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International emergency medicine is a discipline that evaluates current standards and development of emergency medicine in various countries throughout the world.

Emergency medicine has been a recognized medical specialty in the United States and other developed countries for nearly forty years. The term international emergency medicine generally refers to the transfer of skills and knowledge from developed emergency medicine systems to those systems which are less developed--including knowledge of ambulance operations and other aspects of prehospital care.

In most developing countries, steps are being taken to develop emergency medicine as a specialty, to develop accreditation mechanisms, and to promote the development of emergency medicine training programs.

International emergency medicine is a sub-specialty of emergency medicine, and there are several international emergency medicine fellowships in the US, where residency-trained emergency physicians obtain advanced training in international skills and systems development. These programs usually offer an advanced degree in public health to their fellows, such as a Master of Public Health degree.

Overview of international emergency medicine

Definition

The straightforward definition of international emergency medicine is that it is "the area of emergency medicine concerned with the development of emergency medicine in other countries." Those efforts can be broken down into the promotion of emergency medicine as a recognized and established speciality in other countries and the provision of humanitarian assistance. However, that definition has also been criticized as oxymoronic given the international nature of medicine and the number of physicians working internationally. From that point of view, international emergency medicine is not solely about development of emergency medical systems but is instead better described as the training required for, as well as the reality, of practicing abroad.

Importance of emergency medicine in the developing world

Motor vehicle crashes represent a leading cause of death for adolescents and young adults with the majority of deaths occurring in the developing world. In recent decades, while traffic fatalities have declined in industrialized nations, they have been on the rise in developing ones. Furthermore, developing nations tend to have a higher proportion of fatalities per number of vehicles for reasons including lower safety standards for vehicles. The lack of emergency care available in many developing countries only serves to exacerbate this problem. In the United States, it was the high number of traffic and other accident fatalities in the 1960s that spurred by a white paper from the National Academy of Sciences that exposed the inadequacy of the current emergency medical system and led to the establishment of modern emergency medical services. The motor vehicle saturation in Asia and Africa may be lower than in the West but the higher rate of accident mortality per vehicle still leaves a potential need for improved emergency medical care.

Emergency medical care may be applicable in many areas aside from traffic injuries as well. As Razzak and Kellermann identify, many illnesses that with time-sensitive elements are common in developing countries including: severe infections, hypoxia caused by respiratory infections, dehydration caused by diarrhoea, intentional and unintentional injuries, postpartum bleeding, and acute myocardial infarction. These are conditions that potentially threaten the lives of those who are afflicted by them and yet adequate and/or timely treatment may not be available for much of the world's population.

For instance, a 2008 study of Zambia found that only 50% of hospitals had an emergency medical system that transported patients. Just 24% of ambulances carried oxygen and 40% carried drugs of any kind. Furthermore, only 29 intensive care beds were available in all of the hospitals surveyed with only major hospitals having any. This implies that the majority of critically ill patients are receiving care in general hospital wards.

Aside from acute care, emergency medicine can also play a significant role in public health. Vaccinations for many diseases such as diphtheria, tetanus and pertussis can be administered by emergency departments, patients can be targeted for specific interventions such as counseling for substance abuse, and conditions like hypertension can be detected and treated. Emergency departments are excellent locations to train health care providers and to collect data due to the density of patients. Of course, emergency medicine also improves public health by preventing secondary disease developing from an initial presentation and it serves as the first line of defense in disaster scenarios.

Models of emergency care

Two primary models for the provision of emergency medicine exist. Simply put, the Anglo-American model relies on "bringing the patient to the hospital" while the Franco-German model operates through "bringing the hospital to the patient." Thus, in the Angol-American model the patient is rapidly transported by non-physican providers to definitive care such as an emergency department in a hospital. Conversely, the Franco-German approach has a physician, often an anesthesiologist, come to the patient and provide stabilizing care in the field. The patient is then triaged directly to the appropriate department of a hospital. Most developing emergency medical systems have been established along Anglo-American lines but little work exists to establish the advantage of either system. The use of these descriptors for emergency medical systems has been criticized as an oversimplification and an needless source of controversy. Other groupings such as classifying emergency medical systems as a specialty or multidisciplinary models have been proposed. Specialty systems would include those with physicians dedicated to emergency medicine whereas multidisciplinary systems would encompass those that rely on physicians from other disciplines to provide emergency care. Such an approach would seek to categorize pre-hospital care separately from in-hospital systems.

