International Emergency Medicine :
What is it and How has it Developed
?
Jim Holliman, M.D., F.A.C.E.P.
Professor of Emergency Medicine
Program Manager, Afghanistan Health Care Project
Center for Disaster and Humanitarian Assistance
Medicine
Uniformed Services University
Bethesda, Maryland, U.S.A.
International Emergency Medicine (EM) :
Lecture Objectives
Describe exactly what international emergency
medicine is and cover the current status of EM in
different parts of the world
Provide some background history of the development
of international EM
Present reasons why EM physicians should become
involved in international EM
Present methods and options for EM physicians to
become involved in international work
Encourage support by EM program directors for
residents to do internationally related work
What is International EM Anyway ?
It means different things to different people, and includes
(add the words "in other countries" on each of the following
lines) :
–Developing EM and EMS training programs
–Developing clinical EM facilities
–Developing EM as a recognized specialty
–"Charity" clinical service
–Staffing expatriate medical facilities
–"Repatriation" of U.S. or Canadian patients from other
countries
–Conducting exchange programs for health care personnel
–Operating travel medicine clinics
Why is There Increasing Interest in
International Emergency Medicine ?
Recent awakening by many countries that they should
develop EM
EM in the U.S.A. and Canada has fully matured as a
specialty
Collapse of Communism has opened up multiple
countries to people & new ideas (such as EM) from the
outside
Multiple international EM conferences have just gotten
started in the past 10 years
Recent active support for international EM development
from EM organization leaders (such as the leaders of
A.C.E.P., S.A.E.M., C.A.E.P., and A.A.E.M.)
Reasons for Increasing Interest in
Developing EM Within Other Countries
Improved overall medical system development
Rapid urbanization
–Resultant "demographic transition" from infectious
diseases to trauma & cardiorespiratory diseases
Increasing outpatient visits
Demonstrated success of EM in the U.S. and Canada
–Increased public expectations
–International exposure from television shows like
"E.R.", and "Rescue 911", and "Casualty"
Increased international travel
Terrorist and other mass casualty events
What General Benefits Does International EM
Experience Offer U.S. and Canadian EM Physicians
?
Exposure to and interaction with other cultures :
–Can learn more of the historical background of
other cultures
–Can better deal with Emergency Department
(E.D.) patients in the U.S. or Canada who come
from other cultures
–Can better understand how culture influences
compliance with medical care
–Possibility of discovering new foods and / or
crafts to continue to enjoy into the future
General Benefits of International EM Work for
U.S. and Canadian EM Physicians (cont.)
Can learn novel approaches to common clinical
problems :
–Most urban E.D.'s in other countries see similar
case distribution as in the U.S. or Canada
–Trauma from motor vehicle crashes (MVC's)
–Acute coronary syndromes
–Acute respiratory emergencies
–Some useful pharmaceuticals not available in the
U.S. or Canada may be utilized
–How to deal with E.D. overcrowding (a prominent
problem currently in almost all countries)
General Benefits of International EM Work for
U.S. and Canadian EM Physicians (cont.)
Opportunity to see clinical problems not common
in the U.S. or Canada (obviously dependent on
locale) :
–Malaria
–Arboviral fevers
–Parasitic diseases
–Cutaneous and systemic mycoses
–Tetanus, rabies
–Neurotoxic snakebites
–Familial Mediterranean Fever
–Nutritional deficiency syndromes
General Benefits of International EM Work for
U.S. and Canadian EM Physicians (cont.)
Personal satisfaction of having
deeply appreciative patients
–Common for even poor patients to
give thank-you gifts to doctors
Personal satisfaction of having
deeply appreciative foreign E.D.
colleagues
–Most are very "hungry" for
interaction & teaching
–Most enjoy maintaining long term
correspondence links
General Benefits of International EM Work for U.S.
and Canadian EM Physicians (cont.)
