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Abstract Emergency medicine (EM) is a global discipline that provides secondary disease prevention and is also a tool or primaryprevention. It is a horizontally integrated system o emergency care consisting o access to EM care; provision o EM care in thecommunity and during transportation o patients; and provision o care at the receiving acility or hospital emergency department.

EM can oer many tools to improve public health. These tools include primary disease prevention; interventions or addressingsubstance abuse and interpersonal violence; education about saety practices; epidemiological surveillance; enrolment o patientsin clinical research trials ocusing on acute interventions; education and clinical training o health-care providers; and participationin local and regional responses to natural and man-made disasters.

Public health advocates and health policy-makers can beneft rom the opportunities o EM and can help overcome its challenges.Advocating the establishment and recognition o the specialty o EM worldwide can result in benefts or health-care education,help in incorporating the ull scope o EM care into the system o public health, and expand the capabilities o EM or primary andsecondary prevention or the beneft o the health o the public.

Bulletin o the World Health Organization 2006;84:835-839.

Voir page 838 le rsum en ranais. En la pgina 838 fgura un resumen en espaol.

IntroductionPrimary prevention can mitigate tradd

itional global public health problemssuch as isease an malnutrition.1 Howddever, primary prevention is not alwaysapplie, an not all acute illnesses aninjuries can be prevente even with themost strenuous o eorts. Urbanizaddtion, mechanization, local violence anregional conicts have resulte in anincrease in morbiity an mortality romtrauma, especially among the young.1People are living longer, with associateincreases in chronic cariac, respiratoryan vascular iseases.2 Contemporarysociety is ace with new an ierentchallenges, requiring new strategies orprimary an seconary prevention.

Emergency meicine (EM) is aglobal iscipline that unctions as acornerstone or seconary isease preddvention an is one o many tools orimplementing primary isease prevention

The globalization of emergency medicine and its importance

for public healthPhilip Anderson,a Roberta Petrino,b Pinchas Halpern,c & Judith Tintinalli d

839.

a Harvard Medical School, Boston, MA, USA.b University o the Eastern Piedmont, Novara, Italy.c Tel Aviv Sourasky Medical Center, Tel Aviv, Israel.d Department o Emergency Medicine, University o North Carolina at Chapel Hil l, CB 7594 Chapel Hill, NC 27599-7594 USA. Correspondence to Dr Tintinalli

(jet@med.unc.edu).

Re. No. 05-028548

Public Health Reviews

programmes. Many core EM intervenddtions are simple an eective,35 an an

episoe o emergency care can also beuse to acilitate primary prevention.Eective an sustaine EM concepts anpractices can improve the public healtho countries at all levels o socioeconomicevelopment.

Tis article escribes the evolutiono EM into a global meical iscipline,outlines the components o emergencymeical care an its elivery, summaddrizes the contributions EM can make topublic health, an escribes some o thechallenges an opportunities or improvdd

ing EM care worlwie.

Evolution of emergencymedicine as a global disciplineProviing emergency meical care isas ol as the practice o meicine itddsel, but the iscipline o EM an theevelopment o integrate systems o

emergency care elivery are more recentphenomena.

Prior to the 1960s, emergency meiddcal care was a weak link in the chain ohealth care elivery worlwie.6,7 Nointegrate systems o EM care existe.Prehospital care (where available atall) consiste o little more than rapitransport to hospitals. No specic traindding programmes in emergency care wereavailable or physicians an nurses.Tere were no organizations eicateto proviing high quality EM care anto avancing the science an art o itselivery. Te responsibility or stafng

hospital emergency epartments wasistribute among physicians regarlesso their specialization or level o training.Many physicians perceive emergencyuty as an unwelcome buren an aninterruption o their career paths. Needdless to say, the emergency care availableuring this time was erratic, outcomes

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or patients oten ismal, an the benetto public health, minimal.

