In a strategy to improve the emergency care system by offering postgraduate training to the caregivers, the first partnership activity was to establish a forum where educational initiatives could take place. In July 1993, the Emergency Medical Services Institute, housed within the hospital, was authorized by ministerial decree to provide post-graduate medical education in emergency medicine and nursing. The Institute was established as an official Armenian National Institute of Health affiliate. It is the home of all partnership eduvation and trainin programs. By 1999, its emergency medical training branch had taught 128 40-hour courses to over 5000 trainees since 1993 and its nursing branch had reached 426 nurses since 1996. As of today training has been provided for every emergency worker and the system is well-implanted for periodic refresher courses.
- Emergency Medicine Outreach to the Communities
After emergency medical training had been in place for six years, Boston University School of Medicine obtained a one-year contract from American International Health Alliance (AIHA) to take our training programs out into the districts. “Emergency Medicine Outreach to the Communities” provided support for physician- and nurse-instructors who had been trained in partnership training programs to teach in outlying communities. Twenty-six courses in three content areas (nursing physical assessment, pediatric emergency medicine and disaster medicine) were taught. Sites included the Pediatric Emergency Hospital in Yerevan and hospitals in Etchmiadzin, Ararat, Armavir, Metzamor, Sevan and Charentsevan. The first course was conducted in Etchmiadzin March 29-April 2, 1999 and consisted of instruction on nurse assessment skills. Armenian course planners used teleconferencing between themselves and BUSM nurses to plan for the course and to develop course materials. The project demonstrated the expanding influence of the then Emergency Scientific Medical Center, the hospital with which the Partnership Program has been partnered since 1992, recently renamed Grigor Lusavorich Medical Center. The program was well-received by the outreach hospitals whose directors termed it an “outstanding chance” for their participation and an “important step” in development of Armenian continuing medical education.
- Pediatric Emergency Medicine Course
In an example of emergency medicine outreach, a pediatric emergency medicine course was developed for the Pediatric Emergency Hospital of Yerevan. Physicians from this hospital worked with the partnership’s core administration, attended training courses, completed a trainee-instructor phase and then began to teach the curriculum in their hospital.
- Emergency Nursing Course
Emergency nursing, unique to other specialties in the practice of healing, encompasses all specialty areas involved in the treatment of the ill. From this principle an emergency nursing course was developed for Emergency Scientific Medical Center, consisting of topical outline and practical skill stations. The course covers facility design and violence management in addition to basic life support, wound care, and critical care issues. Trained ESMC nurse-instructors teach the course at the hospital and in outlying communities.
- Train-the-Trainers Course for the International Medical Education and Harmonization Program for Nuclear Accident Preparedness
A newly-developed curriculum is a trainer program on assessment of radiation exposure to humans, diagnosis and treatment of radiation injury, and organizational aspects of medical preparedness in radiation accidents. The course is based upon principles taught by the Radiation Emergency Assistance Center/Training Site, of the Oak Ridge Institute for Science and Education, a U.S. Department of Energy facility. Instructor trainees from five AIHA-sponsored regional training centers (in Armenia, Estonia, Moldova, Russia, and Ukraine) and 10 Eastern European countries took the trainer course which included an instructor training workshop led by the Boston University Center for Educational Development in Health. The course took place in October 1997 in Oak Ridge, Tennessee, with subsequent “echo” courses taking place first in Armenia then in other countries. As the program has grown, the Yerevan center has frequently served as the “field-test” center where this program’s activities are initiated.
- Basic and Intermediate Emergency Care for Ambulance Professionals
The first curriculum to be developed was a basic and intermediate emergency care course, designed to update the knowledge and skills of the ambulance workforce. One of the components of the emergency care curriculum was a disaster simulation, Yerevan, July 1993. In December, 1993, a trauma/training ambulance (see picture below) was deployed in Yerevan to provide a training site for skills newly learned and a data collection unit. Data are entered into a computer database, permitting longitudinal studies of the nature of ambulance calls, call intervals and patient outcomes. Continuing the theme of emergency preparedness, the partnership uses drills, instruction, video, telemedicine, and internet resources in combination to develop programs.