Opportunity as a single individual to have a big impact
on influencing development of EM at a national level
–Training EM "core" faculty
–Organizing EM residencies
–Making E.D. design recommendations
–Coordinating prehospital and E.D. care
–Obtaining government support
–Statements by visiting U.S. or Canadian EM physicians may
have very big influencial impact on officials and
administrators to support local or academic EM development
General Benefits of International EM Work for U.S.
and Canadian EM Physicians (cont.)
Opportunity to perform procedures which may
often be done by other specialists in U.S. or
Canadian E.D.'s :
–Thoracotomy, thoracostomy
–Peritioneal lavage
–Peritoneal dialysis
–Complex facial or hand laceration repairs
–Closed fracture reductions
–Emergency amputations
–Major surgical procedures
–Endoscopy
–Ultrasound
General Benefits of International EM Work for U.S.
and Canadian EM Physicians (cont.)
Experience the fun (& ? greater efficiency) of
clinical practice without excessive paperwork,
documentation requirements, and worry about
malpractice suits
Can learn how to practice without excessive
reliance on diagnostic tests
Appreciation of how good one's own health
care system really is (despite its many
problems and faults) compared to most
foreign systems
Potential Disadvantages of International EM Work
for U.S. and Canadian EM Physicians
Frustration due to local resource limitations
–Some key lab or radiology tests may not be available
–The most effective meds (such as some antibiotics or
antiarrhythmics) may not be available
–Lack of ventilators or ICU beds
–Lack of specialty backup
Lack of guaranteed access to emergency or inpatient care in
some countries (unless the patient or family can pay for care)
Language differences may inhibit patient or staff interactions
Personal safety issues in some countries
Why Should EM Program Directors
Support International EM Rotations ?
• Availability and support for international
rotations has been shown to be an important
criterion for residency selection by applicants
• International experience meets the ACGME
requirement to provide training in the six core
competencies
• The malpractice risk for residents is close to
zero
What Requirements Need to be Met for
International Rotations to be
Accredited ?
• The sponsoring institution is JCAHCO
International approved or approved by
the accrediting body for that country
• The resident or student will be working
under the supervision of a “sponsoring”
physician who agrees to provide grading
evaluation of the student or resident
• An inter-institution MOU must exist to
explicitly present the rotation structure
The Six ACGME Core Competencies
Addressed by International EM
Rotations
•
•
•
•
•
•
Patient care
Medical knowledge
Interpersonal skills
Professionalism
System based practice
Practice based learning
International EM Research
• Academic EM has reached a sufficient state of
maturity in a number of countries to allow
participation by U.S. residents and students in
EM research projects
• EM faculty in many other countries are under
the same academic productivity pressures as
in the U.S. and Canada
• Inter-institution projects need to be approved
by IRB’s at each site
Comparative Milestone Years for EM
Development in the Countries with
"Mature" EM
U.S.A.
Recognized
specialty
National
Organization
Academic
Society
National
certification
exam
U.K.
1973 1986
(1979)
Australia
Canada
Hong
Kong
Singapore
1981
1980
1983
1984
1981
1984
1985
1993
1968
1967
1970
1989 (1988) (1988) 1994 (1993)
1979
1983
1986
1985
1997
1994
Organizations Which Have Been
Involved in International Emergency
Medicine
International Federation for EM (I.F.E.M.)
American College of Emergency Physicians (A.C.E.P.)
Society for Academic Emergency Medicine (S.A.E.M.)
World Association of Disaster & EM (W.A.D.E.M.)
American Academy of EM (A.A.E.M.)
European Society for EM (EuSEM)
Asian Society for EM
Emergency International
International Medical Corps (I.M.C.)
Doctors Without Borders (M.S.F.)
Pan-Arab Society of Trauma and EM
History of I.F.E.M.'s Involvement in
International EM
Represents a consortium of national EM organizations
Founded by A.C.E.P., B.A.E.M., A.C.E.M., C.A.E.P. in 1989
Operated the International Conference on EM (I.C.E.M.) every
other year since 1986
–First held in London, then in 1988 in Brisbane, Australia
–Original rotating host cycle for the I.C.E.M. : U.K. -- Australia - Canada -- U.S.A.
