Transferring Japan’s expertise in Mongolia’s emergency
medicine
Prof. Takushi Sato(AMDA Board Member, Professor at the Faculty of Allied Health Sciences, University ofEast Asia)

Introduction:Since 2017, AMDA has transferred medical expertise to Mongolia in the field ofemergency medicine. Ulaanbaatar Emergency Service 103 (hereafter referred to as 103)
being AMDA’s counterpart, seminars and workshops have been held at its headquarters
in Ulaanbaatar. This year, Erdenet, Orkhon Province, the second-largest city in thenation, was added to the list of destinations in which AMDA organized the training.
Erdenet is located 375 km (seven-hour drive) from the capital.

Seminar in Erdenet (27-28 April 2019):
AMDA held a two-day seminar for local doctors andmedical practitioners with a special focus on
emergency medicine. The event garnered around 100
participants, most of which were from Erdenet Medical
Central Hospital, state-run Medipas Hospital andprivately-owned clinics.

Day 1:The seminar kicked off with opening remarkspresented by Dr. Oyunhand (Director of Policy Making,Mongolian Ministry of Health) and hospital officials.
103 addressed the full contents covered in the past
which ranged from FAST (Focused Assessment withSonography for Trauma) for external injuries,
intraosseous infusion, pericardiocentesis, to surgicaltracheostomy. The lecture focused on the basic
approach to emergency patient transfer, especiallylooking at severe external injury cases.

Medipas Hospital

Opening remarks by ministry andhospital officials

On the first day, I showed the participants how to use an ultrasound scan to diagnose
the bleeding part after explaining the circulatory shock caused by external wounds.

Doctors who had seldom used the scan found it a little tricky handling it. I also explained
the characteristics of chest ultrasound using actual images.

FAST training

Responding to a request made by local medical
personnel, I also gave guidance on how disastermedicine is regarded in Japan. Based on AMDA’s
past experience, I stressed the importance ofCSCATTT (Command & Control, Safety,Communication, Assessment, Triage, Treatment
and Transport) which is the fundamental principleof disaster medicine. To wrap up my lecture, I told
participants that the safety of relief personnel also
needs to be prioritized, because they are always at
the risk of losing their lives in the secondary Lecture on disaster response in Japan (i.e.
Kumamoto Earthquake etc.)
disaster.

Day 2:

Checking the position of one’s cricothyroid
ligament

On the second day, we organized apractical workshop on intraosseous
infusion,pericardiocentesis,andsurgical tracheostomy. For surgicaltracheostomy, we highlighted on
cricothyroidotomy and checked theactual position of cricothyroid ligamentthat needs to be cut open. As forpericardiocentesis, after identifying thepericardial effusion collection using
ultrasound, I practically demonstrated
how to insert indwelling needles (over18G) using an anatomical model.

Intraosseous infusion is not commonly practiced inMongolia. However, for infants who sometimes havedifficulty getting the infusion route, this is an essential
technique that emergency doctors need to learn. Since
intraosseous needles are not available in Mongolia, weborrowed them from Mongolian National University ofMedical Sciences (MNUMS). The trainees practiced theprocedure on bone-in chicken meat using the needles theschool imported from China. This way, it allowed theparticipants to get the actual feel of putting the needle
through flesh.
Using actual needles toexperience the procedure
103’s Training Manager Dr. Tegshjargal Baast, who acted
as my assistant, did a tremendous job based on what he had
gained in the last couple of years. His technical progress was remarkable and I washappy to see it before my eyes.

Dr. Tegshjargal Baast whoserved as Prof. Sato’s assistant(right)Conclusion:
The participants said the workshop was truly meaningful
because it was a rare occasion for Erdenet’s emergency
doctors to come together irrespective of what hospitals they
belong to. They said the so-called “practice-oriented” lectures
made a difference since the contents were directly linked withactual procedures.

Notes:A local endoscopy specialist sought my advice on howcholedocholithiasis (a large calculus) should be treated.
Since it is difficult to remove the calculus with a standard
endoscopic method using basket/balloon catheter following
EST, I told the doctor that alternatives such as ESWL orlaser lithotripsy below POCS must be considered. (On aside note, the doctor had previously attended my seminar atMNUMS two years ago.)

Seminar at Ulaanbaatar Emergency Service 103:
I chose OSCE (Objective Structure Clinical Examination) for this year’s topic considering
my seminars over the past two years at 103. This time, I decided to conduct a training
session assuming that 103 doctors were working at a hospital emergency ward. I cameup with this idea because their capacity is limited especially due to the fact that their main
work is patient transfer and most of the treatments are done in the ambulance.

OSCE (Objective Structure Clinical Examination):
OSCE is all about going through the actual scenarios of possible emergency cases suchas acute patient deterioration. During the training, the doctors used an anatomical model
to assess the life risks with which a patient maybe faced and come up with precise care.
I strongly believe this workshop helped them understand the essential treatment that isrequired during the patient transfer and made them realize what it takes to be anemergency doctor at medical centres.

Through this training, the participants learned that they should not be overconfident ofthings they had already known, because quite a few things might be overlooked. “Theonly way to make up for it is to always hone our skills and thoroughly make efforts at
improving diagnosis and cure," they said.

After the seminar ended, 103 Director Mr. Prevdash
commended AMDA’s three years of contribution touplift the expertise of its staff and issued a certificateof appreciation, stating that 103’s ambulance service
has been increasingly gaining a good reputation.

As 103 will be celebrating its 90th anniversary in2020, Mr. Pravdesh said he would be happy to invite
me to the celebratory function. At the moment, there seems to be a lot of plans in hismind including a training session for emergency doctors in regional areas, as well as
their building renewal and facility enhancement (with Asian Development Bank being
their expected donor.) For the latter, Mr. Pravdesh revealed that a plan to introduce a
medical helicopter is also in sight.

Message from Mr. Pravdesh (Director, Ulaanbaatar Emergency Service 103)“For our staff who joined the training in the last years, this year’s
program provided more practical and advanced materials. The training
was a must for our staff as we are now trying to expand our services. I
would like to extend our sincere gratitude to Prof. Sato for his
assistance thus far and wish for his continued guidance.” “This year,
we feel thankful that Prof. Sato undertook the training session inErdenet, the second largest city in Mongolia. For its geographicalcharacteristics, emergency medical practitioners in Erdenet arerequired to tackle more external injury cases from mining and traffic accidents. It was thefirst full-scale seminar to be held locally that involved practical training. As a result, it
turned out to be one of the most satisfying seminars held in the region. “Message from Ms. Batmunkh Urtnasan (Head of Department of Hospital Health Service,
Orkhon Province Health Department)“Orkhon Province Health Department and 103 have jointly worked atorganizing ER training programs in which more than 150 medical
institutions took part. Having Prof. Sato from AMDA Japan, theparticipants were pleased to see his techniques in learning how torespond to emergency cases. As it is rare for us in Mongolia to attend
a participatory-type workshop, every moment felt like a new learning
experience. Prof. Sato’s session (in which he talked about disaster
response in Japan) took place at the right time, because a nationwide
disaster drill was recently held in our country for the first time in 32 years. On behalf ofour department, I would like to express our heartfelt thanks to Prof. Sato and AMDA for
providing a wonderful opportunity and support.”