- Train-the-Trainers Course for Regional Training Centers
A train-the trainers course incorporated disaster preparedness training, University of Massachusetts Medical Center, Worcester, July, 1994.
- EMS Training Curriculum for NIS Regional Training Centers
The basic and intermediate courses became the model for a training curriculum offered at regional training centers that now operate in 8 centers across the former Soviet Union. The first center (see below) opened in Yerevan on September 21, 1994. Over 3166 physicians, nurses, ambulance drivers and first responders have been trained in the Yerevan center.
- Emergency Department Curriculum for NIS Regional Training Centers, a curriculum for emergency professionals based in-hospital, was offered in 1996.
- A Train-the-Trainers Course for the Emergency Department Curriculum
took place in Worcester and Boston, July 1996. Instructors from the Centers in Yerevan, Armenia; Almaty, Khazakstan; Chisinau, Moldova; and Vladivostok, Russia participated.
- 100-hour Basic Nursing Course
Several courses were developed specifically for nursing. They have become required programs for the advancement of nurses within the hospital.
- 400-hour Advanced Nursing Course, developed and offered in 1994
- Emergency Residency Curriculum
A 24-month program for emergency physicians at the Emergency Hospital is the first approved emergency residency program in Armenia. It has graduated 17 residents to date. Several residents have pursued their training at Boston Medical Center and University of Mass. Medical Center upon completion of the residency program.
- Tutorial Sessions in Critical Care
- Management Methods for International Health
This course is adapted from a certificate program of Boston University School of Public Health’s Department of International Health
- Medical Elective, “Medical Care in Armenia”
Open to all fourth-year medical students under Boston University School of Medicine’s International Health Elective. The elective is a combination rotation and offers the opportunity to work in hospitals and clinics in Yerevan and participate in ambulance calls to patients’ homes. 13 US fourth-year medical students have received academic credit for their participation in this elective.
- The Emergency Medical Services Institute at the Emergency Scientific Medical Center houses a Nursing Learning Resource Center, established in 1996. The Center was formally recognized as an ANIH Center for Post-Graduate Nursing Education and provides nurse training for licensure. Over 426 nurses have received post-graduate instruction, skill building and programs in leadership development. The Nursing Learning Resource Center has served as the home base for activities concerning improvement of hospital infection control practices and policies, the establishment of regular nursing professional rounds, and an (electronic) journal club by which Armenian and US partners share information through the Center’s telecommunications capability. Recently its director, Rosanna Ginosian, former Chief Nurse, Armenia Ministry of Health, and currently MOH Chair of Clinical Nursing, was inducted into the international nursing honor society, Sigma Theta Tau, one of a small group of nurses from the NIS to be chosen for this prestigious society.
- As the educational program evolved, Armenian nurses desired to create their own, first-ever professional nursing association. The Association was aided by the collaboration with the Council of Armenian American Nurses, on whose board sit members of this partnership and that of the Erebouni Medical Center College of Nursing/UCLA Medical Center partnership. The Armenian Nursing Association has sponsored three annual meetings. The first one, the inaugural meeting, was held in April 1996 and the second took place in June 1997, coinciding with the opening of AIHA-funded Nursing Learning Resource Centers. The most recent meeting, held in June 1998, was an ANA-led activity, sponsored, organized and partly paid for by the Armenian Nurses Association.