–Average about 1000 registrants per conference
Full membership extended to national organizations from other
countries with developed EM in 1998
Developing policy statements on international health issues and
international core curriculum for EM
Voted to "open up" the host site for the I.C.E.M. to countries
other than the original 4 founders starting in 2010
Earliest Members of the I.F.E.M.
(and year the organization joined)
A.C.E.P. (1989)
B.A.E.M. (1989)
C.A.E.P. (1989)
A.C.E.M. (1989)
Hong Kong (1998)
Mexico (1999)
China (1999)
Korea (2000)
Czech (2000)
Taiwan (2000)
Singapore (2000)
Israel (2000)
Turkey (2002)
Poland (2002)
Now (2009) 11 other
full members
10 affiliate members
3 “ex-officio” members
(other multinational
societies)
History of A.C.E.P.'s Involvement in
International EM
For many years A.C.E.P.'s only international work was the
International Meetings Subcommittee helping with the I.C.E.M. (and
conducting the 2 worst I.C.E.M.'s in 1992 and 2000)
In the late 1990's the A.C.E.P. leadership started to directly support
international EM activities
–The Section on International EM was founded in 1998 and has
become the largest section in A.C.E.P. (over 1000 members)
–The Task Force on International EM (1999 to 2002) developed a
long term plan for further A.C.E.P. support of international EM
In the mid to late 1990's the Annals of EM published a series of
articles describing EM development in different countries
A.C.E.P. leaders have been increasingly active with other countries'
EM organizations
Has started formally endorsing other international conferences
History of S.A.E.M.'s Involvement with
International EM
Had an International Committee from 1991 to 1996, then an International
Interest Group (which quickly became the biggest interest group within
S.A.E.M.) ; now the Committee has been reinstated
Developed reference databases on international EM rotations (since
transferred to A.C.E.P.) and fellowships (listed on the SAEM website)
Published standard curricula for different types of international EM fellowship
programs & a "generic national EM development plan" (AEM August 2000
issue)
The sum of the articles produced by the Interest Group constituted the
"academic underpinning" for international EM work
Conducted business meetings at annual meetings of A.C.E.P. and S.A.E.M.
since 1993
Held conjoint meetings with the U.K. Faculty of A&E Medicine in 1990, 1993,
and 1998, and with EuSEM in San Marino in 1998
Interested in promoting international research projects
History of W.A.D.E.M.'s Involvement in
International EM
Founded in 1976 as the "Club of Mainz"
Has conducted an international conference
every 2 years since 1987 (next in May 2009 in
Victoria, British Columbia))
Concerned mainly with Disaster Medicine
discussions, and not so much with EM
system development
Many of members are physicians from nonEM specialties
Prehospital and Disaster Medicine is the
official journal of the organization
History of A.A.E.M.'s Involvement in
International EM
Have had an international committee since 2000
Co-sponsor with the European Society of EM
(EuSEM) of the Mediterranean Congress on EM
since 2001 (in odd-number years)
Co-sponsor with EuSEM for EuSEM Congresses
since 2002 in even-numbered years
Co-sponsor with the Argentine EM Society for
the InterAmerican EM Congress every other year
since 2006
Co-sponsor for the Caribbean EM Conference in
Barabados January 2009
History of the European Society of EM
(EuSEM) Involvement in International EM
Founded at the I.C.E.M. in London in 1994
Conducted First European Congress on EM in San Marino in
1998 (dropped out of sponsoring the original Second Congress
which was held in Wroclaw, Poland in 2000, but resumed with
Congress in Slovenia in Sept. 2002)
Conducted Mediterranean Congress on EM since 2001
Published European Journal of EM since 1994
Published Manifesto for EM in Europe
Interested in developing standardization of training and
certification for EM
Supports Disaster Medicine training center and degree program
in San Marino
Membership both for individuals and for national EM societies
History of the Asian Society of EM
Founded in 1998 at the First Asian Conference on EM
in Singapore
Has conducted multinational conferences in
Singapore (1999), Taiwan (2001), Hong Kong (2003),
Japan (2005), and next in Busan, Korea, May 16 to 19,
2009
Starting to develop curriculum recommendations and
exchange programs
Societal members include Hong Kong, Singapore,
Malaysia, Taiwan, Japan, Korea, Bahrain, Thailand,
and India
History of Emergency International's
Involvement in International EM
Started in the late 1980's as the "Society for the International
Advancement of Emergency Medical Care"
Early on mainly conducted medical tour trips, but later
developed into a "grass roots" organization devoted to
assisting EM development in other countries
Nonprofit organization ; was headquartered in Maryland
Had regional based projects in Asia, Middle East, and Latin
America
Had conducted business meetings at the annual meetings of
A.C.E.P. and S.A.E.M.
