Little things that make a big difference: Ian B. K. Martin, MD

March 1, 2010 — Ian B. K. Martin, MD, is assistant professor of medicine and emergency medicine at UNC. He also directs UNC’s Global Emergency Medicine program.

He received his medical degree in 2000 from the MCP Hahnemann School of Medicine and completed his residency at the University of Maryland Medical System. He joined the faculty of UNC in 2009.

dr martin on the right, crouching, with his arms around two Kenyan boys and a crowd of children behind them

Dr. Ian Martin in Kenya

The World Health Organization has warned that developing countries will increasingly face the double disease burden of infectious diseases and an increasing rate of chronic diseases. IGHID communications director Lisa Chensvold talks to Professor Martin about how emergency medicine fits into the global health landscape, his recent trip to UNC Project-Malawi, and the future of global emergency medicine at UNC.

Q: What is the role of emergency medicine in an overall global health strategy?

A: That’s an important question. Emergency medicine has been at the table of global health for some time. There are currently about two dozen international emergency medicine fellowships in existence. I think emergency medicine is going to play an integral role in a comprehensive global health strategy. Particularly in low income countries, the World Health Organization talks about the impending “double burden” of disease. When we think about the developing world, we all think about communicable diseases such as malaria, TB and HIV, which is why most people who’ve been involved with global health have been infectious diseases specialists. But over the next 30 to 50 years, these countries will also be burdened with chronic diseases such as diabetes, hypertension, and heart disease. Where the two intersect, emergency medicine is uniquely positioned to affect change, just as it is here in the U.S., where emergency medicine is well developed.

Q. What brought you to emergency medicine, generally, and global emergency medicine specifically?

A: When I went to medical school, I was planning to be a trauma surgeon. As it turns out, the majority of trauma patients are managed non-operatively. A mentor suggested I try emergency medicine, which I did, and I ended up loving it. I think it’s because I like all kinds of patients: kids, adults, elderly patients. On top of that, emergency medicine patients present with so many kinds of illness, whether medical illness, surgical illness, ob-gyn illness, etc. Emergency Medicine gives me the opportunity to care for a myriad of patients.

As for the global part, in the early 1990s I took some time off after college to travel and explore the world. I was considering something like the Peace Corps. I knew I wanted to go to a French-speaking African country, so I closed my eyes and put my finger over the map and it landed on Cameroon. I spent quite a bit of time there and saw what the Peace Corp was doing — it’s a fabulous organization, but I realized I wanted to contribute in a health care sense, so I returned to the U.S. and after briefly teaching middle school science, went to medical school.

Q: What are some of the challenges of doing global emergency medicine?

A: The first thing I would say is this: there is no shortage of good ideas. Let me say that again: there is no shortage of good ideas. The challenge is how you fund them. In my experience, it’s not that difficult to get someone to buy you some equipment or donate medicine. I think people see that as a way to contribute and be philanthropic, but those are all finite things. The real challenge is how to finance putting people on the ground, to do the training, to do the clinical care. This is seen as an infinite investment.

There are other challenges. Because you’re working in a resource poor environment, much of how I’ve been trained to practice medicine is just not applicable, or even possible. There are no CT scans, no MRIs, few blood tests. So that makes what we do extremely difficult. As a result, I’ve found that the people who do this kind of work tend to have first-rate clinical skills. Many times that’s the only tool available to you. I think it hones people’s clinical skills, and I find it makes me a better doctor. I see that in the learners we take internationally as well.

Q: As a new faculty member, what attracted you to Carolina?

A: Well, I must say that I come to UNC from our competitor down the street. Dr. Charles Cairns was a colleague at Duke briefly, before he came to UNC and became chair of emergency medicine. Let’s just say, Chuck can be very persuasive, and I’d have been stupid to pass up the opportunity to be part of something great here. Chuck is a great mentor who believes in the work I do and has a commitment to moving the department forward with regard to our international aims. Dr. Cohen and the Institute for Global Health & Infectious Diseases have also welcomed me and expressed their support for what I’m doing.

ian martin seated in front of Tidziwe Centre colorful tiled sign

Dr. Martin at Tidzewe Centre, home of UNC Project-Malawi

Q. Speaking of the institute, you recently returned from UNC Project-Malawi. Tell me about your visit.

A. I’ve been to about 10 of the 55 African countries, but this was my first time in Malawi, and it was a whirlwind trip. UNC is doing some amazing things there, for sure. The really important research they’re doing is informing what others are doing on the ground, such as Baylor, which also has a big presence in Lilongwe. I was really impressed with that.

Kamuzu Central Hospital is more developed than I thought it was going to be. Malawi is probably the poorest African nation I have been to, yet this referring hospital has a fairly sophisticated ICU. I think this is definitely because of the presence of these two major universities: Baylor and UNC.

I had one very moving experience on the last day I was there, just a few hours before I was scheduled to fly out. I was in the hospital, wearing a white coat, and two Irish medical students came up to me and said, “Can you help us?” They were caring for a patient in her early 50s who had malaria, but that was the least of her problems. She had probably had a devastating stroke, and she had a nasal gastric tube for feeding and it had come out. The med students needed help getting it back in. I asked, “Who’s caring for this patient with you?” “No one, really,” they replied.

After seeing the patient, I started a serious, but brief, conversation with the two Irish students about the woman’s condition. I told them to look at the big picture. This woman was not going to do well. She was probably going to die, so we should probably focus on keeping her comfortable. I said, “This is the conversation you need to have with the husband, and you need to get an interpreter to help him understand.” I found a clinical officer to help them facilitate this process. I hated to leave, but I had a plane to catch. But it definitely stayed with me how there are so few folks to care for these desperately sick patients.

For some reason, I was touched more than usual. Maybe it was because just over 36 hours later, I was back at UNC working in the emergency department, where I have a whole team of dedicated, well-trained personnel to help me provide excellent care to our patients.

Q: How can UNC’s Global Emergency Medicine program partner with UNC Project?

I was at UNC Project to see how acutely ill patients interface with the hospital when they come in for treatment. I spent some time with a doctor from Baylor who has broken off from traditional ID work and is focusing on pediatric acute care at the Under 5 clinic. By implementing some very simple things, such as the WHO’s Emergency Triage Assessment and Treatment guidelines, at least anecdotally, the doctor has noticed a 50% reduction in admission to the pediatric ward as well as a reduction in mortality.

At the Under 5 clinic, patients were identified up front as needing acute care, and brought off to a side room where health care workers could get IV access, test hemoglobin, glucose and oxygen levels, administer fluids, antibiotics, antimalarials, etc. These are not high tech things, but they are necessary things that are able to make a huge difference in terms of whether the patient is even going to be able to have a fighting chance. From that day I got an idea of what we could potentially do on the adult side of acute care at Kamuzu Central Hospital, and I’m excited to partner with UNC Project to move in this direction.

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Institute for Global Health & Infectious Diseases contact: Lisa Chensvold, (919) 843-5719, lisa_chensvold@med.unc.edu.

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