- Mechanical Ventilation
- Airway Management
- Part 2, Ventilation Modes and Techniques
- Shock: Types, Assessments, Treatments
- Nursing in the United States
- Non-Invasive Physical Assessment
- Cardiac Assessment
- Pulmonary Assessment
- Neurologic Assessment
- Continuing Nursing Education (via Telemedicine)
- Nursing Documentation
- Nursing Leadership
- Train-the-Trainer Program
- Nursing Leadership
- Infection Control Manual Development
- Mechanical Ventilation
- Other programs have been held conjointly during nursing training rotations at Boston Medical Center.
- Nursing Leadership Development
- Policies and Procedures
- Standards of Care and Practice
- Job Descriptions
- Infection Control
- Organizational Development
- Competency-Based Orientation
- Critical Care Nursing
- Medical-Surgical Nursing
- Emergency Nursing
- Physical Assessment
- Council of Armenian American Nurses
- Executive Committee
- Relationship to Armenian Nursing Association
International Health Elective of the Boston University Medical Center Partnership with Emergency Scientific Medical Center
Fourth-year medical students from accredited medical schools in the United States and Canada are taking part in the “International Health Elective” offered at the Emergency Scientific Medical Center in Yerevan, Republic of Armenia through Boston University School of Medicine’s program. (application form) Rotations in emergency care and trauma, chest medicine surgery, critical care and pulmonary medicine are offered. Students also rotate through the Armenian National Institute of Health and its affiliated clinics. The program, which started in 1994, is the only externship for credit available in the Newly Independent States. The elective lasts four weeks and affords the opportunity to observe medical care in a post-Soviet setting as well as participate in ambulance runs throughout the capital. Student evaluations have been very positive and have been used to make changes to enhance the program. To date over 20 medical students from the following universities have participated in the program: Boston, California-Irvine, California-Los Angeles, California-San Francisco, Hawaii, St. Louis, Tufts, Tulane and Wright State.
Medical preparedness for radiation accidents is high on the agenda for emergency preparedness in the Newly Independent States. BUSM, the U.S. Department of Energy’s Radiation Emergency Assistance Center/Training Site, and the University of Massachusetts Medical School developed a training program that aims to:
- Train a cadre of instructors on recognition and management of patients accidentally exposed to ionizing radiation;
- Train the cadre in pedagogical technique and educational assessment;
- Support the cadre’s conduct of further training by providing structured opportunities for teaching; and
- Integrate regional medical response in the event of a radiation accident.
The program consists of core curriculum, manual, faculty development, course instruction, an online regional accident management network and practical exercises using monitoring equipment. The program is targeted to emergency first-responders in Eastern Europe and the Newly Independent States. The International Atomic Energy Agency provides funding and guidance with respect to integration of the project into regional emergency preparedness. American International Health Alliance-sponsored regional training centers are used as training sites. Three trainer cycles, 21 training courses and one Internet-based radiation accident exercise have taken place, reaching 466 emergency professionals from 25 European member states. The trained instructors have delivered the course 12 times in their own countries.
In this program, increasing numbers of emergency first-responders are becoming familiar with regional and national policies, procedures, roles, and responsibilities with respect to radiation accidents. Medical professionals are being trained under a unified approach and constitute a core network that holds promise for their incorporation into national response plans leading to integration into overall emergency response. This training program demonstrates the joining of academic, local, and governmental institutions with a United Nations agency to address an issue of high regional concern.
One of the components of the training is web-based simulations. In Yerevan, August 15-18, 1999, a radiation accident exercise involving regional training centers in Armenia, Estonia, Moldova, Russia and Ukraine was conducted. In the exercise, an accidental exposure to radiation was simulated and inter-regional cooperation among eight nations was tested. The exercise provided a new use of telecommunications technology for emergency preparedness training in this specialized field in which preparedness is essential but practical exercises are lacking. The exercise objectives were that participants:
- Recognize accidental exposure to a radioactive source and initiate the appropriate cascade of events by emergency medical personnel;
- Conduct a medical assessment of potentially exposed individuals;
- Arrange for a radiation exposure assessment at the site of the accident;
- Report the accident to proper authorities in Armenia and in participating countries and to international agencies;
- Demonstrate international coordination/cooperation in victim identification, assessment and medical management;
- Employ telecommunications technology to connect medical responders in participating countries during the exercise; and
- Carry out a debriefing teleconference immediately following the exercise.