Unfortunately dissolved in late 2003
History of I.M.C.'s and M.S.F.'s
Involvement in International EM
I.M.C. started by Dr. Bob Simon in the 1980's to provide medical
care for Afghan refugees
M.S.F. was dominated by French non-emergency physicians
until the mid-1990's when it started to utilize more real EM
physicians
Both organizations are mainly interested in providing
emergency clinical care for disaster and refugee situations &
have not done much EM system development
Both are independent private N.G.O.'s
I.M.C. has had prominent programs in Afghanistan, Pakistan,
and Bosnia
M.S.F. has been prominent in Africa
M.S.F. won the Nobel Peace Prize in 1999
History of the Center for
International EMS
Founded in 1991 by Dr. (?) Eelco Dykstra
First headquartered in Weisbaden, then in
the Netherlands
Organized a series of good international
networking conferences (the "Pan-European
Conferences on EMS") :
–Budapest, Hungary 1992, Abano Terme, Italy
1994, Prague, Czech. Rep. 1996, Opatija,
Croatia 1998
Fizzled out after failing to continue the
conference series in Turkey in 2000
History of the Pan-Arab Society of
Trauma and Emergency Medicine
Founded in 2002
Headquartered in Doha, Qatar
Conducted Qatar International Trauma & EM
Conference in Doha every other year since
2002 (over 800 attendees annually)
Published Middle Eastern Journal of EM
since 2001 (recently renamed Journal of
Emergency Medicine, Trauma, and Acute
Care or JEMTAC)
History of the American Academy
for EM in India (A.A.E.M.I.)
Started in 2000
Represents an organization focused on
helping EM develop in a single country
(India)
Has cosponsored international conferences
in India every other year since 2002 with the
Society for EM in India (S.E.M.I.) and has
helped SEMI with its national conference each
odd-numbered year
Classification System for Stages of
National EM Development
This classification system proposed by Dr.
Jeff Arnold in 1999 (Ann. Emer. Med. 1999; 33: 97103).
Places countries into one of 3 categories
related to their "stage" of national EM
systems development :
–Underdeveloped (most African countries)
–Developing (some European and Middle
Eastern countries)
–Mature (U.S.A., U.K., Canada, Australia, Hong
Kong, Singapore)
Categories of Dr. Arnold's Classification
Scheme for National EM Development
Specialty systems
Academic EM
Patient care systems
Management systems
The following 4 slides will show how to use
this scheme to analyze the status of EM in a
particular area or country (for example the
Middle East)
Comparison of EM Specialty
Systems
Country
Class :
Underdeveloped
Developing
Mature
Middle
East
Countries
National EM
Organization
No
Yes
Yes
Some
EM
Residency
Training
EM Board
Certification
No
Yes
Yes
Some
No
Yes/No
Yes
No
Official
Specialty
Status
No
Yes
Yes
Some
Comparison of Academic EM
Features
Country
Class :
Underdeveloped
Developing
Mature
Middle
East
Countries
Specialty
Journal
No
Yes/No
Yes
Some
Research
No
Yes/No
Yes
Limited
Clinical
Databases
No
No
Yes
No
EM SubSpecialty
Training
No
No
Yes
No
Comparison of Patient Care
Systems
Country
Class :
Underdeveloped
Developing
Mature
Middle
East
Countries
GP's, some
residency
trained
Some EM
Emergency
Physicians
E.D.