Role in overall health system

Developed countries

In developing counties international emergency medicine is one among many initiatives underway to shape the future of the specialty. Training programs specifically relating to the international practice of emergency medicine are now available within many emergency medicine residences. The curriculum that should be covered by such programs has been the subject of much discussion. Patient care, medical knowledge, practiced-based learning, communication skills, professionalism, and system-based practice are the basic six competencies required of programs approved by the Accreditation Council for Graduate Medical Education (ACGME) but the application of those goals can take many forms. Indeed, the breadth of skills needed in international emergency medicine make it unlikely that one standardized program could fulfill the training needs for all of the various future tasks in international emergency medicine. One study found that the primary topical areas of U.S. fellowship programs were emergency medicine systems development, humanitarian relief, disaster management, public health, travel and field medicine, program administration, and academic skills. Its authors argue that attempting to cover all of those areas may be unrealistic and that a more targeted focus on acquiring necessary skills might be more productive.

After such training is completed or even without any training, working or visiting in other nations is a route through which many physicians participate in international emergency medicine. Some physician choose to make their careers overseas while other opt for shorter trips. For example, a team of U.S. physicians spent seven months helping to establish a new emergency department and emergency residency program in Hangzhou, China.

Developing countries

The experience of international emergency medicine in developing countries is in some ways the reciprocal of that of developed ones. They are attempting to establish effective systems of care and recognized speciality programs with assistance from health care providers from the developed world. Given the relatively young nature of emergency medicine as a specialty in the world as a whole there are only a few advanced emergency medical systems and a far greater number of nations (50+) are in the process of developing those systems. The process of development has been described as usually beginning in academia and patient care before burgeoning out to administrative and economic concerns and finally health policy and agendas.

Given the limited resources of many developing nations a vital part of how emergency medicine fits into the health system is how to fund it. Preventive care is clearly a crucial part of healthcare in developing countries and it may be difficult to budget for emergency medicine without cutting into those resources. This is a particularly problem for a nation like Zambia which had a per capita health expenditure of 23 US dollars in 2003. Some money may be available from wealthier nations or international organizations but careful decisions still need to be made. Regardless of the amount of preventive care available, though, health problems requiring immediate attention will still occur and emergency medical programs could increase access to care.

Initiatives to expand emergency medicine

Curriculum development

One key part in equipping nations to develop emergency medical systems is to identify the aspects of training that are essential for health care providers. Despite the myriad differences in the contexts of counties a standard curriculum is still useful for identifying core issues to be addressed. To address this goal, the International Federation for Emergency Medicine developed a model curriculum to fulfill that need. This initiative seeks to provide a minimum basic standard that can be tailored to the specific needs of the various nations implementing training in emergency medicine. It is targeted towards all medical students in order to produce a minimum competency in emergency care for all physicians, regardless of their specialty.

Transferring knowledge

As would be expected, countries that have had comprehensive emergency medical systems for a number of decades have expertise that nations that are just beginning emergency medical programs lack. There thus exists considerable scope for the transfer of knowledge to assist newly founded programs in their progression. Such transfers may be made either from a distance or in-person. For instance, the International Emergency Medicine Fellowship at the University of Toronto sent a three-person team to Cluj-Napoca, Romania to promote the local development of emergency medicine. An assessment of the present status was performed that identified targets for improvement in: physical plant organization and patient flow, staffing, staff education, equipment, medication and supplies, and infection control practices. Following those designations plans regarding those areas were collaboratively drawn up and then implemented, partially through international exchange trips.

Another conduit for the transfer of knowledge is The International Conference on Emergency Medicine (ICEM) is a conference held every two years by worldwide emergency physicians by the International Federation for Emergency Medicine. The most recent conference took place in Dublin, Ireland on the 27 - 30 June, 2012. The organization was founded by four national emergency physician organizations: the American College of Emergency Physicians (ACEP), the British Association for Emergency Medicine (BAEM), the Canadian Association of Emergency Physicians (CAEP)and the Australasian College for Emergency Medicine (ACEM). Up until now the conference has rotated between the founder members, but numerous new members have been accepted in recent years and the conference will rotate to them as well.