As a component of the Armenia Medical Partnership Program, teleconferencing has been developed. The teleconferences provide a regular, direct link between Yerevan and Boston and enhance learning beyond the limited opportunities of travel. A simple, interactive, audiographic system, the Optel Teleconferencing System, in use at Boston University Medical Center since 1987, is used for the project. It requires a computer, Optel software and two standard telephone lines, one for voice and the second for still image transmission. The system is suitable for environmental conditions in Armenia which are marked by frequent power outages, unreliability of local phone connectors and the complexity of the communications infrastructure.
In March, 1995, a BUMC team traveled to Yerevan to install the equipment and train personnel on its use. In addition, a protocol for presentations was established that included length of time, number of screens per session, visual format, compatibility with interpretive services, congruence with project mission and adaptability to the Armenian health care system. Each time there is a teleconference the prescribed format is used, thus ensuring that clinicians understand each other and receive the proper information.
To date there have been 42 programs linking over 100 physicians, nurses and hospital administrators, including a series on disaster preparedness. The teleconferences have provided 100 contact hours of teaching and patient consultation. With the recent installation of web-based teleconferencing among regional EMS training centers, the Yerevan center now has a forum for regional exchange. Our teleconferencing project was honored as the 1999 recipient of the International Teleconferencing Association’s Award of Excellence for Best Application in Audiographics/Multi-Media. The award recognized the creation of an electronic network linking the regional training centers, BUSM, and the International Atomic Energy Agency and the potential for peer collaboration and communication.
Boston University Medical Center/Armenia Partnership Program Telemedicine Conferences, 1995-2001
|3/9/95||Laparoscopic Assessment of Resectability of Carcinoma of the Pancreas||3||Hirsch, Becker, Birkett, Babloyan, Minassyan, Joseph, Gaboyan, Hovakimyan, Sargavakyan||Didactic Session and Case Presentation|
|3/13/95||Case Studies in Emergency Medicine||3||Manukyan, Vanyan, Shakaryan, Minassyan, Caggiano, Kharasch, Hirsch||Didactic Session and Case Presentation|
|4/18/95||Nursing Patient Documentation System||1.5||Vartanian, Brush, Joseph, Ginosyan||Didactic Session|
|6/20/95||Adult Respiratory Distress Syndrome||3||Manukyan, Sargavakyan, Hirsch, Minassyan||Didactic Session|
|6/22/95||Hypophyseal Tumors and Post-operative Care||3||Gaboyan, Babikian, Reed, Spatz, Minassyan||Didactic Session|
Planning and Implementation
|2||Mitchell, Vartanian, Joseph, Brush, Ginosyan||Didactic Session|
Planning and Preparation: The Keys to Successful Disaster Response, special session of AIHA annual conference held in St. Petersburg, Russia, with Boston University School of Medicine
|3||Hirsch, Mottley, Aghababian, Racht, Minassyan, Mosneaga, Poladko, Reva, Selutin||Didactic Session and Panel Discussion|
|12/7/95||Gunshot Wound to the Head||2||Sargavakyan, Minassyan, Grindlinger, Hirsch, Brush||Consult|
|4/24/96||Telemedicine Demonstration and Troubleshooting||2||Screnci, DerBoghosian, Tadevosyan||Demonstration and Management Exercise|
Planning and Preparation: The Keys to Successful Disaster Response
|3||Varadian, Mottley, Abrahamian, Serino, Donahue, Minassyan, Hirsch||Didactic Session|