Director
Housestaff,
other
doctors
Other
specialty
Some EM
residency
trained
EM
physician
All EM
residency
trained
EM certified
physician
Prehospital
Care
private car,
taxi
BLS or EMT
ambulance
paramedic
or doctor
Varies by
area
Transfer
System
No
No
Yes
No
Trauma
System
No
No
Yes
No
Comparison of Management
Systems
Country
Class :
Underdeveloped
Developing
Mature
Middle
East
Countries
Quality
Assurance
Programs
No
No
Yes
No
Peer
Review
Programs
No
No
Yes
No
Specialty
C.M.E.
Required
No
Yes/No
Yes
No
How Can Students or Residents Start
to Get Involved in International EM ?
I think often the best and fastest way is to attend any of
the international EM conferences (listed on later slides)
–If you have some clinical research projects you can
present as abstracts or posters, this often will result in
foreign physicians who are interested in your work
coming up to you for more discussion and followup ;
often long term professional associations come out of
these presentations
–If you don't have any research to present, and are not
an invited speaker at the conference, then just make the
effort to speak directly with the other attendees at the
conference, and participate in the social events
Additional Methods to Get
Started in International EM
Join the A.C.E.P. Section on International EM
–$ 35 surcharge on your ACEP dues
–The largest section in A.C.E.P.
Join the S.A.E.M. International Interest Group
–$ 25 surcharge on your S.A.E.M. dues
–The largest interest group in S.A.E.M.
–Join C.A.E.P.’s International Committee
Join the W.A.D.E.M. or EuSEM or Asian Society of EM
Join or attend any meetings of local medical student
international interest groups or of local multicultural interest
groups
Attend any local lectures by foreign speakers
Regularly Held International EM Conferences
W.A.D.E.M. : Biennial, odd # years
I.F.E.M. I.C.E.M. : Biennial, even # years
Eu.S.E.M. : biennial, even # years
–Mediterranean Congress, biennial, odd # years
Asian Society of EM : Biennial, odd # years
InterAmerican Conference on EM (Argentina) : biennial, even
# years
Pan Arab Society of Trauma & EM (Qatar) : Biennial, even #
years
Asian-Pacific Conference on Disaster Medicine : Biennial,
even # years
Caribbean EM Conference ; proposed biennial, odd # years
Other International EM Conferences to
Consider Attending
A number of countries now have annual national
organization EM conferences which include international
participation :
–Slovenia (June)
–Croatia (October)
–Turkey (May and September)
–Israel (March or October)
–Hong Kong (October or November)
–Argentina (April or May)
–India (November)
–Poland (February)
–U.K., Canada, and Australia each have several
conferences per year
Additional Considerations for
International EM Work
If you are interested in providing volunteer clinical work in other
countries :
–Check directly with the organizations listed in the Aug. 7, 2002
issue of J.A.M.A. (288(5): 561-565) for specifics of opportunities,
or the updated web site : http://jamacareernet.amaassn.org/misc/volunteer.dtl
–Check the job advertisement sections of J.A.M.A. and Annals of
EM
–Often they have advertisements for paid overseas positions,
such as companies like Global Medical Staffing
–Contact the U.S. State Department or a foreign embassy
–Sometimes they know of specific country opportunities
Other Opportunities to Get Involved
in International EM
If you are interested in EM in a certain country, consider joining
organizations which are focused on helping specific countries
Examples :
–The American Academy for EM in India (A.A.E.M.I.)
–The Behrhorst Foundation for Guatemala
–OTZMA : emergency medical volunteers for Israel
–PACEMD for Mexico (www.PACEMD.org)
–REEME for Latin America (www.reeme.org)
Another consideration is to collect medical equipment (such as
used but clean cervical collars) or textbooks for donation to
other countries (these can often be shipped cheaply or sent via
the U.S. or Canadian military)
Organizing Your Career if You Are Interested in
Long Term International Work
If you are in an academic setting :
–Get the department director to agree that your area of
academic focus will be international work
–Arrange to have a flexible clinical schedule so you can be
"freed up" for travel projects
–However this may require you to "batch" your clinical shifts
into longer numbers of shifts in a row
–Develop lectures for students & residents on international EM
–Integrate yourself into the counseling and scheduling of
students and residents who are doing international rotations
–Consider starting foreign personnel exchange programs
–Investigate separate funding from your clinical income
Organizing Your Career if You Are Interested
in Long Term International Work (cont.)
