lily Du Yan and Mackensie Yore traveled to the Asian country to gather epidemiological data on patients from two hospitals (Battambang Provincial Hospital in Battambang and Sampov Meas Provincial Hospital in Pursat) and to assess a novel triage system implemented at one hospital to determine whether it should be expanded to others.

In the following Q&A, Yan describes how these initial projects will be useful in improving emergency medical care in Cambodia, and she discusses the challenges of working in a developing country.

What sparked your interest in the project and motivated you to spend the summer researching ways to enhance emergency medicine care in Cambodia?

As a first year medical student, I was interested in this project for three main reasons: [I wanted] to contribute in a meaningful way to improving international health on a local level, gain the skills to develop and implement a project in a developing country, and explore emergency medicine as a medical field.

As Stanford medical students, I think one of the major assets we have to contribute to international health is the research framework of asking questions and answering with evidence. This project is a way for me to contribute meaningfully.

In addition, working with emergency medicine physicians both at Stanford and in Cambodia presented a great opportunity to learn more about this career path. Emergency medicine is appealing because of its immediate utility and balanced emphasis on both diagnosis and treatment.

How will the epidemiological data collected on common illnesses emergency patients be used to help hospital staff improve emergency medicine care?

Data has been collected on everything from the patients' chief complaint to their occupation to the distance they traveled to arrive at the hospital. Each question measures an indicator that may affect the patient's final outcome and ability to return to normal activities. After analysis, this birds-eye view of epidemiological data may provide clues as to why some patients fare better than others. Once these indicators have been identified, this information can facilitate better planning, staffing, resource management and outreach to improve emergency case management at Battambang, Sampov Meas and other Cambodian hospitals.

Furthermore, this epidemiological data provides the foundation for the education modules mentioned above. Our research will help tailor the education modules to the local Cambodian context.

What methods did you use in evaluating the triage system established at Sampov Meas Provincial Hospital?

In addition to collecting data on triage times and associated mortality outcomes, we are also measuring the inter-rater reliability of this novel triage system as used by nurses at Stanford and by nurses at Sampov Meas. Triage systems are built to quickly identify patients with serious conditions that require immediate care, with severe patients assigned to severe triage levels. Thus, in an ideal world, different raters (nurses) should rate the same patient cases with the same triage level. Inter-rater reliability is a statistical tool that measures how much consensus there is among different raters for a series of standardized cases.

What have been some of the most challenging aspects of working on the project?

The language barrier has been one of the most challenging aspects of the research. Cambodians speak Khmer, which shares roots with Thai. My team spoke zero Khmer, except for a few courtesies, so all patient interviews were conducted through a team of local medical students who acted as our translators and cultural ambassadors throughout the project.

Working through a translator immediately doubles any interview length. As a result, there were times where our interviewing speed was the limiting factor in the number of patient cases we were able to capture. In addition, it's much more difficult to connect with a person with whom you cannot communicate directly. So much of building rapport is in the small gestures and comments that are trimmed for the sake of efficiency when translation is necessary.

Luckily, we happened to work very well with our medical-student translators, and our strong working relationship was instrumental in the completion of this project.

What was your most memorable experience working in Cambodia this summer?

At both Battambang and Pursat, we have been pleasantly surprised by how welcoming and open the patients have been to our research teams. One of our initial worries was that patients would not want to participate because they receive no compensation for completing the interview. But we've found the situation on the ground to be quite different.

Many people are happy to speak with us and seem genuinely grateful to have someone listen to and ask questions about their experiences of illness. We've even had a few people who said they decided to come to the hospital now because a friend or relative told them we were interviewing patients.

I think this is reflective of our experience working with Cambodians in general - very warm, welcoming, and curious about our presence.

Previously: What I did this summer: Stanford medical student helps India nonprofit create community-health maps
Photo by Lily Du Yan

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