|6/6/96||Neurology Case Presentation||2||Babikian||Consult|
|7/19/96||Preparation for Armenian physicians’ experience at Boston Children’s Hospital||2||Giragosian, Crocker, Szymanski, Helm, Hakopyan, Danielyan, Shishmanian||Discussion|
|11/12/96||Hepatitis B and Hospital Infection Control||2||Vartanian, Joseph, Sulis, Atamian, Barsamian, Murphy||Didactic Session|
|2/12/97||Surgical Patient with Abdominal Pain||2||Hirsch, Minassyan||Consult|
Management of Infection in the Immune-Compromised Patient
|3||Hirsch, Sugar, Davidyan, Turai||Didactic Session|
|12/4/97||Pulmonary Sequestrum||1||Hirsch, Lerman, Aldea||Consult|
Use of Cytokines in Management of Bone Marrow Suppression, Videobridge International, Moscow, Russian Federation
|3||Hirsch, Comenzo, Antipin, Konchalovsky, Selidovkin, Baranov, Turai||Didactic Session|
|1/28/98||Nursing Electronic Journal Club
Physical Assessment of the Cardiac Patient
|2||Brush, Joseph, Ginosyan Jenkins, Sahakyan, Vartanian||Didactic Session|
|3/31/98||Acute Renal Insufficiency||1||Schwartz, Babayan, Tsaturyan||Consult|
|4/22/98||Nursing Electronic Journal Club
|2||Brush, Jenkins, Ginosyan, Vartanian||Didactic Session|
|5/20/98||Nursing Electronic Journal Club Organizational Structure||2||Joseph, Brush, Jenkins, Ginosyan, Vartanian||Didactic Session|
Radiation Accident at Boston Logan International Airport and Highway Car Accident with Radiation Exposure, Regional EMS Training Center, Chisinau, Moldova
|3||Hirsch, Serino, Brinsfield, Parker, Collins, Ciobanu, Turai||Didactic Session|
|7/27/98||Congenital Dislocation of the Left Femur of a Pediatric Patient||2||Discussants from three sites in Yerevan, Armenia; Boston, Mass., USA, and Tallinn, Estonia included Hirsch, Pacicca, Vosumaa, Jakovleva, Luik, Korsakova||Consult and Discussion|
Radiation Accident at Logan International Airport and Radiation Accident in Estonia 1994: Discovery, Management and Victim Treatment, Estonian Disaster Medicine Center, Tallinn, Estonia
|3||Hirsch, Serino, Brinsfield, Parker, Collins, Vosumaa, Turai||Didactic Session|
|9/30/98||Telemedicine Demonstration and Troubleshooting||2||Screnci, Tadevosyan, Zverev, Russo||Technical Training|
Community Preparedness: The Seabrook, NH Nuclear Power Plant, Ukrainian Emergency and Disaster Medicine Center, Kiev, Ukraine
|3||Hirsch, Cash, Tailleart, Turai||Didactic Session|
Emergency Medical Response Plan for Radiation Accidents, web-based teleconference
|3||Speakers logged on from remote sites in Yerevan, Armenia; Vienna, Austria; Boston, Mass., USA; Tallinn, Estonia; Chisinau, Moldova; Moscow, Russian Federation; Kiev, Ukraine; Washington, DC, USA||Web-based
|1/19/99||Congenital Dislocation of the Left Femur of a Pediatric Patient: Follow-up||2||Pacicca||Consult|
|1/21/99||Steering Committee Meeting||1||Hirsch, Levy, Chobanian, Harbick, Samiei, Ricks, Vanderschmidt, Segall, Aghababian, Ciottone||Meeting|
|1/22/99||Teleconference to plan nursing outreach course||1||Vartanian, Jenkins, Brush, Ginosian||Management Session|
|2/3/99||Teleconference to plan nursing outreach course||1||Vartanian, Jenkins, Brush, Ginosian||Management Session|
|Harmony 1 – Regional Medical Response Exercise Involving Radiation Exposure||72||Exercise participants logged on from remote sites in Yerevan, Armenia; Vienna, Austria; Boston, Mass, USA; Tallinn, Estonia; Chisinau, Moldova; Moscow, Russia; Kiev, Ukraine; Washington, DC, USA||Web-based Simulation and Discussion|
|1/27/00||Teleconference to train Armenian National Institute of Health users on MEDLINE electronic database system||2||Ginn, Schilling, Russo, Screnci, Levy, Vartanian, Mnatsakanian, Lalayan, Hovhannisyan, Pirumyan, Aslanyan, Gabrielyan||Training Session|