If you are in private practice or
employed at a community hospital :
–Consider all the same things listed
for academics on the prior slide
It is definitely possible to have a rewarding
career focused on international work whatever
your practice background is (you certainly do
NOT have to be in academic practice)
Practical Things to Remember Prior to
Undertaking International EM Work
If you don't have a passport, then get one
If you don't have any credit cards, then get some
Check on visa requirements early (at least 3 months in
advance) for each country you are planning to visit
Update your immunizations, and check with a travel
medicine clinic if you are not knowledgeable about
required prophylactic meds
Take key toiletries and lecture handouts & projection
materials in your carry-on bag
Update your will if going to the Middle East or Central
Asia or Africa (I can also get you a good deal on body
armor)
The Two General Types of Emergency
Medical Services (EMS) Systems
"American-Anglo" system :
–Prehospital care by "physician extenders" (emergency
medical technicians and / or paramedics)
–Patients are delivered to hospital-based emergency
departments staffed by EM specialist doctors
"Franco-German" system :
–Prehospital care by physicians
–Patients are delivered directly to inpatient specialist
services
Before undertaking EM work in another country, you
should find out which type of EMS system is operational
there at the local level
General Operational Philosophies
of the Two Types of EMS Systems
American-Anglo system :
–"Bring the patient to the doctor"
Franco-German system :
–"Bring the doctor to the patient"
Which of the Two Types of EMS
Systems is Better ?
Often debated, but not really an answerable
question because so many nation-specific
factors influence the systems' structures
and operations
Remember : the U.S. paramedic based
system was developed NOT because it was
thought inherently better, but because of
economic reasons (it's cheaper) & a relative
shortage of available physicians for EMS
work
Countries Utilizing the "AmericanAnglo" EMS System Type
U.S.A.
Canada
United Kingdom
Australia
Ireland
Mexico
Hong Kong
South Korea
Iran
Countries In Which Physicians
Provide Most Prehospital Care
Germany
Croatia
France
Switzerland
Austria
Hungary
Russia
Czech Republic
Ukraine
Slovakia
Estonia
Portugal
Slovenia
Latvia
Spain
Poland
Italy
Belarus
Countries Using A "Mixed" EMS System (with both
Physician & Non-physician Staffed EMS Units)
Belgium
Norway
Sweden
Israel
Argentina
Turkey
Note that the Netherlands
mainly uses a nurse-staffed
EMS system
Status of Emergency Medicine as a
Specialty in the "Franco-German" System
"Emergency physicians" are prehospital only
Emergency Medicine not recognized as separate or
unique specialty (although France nominally
recognized EM in 2006)
Resuscitation attempts done mainly by
anesthesiologists, not by other doctors
Breadth of "EM" often regarded as only
encompassing CPR or shock cases
No training programs equivalent to U.S. or
Canadian EM residencies
Operational Problems with the
Franco-German EMS System Type
Patients are directly admitted from the "field" to
inpatient services based on the presenting chief
complaint
Results in higher admission rates and greater per
capita hospital use and bed occupancy
Mis-triage is common, especially for patients with
complex or multisystem medical or trauma
conditions
–Existence of single-specialty hospitals
complicates this
Results of the Operational Problems
of the Franco-German System
Mortality for major or combined systems
trauma is poor ( typically > 10 % or more,
compared to 1 to 5 % in the U.S.)