Developing emergency medicine as a specialty

An important step for the advancement of emergency medical care is obtaining the recognition of emergency medicine as a specialty in countries that currently lack it. Without such recognition it is difficult to set up training programs or recruit potential students as they face the uncertainly of training to obtain a credential that may end up being useless to them. Recognition increases visibility and prestige for the profession and promotes other efforts to advance its development. Botswana may serve as a case study. The recent recognition of emergency medicine as a specialty has been closely accompanied by the creation of the Botswana Society for Emergency Care (BSEC), the establishment of a Resuscitation Training Centre and a Trauma Research Centre at the University of Botswana, and the formation of a committee to design a national policy for pre-hospital care.

An alternate route is providing additional training of other specialists to equip them to practice in emergency medicine. This has the benefit being more rapid to implement as physicians already trained in other areas can add the necessary emergency skills to their repertory. However, after the initial expansion it is difficult for emergency medicine to progress further in nations that adopt this strategy as the retrained partitioners identify more with their original specialty and have less incentive to continue to press for continuing innovations in emergency medicine.

Challenges

Training

Educational opportunities in emergency medicine are simply not available in many countries and even when present it is often in its infancy. Botswana just opened its first medical school in 2009 with a program in emergency medicine following in 2011. The program aims to train four to six physicians in emergency medicine each year. Limitations on in-country training mean that the program includes six months of training at an international site. The organization of the program is modeled on South Africa's program due to the similarities in resource constraints and disease burdens and the eagerness of College of Emergency Medicine of South Africa (CEM(SA)) and Emergency Medicine Society of South Africa (EMSSA) to support the expansion of emergency medicine. Two years of clinical practice are required before entering the residency program as in the South African and Australian approaches.

An important notion present in emergency medical systems development is the idea of training the trainers. This approach works by sending developed country health care workers to equip a small of trainees with the necessary skills to then go on and teach the concepts to others. This approach may be able to leverage the insights of developed emergency medical systems while remaining sustainable as the newly trained trainers continue to spread the knowledge. The Tuscan Emergency Medicine Initiative is an application of that approach with the physicians from other specialities who are currently working in emergency departments being taught how to teach a new group of emergency medical specialists.

Emergency transport

The limitations on resources available in developing countries is particularly evident in the area of emergency transport. Ambulances, the developed country standard, are costly and not practical for the road conditions present in many countries. Indeed, no roads at all may be present. One study found that modes of transport as diverse as motorboats, canoes, bicycles with trailers, tricycles with platforms, tractors with trailers, reconditioned vehicles, and ox carts were used for emergency transport

In more advanced developing countries establishing ambulance transport systems is more feasible but still requires considerable expertise and planning. Prior to 2004, Pakistan did not have an organized emergency medical system. In that year, Rescue 1122 was launched as a professional pre-hopsital emergency service and it has managed to achieve an average response time of 7 minutes, comparable to that of developed nations. Some of the critical factors in its success included local manufacture of vehicles, training instructors to certify emergency medical technicians, adopting training materials to the local context, and branching out to include fire and rescue service response under a united command structure.

Resources

The vital nature of coping with the lack of resources available in international emergency medicine may be seen in the proportion of scientific articles that grapple with that topic. Of the top 27 articles identified by a review of the international emergency medicine literature from 2010, 14 were classified as regarding the practice of emergency medicine in resource constrained environments. Topics covered included the use of the Broselow tape as the best estimate for children's weight, green bananas as an effective treatment for diarrhea, and misoprostol as a potential alternative for postpartum hemorrhage when oxytocin is not available.

Lack of research

Despite the clear intuitive appeal of the thought that increasing availability to emergency medicine will improve patient outcomes, little empirical evidence exists to directly support that claim even in developed counties. Between 1985 and 1998 only 54 randomized controlled trials related to emergency medical services were published, implying that much of the current standard of care rests upon meager support. More to the point, a similar lack of direct proof exists for the effectiveness of international assistance in promoting emergency medicine in other countries. Although it may seem obvious that such efforts improve health, the failure to quantify international emergency medicine's impact renders it more difficult to identify the best practices and target areas in which the most benefit may be achieved.

A development in recent years that seeks address these issues has been termed evidence-based medicine. As its name suggests, this approach strives to rigorously study the effects of different interventions instead of relying on logic or tradition. Its application worldwide could led to the boon of sharing best practices between emergency medicine practitioners in various countries and advance the current standard of emergency care.