|3/30/00||Teleconference to train Armenian National Institute of Health users on MEDLINE electronic database system||2||Schilling, Russo, Vartanian, Lalayan, Hovhannisyan, Pirumyan, Aslanyan, Gabrielyan||Training Session|
|6/20/00||Patient Unable to Breathe Without Artificial Ventilation: Principles of Weaning||2||Hirsch, Boshyan, Sarkavagyan, Minassyan||Consult|
|5/22-24/01||Radiation Safety and Radiation Injury videoconference, Washington DC and Tbilisi, Georgia||8||AFRRI, USUHS, BUSM, ORAU, Georgian Ministry of Extreme Situations and Civil Defense, Central Military Hospital, Radiation Safety Dept. of Ministry of Labor, Health, and Social Affairs and Georgian Regional EMS and Disaster Medicine Training Center.||Panel Discussion|
 Teleconferences took place between Boston University School of Medicine, Boston, Mass, USA and sites in the New Independent States, usually Emergency Scientific Medical Center, Yerevan, Armenia unless otherwise noted. Test calls not included.
Event #1:Planning and Preparation, the Keys to Successful Disaster Response
Oct. 17, 1995
Boston University School of Medicine and American International Health Alliance from St. Petersburg, Russia.
Event #2, Experts’ Panel Discussion of an Airport Disaster
May 31, 1996
Boston University School of Medicine and Emergency Hospital, Yerevan, Armenia. Other events in the disaster preparedness series include:
Event #3, Management of Infection in the Immune-Compromised Patient
Nov. 19, 1997
Boston University School of Medicine and Emergency Hospital, Yerevan, Armenia.
Event #4, Use of Cytokines in Management of Bone Marrow Suppression
Jan. 14, 1998
Boston University School of Medicine and Moscow Regional EMS Training Center of the Federal Department of Medical, Biological and Extreme Problems, Moscow, Russian Federation.
Event #5, Radiation Accident at Boston Logan International Airport
June 8, 1998
Boston University School of Medicine and Chisinau Regional EMS Training Center, Chisinau, Moldova.
Event #6, Radiation Accident in Estonia 1994
August 26, 1998
Discovery, Management and Victim Treatment, Boston University School of Medicine and Estonian Disaster Medicine Center, Tallinn, Estonia
Event #8, Emergency Medical Response Plan for Radiation Accidents
October 14, 1998
Boston University School of Medicine and Ukrainian Emergency and Disaster Medicine Center, Kiev, Ukraine
Event #9, “Harmony I,” Regional Medical Response Exercise
Boston University School of Medicine, regional training centers, International Atomic Energy Agency, American International Health Alliance.
The Department of International Health of Boston University School of Public Health has a long tradition of providing management training programs in international health. Recently, it inaugurated an intensive certificate course providing one-third of the credits towards a Master’s degree in Public Health on the management of disasters and complex human emergencies. The certificate course grew out of this partnership’s work in emergency medical training.
In 1999 BUSPH, BUSM, and ANIH obtained funding from the Tavitian Foundation for a one-year health management trainer project. Four trainees from ANIH enrolled in a customized management training program from September 1999 to May 2000 to enhance ANIH management and program capacity and equip its trainees with skills in finance and curriculum design as well as permit them to pursue specialized interests in licensing, regulation, and quality assurance; public administration; and patient and human rights.