On scene times for trauma cases are long (
> 20 minutes is typical)
Inefficient, and in fact often dangerous,
interfacility transfers are more frequently
required
Requires much larger number of vehicles
and on-duty physicians per unit population
Other Problems with the Current
Franco-German EMS System Operation
No quality assurance or EMS care
supervision programs are in place
Many prehospital physicians are young
and inexperienced
Prehospital work is often regarded just as
a temporary stepping stone to another
specialty
There are not well defined or in-depth
training programs or certification for
prehospital physicians
Features of the Princess Diana Debacle Showing
Deficiencies in the Franco-German EMS System
Very long on scene time despite lack of
entrapment
Very long transport time despite close proximity to
hospital
Poor prearrival notification and care coordination
with the hospital
No effective quality assurance review of case
management
Note her only injury was a small pulmonary vein tear
Countries Which Have Designated Emergency
Medicine to be a “Super-Specialty”
This means that to qualify to enter an emergency
medicine training program, one first has to complete
training in another specialty (such as anesthesia,
internal medicine, critical care, or surgery).
Counties using this specialty model include :
Israel, Belgium, Greece, Sweden, Italy, and as of 2006 :
France !
Later conversion of the specialty to a “Primary
Specialty” may be possible
Relationship of Disaster Medicine
(DM) to Emergency Medicine (EM)
DM is really a small subset of EM
The daily practice of EM encompasses management
of frequent small disasters
Development of an independent DM system is an
inefficient use of resources & personnel
Far more lives are saved by application of good day to
day EM than by a separate DM system, even in
countries prone to disasters (an example is to
compare the high mortality from the Kobe, Japan
earthquake with the much lower mortality from the
similar magnitude Northridge California quake)
Best Relationship of EM & DM
System Development
Countries without well established EM should develop
this first, before developing elaborate DM systems
Daily practice of the EM & EMS systems:
–Allows skill acquisition & maintenance
–Provides more efficient & cost-effective use of
personnel & resources
–Allows commonality with outside assistance
All review studies have shown that main benefits of
disaster response are dependent on the pre-existent local
system (of which EM and EMS are key)
What Basic Health System Improvements
Can Emergency Medicine Offer to
Developing Nations ?
Basic trauma care
Training of non-physician prehospital care
providers
Decreased hospital admissions for diagnostic
workups (which saves money)
Management of multi-casualty incidents
Coordination of care for patients with multisystem problems
So EM should be of great public health benefit
even in countries with poor economies
Necessary Features for Development of
Emergency Medicine in a Country
Cadre of physicians interested in developing EM
Governmental support
Support from other physician specialties
Infrastructure components :
–Health care facilities capable of providing emergency
care
–Transport & communication systems for patient access
–Availability of referral & followup care
–Training programs for physicians & other emergency
health care personnel
Countries in Which EM is a Well Established Specialty
In these countries EM is an official well- established
specialty with its own training programs & board exam :
–U.S.A.
–Canada
–United Kingdom
–Australia
–Hong Kong
–Singapore
EM practice in these is similar to that in the U.S., except
EM residents may not be so closely supervised, and some
E.D.'s have no attending night coverage
Countries Which Have Graduated
EM Residents from EM Residency
Programs (# of programs)
Costa Rica (1)
Nicaragua (1)
Barbados (1)
South Korea (55)
Turkey (33/19)
China (6)
Jordan (3)
Taiwan (2)
Hungary (1)
Estonia (1)
Bosnia (1)
Israel (7)
Belgium (5)
Bulgaria (1)
Iran (3)
Qatar (1)
Mexico (3)
Countries with EM Residency
Programs in Development
India
Italy
Ireland
Netherlands
Paraguay
Sweden
Chile
Romania
Guatemala
Philippines
Colombia
Poland
Argentina
Czech Republic
Egypt
Oman
South Africa
Saudi Arabia
Brazil
Peru
Characteristics of Existing EM
Residencies in Other Countries
Most closely follow U.S program structure (most
are 3 years duration)
Most utilize U.S. textbooks & curriculum
U.K., Australia, Hong Kong have much longer, but
less structured, programs
Some include extensive Intensive Care Unit (ICU)
experience (almost a "co-residency" in ICU
medicine)
Residents often have less supervision and more
responsibility
Potential Dfficulties in Establishing
EM Residencies in Some Countries
Fear by other specialties of loss of patients
or revenue
Lack of understanding of the breadth of the
specialty
Cultural resistance to adopting something
perceived as "American"
Perception that it is hard work and lowpaying relative to other specialties
Lack of exposure to EM faculty role models
for interested students and residents
How U.S. and Canadian EM Physicians
Can Contribute to Developing EM
Residencies in Other Countries
Speak to the other medical specialties about
how having good EM will help them (rather
than compete with them)
Emphasize to the local EM core faculty how the
same EM development problems they face were
historically overcome in the U.S. and Canada
Supply some core teaching materials
Act as role models for students and residents
to stimulate their interest in the specialty
General Methods to Foster EM
Clinical Faculty Development
Physicians complete a U.S. or Canadian EM residency,
& then return to their home country to form a faculty
nucleus
Physicians obtain local clinical experience in EM
(perhaps with on-site U.S. or Canadian physician coworkers) & then start a training program
Physicians come to the U.S. or Canada for various
short-term training courses, & then return to their
home country
U.S or Canadian physicians travel to the host country
to present various short-term training courses
Potential Problems with Training Other Countries'
Physicians in U.S. or Canadian EM Residencies
Medical licensing restrictions
Restrictions of government funding for non-U.S.
schooled residents
Tendency of non-U.S. residency graduates to stay in
the U.S. or Canada after residency
Relative shortage of U.S. and Canadian EM residency
positions & high competition for spots
Greater net cost of housing trainees in the U.S. or
Canada rather than in their own country
Trainees have to speak fluent English
Language Considerations for
Modular Courses
Course materials should be designed to be easily
translatable and free of idioms
If course materials are only available in English,
best use may be to train initial cadre of instructors
in English, then have them use the translated
materials to train others locally
If using simultaneous or "immediately after"
translation, must allow 25 to 50 % more time for
presentation for each lecture
Avoid use of difficult to translate humor
General Sequence of National
Emergency Medicine Development
Interested cadre of physicians forms
Initial physician cadre obtains EM training for
themselves
Model clinical departments set up
National professional society formed
Training standards & curricula set
Residency programs organized
National specialty journal published
Specialty exam established
Declared an officially recognized specialty
Important Considerations for
International Teaching or Clinical Work
Maintain respect for local culture and
customs
Do a careful needs assessment before
initiating programs
Adapt programs to local needs &
resources, but don't compromise quality
or integrity
Ensure efforts are part of a coordinated
and long term plan
Make the effort to evaluate outcomes or
benefits of programs you participate in
Summary of Specific Recommendations to
U.S. and Canadian Physicians to Assist in
International EM Development
Develop linkages with other national EM
organizations or societies and with individual EM
physicians
Facilitate two-way exchange of physicians for
study tours and / or clinical or course work
Provide educational materials
Develop fellowship training programs
Act as system structure & training consultants
Promote international collaborative research
projects
Participate in international EM conferences
Additional Longer Term Goals for
International EM Development
Integration with the country's government & military
Education of all medical students in basic EM
Public education by EM :
–Appropriate use of the E.D.
–Injury & violence prevention
Collaboration with international societies & research
projects
Hopefully contribute to achievement of peace and
stability
Get the specialty of EM going in Africa (where it is
virtually non-existent)
Features of the U.S. EM / EMS System Which
Should NOT Be Recommended to Other Countries
U.S. malpractice system
U.S. principle that the individual is not
responsible for himself or the effects of his own
behavior
Overly large & expensive ambulance vehicles
Adoption of untested or unproven items :
–MAST
–EOA
–External pacer
–Telemetry
Overuse of aeromedical helicopters
Excessive documentation
International Emergency Medicine
Summary
EM is just starting to develop in many countries
There is great opportunity for U.S. and Canadian
medical students, EM residents, & EM physicians
to participate in EM's international development
There are great professional and personal benefits
from participating in international EM work
U.S. and Canadian EM organizations should
support efforts at international EM development
with the ultimate goal of improving emergency
patient care and access worldwide