During the 1960s eorts to organizean improve EM care elivery began withsimultaneous grassdroots movements inevelope countries, with traitionally

traine internal meicine specialists, surddgeons an amily practitioners assumingleaership roles in eveloping systems toensure optimal care or all patients withmeical emergencies. Tis came at a time

when rapi avances in technology, iagddnostics an therapeutics provie betteropportunities or recognizing an treatdding meical emergencies. Horizontallyintegrate emergency care systems beganto be evelope in response to verticallyintegrate systems o specialty care. Suchvertically integrate systems were silos

(inepenent, close omains or uncddtions without linkage o aministrative,cognitive or technical skills to other speddcialties) that create problems o accessto appropriate care or patients with asyet uniagnose meical emergencies,or or patients with complex meicalemergencies that cut across traitionalspecialty bounaries. At the same time,early EM pioneers in several countriesbegan eveloping training programmesor physicians intereste in this el.Growing public concerns about poor

EM care inrastructure resulte in poddlitical pressure to un programmes oreveloping integrate EM care eliverysystems.

Forty years on, EM has evolve intoa coherent iscipline: a unique set o cogddnitive, aministrative an technical skillsor managing all types o patients withacute illness or injury, regarless o age orgener.8 Tis moern approach to EMcare is horizontally integrate in that itcombines knowlege an skills traitionddally associate with multiple specialties

together with the new knowlege anskills necessary or prompt an eectivemanagement o emergency patients.

One measure o the egree o gloddbalization o EM is that there are nowmore than 30 proessional an scienticpublications relate to EM worlwie.

At the time o writing, 46 countrieshave recognize EM as an ofcial meiddcal specialty (see able 1; web versiononly, http://www.who.int/bulletin).911Delivery o EM care toay is largelycoorinate through integrate systems

that acilitate continuity o emergencycare rom the community, through preddhospital care systems, an into hospital

are specically esigne to minimizemorbiity, mortality an isability romacute illness an injury to the greatestextent possible, given available localresources. EM care elivery systemshave come to represent a cornerstone o

seconary isease prevention in moernhealthdcare systems.

Components of EM careand delivery systemsTe core concepts an strategies o EMcare require ocuse meical ecisiondmaking an action with the goal opreventing neeless eath or isabilityrom timedsensitive isease processes (i.e.conitions that must be treate within acertain time perio to prevent or minidd

mize mortality or morbiity). EM carehas the ollowing components: accessingcare, care in the community, care uringtransportation, an care on arrival at areceiving acility.12

Accessing EM careMeical emergencies are time sensitive,because the longer the time that elapsesbeore recognition an treatment, thegreater the likelihoo o morbiity, morddtality or isability. Accessing EM careshoul thereore be mae easy. Delays

in accessing care can be reuce throughpublic eucation about how an whento seek EM care. A universal emergencytelephone access number can simpliyaccess a single telephone numberconnects the caller to a ispatch systemor prehospital care services. In manycountries, access to public saety, policean re services is also integrate withaccess to prehospital care.

EM care in the communityWith appropriate training, bystaners,

community health workers, nurses, priddmary care physicians an other healthdcare proviers can provie eective EMcare in the community. Eucational proddgrammes in rst ai, cariopulmonaryresuscitation, management o oreignboies in the airways, control o externalhaemorrhage an immobilization oinjure extremities using local materials,can ensure an immeiate, basic level oEM care where there are no prehospitalsystems, or beore proviers o prehosddpital care arrive.

EM care during transportationSystems or transporting patients with

l h l h

cilities are another essential componentor reucing morbiity an mortality.Communication systems allow providders o prehospital care to notiy receivingacilities beore a patient arrives, anto obtain meical consultation uring

transport. Te extent to which prehosddpital care systems provie EM care enroute varies consierably rom countryto country an epens on many acddtors incluing socioeconomics, localtraitions an legislation.5,12,13 Systemapproaches range rom those that proddvie only transportation; those thatprovie a basic level o care (rst ai);those proviing an avance level ocare by parameics, nurses or physicians;to those that provie treatment in theambulance an release patients rom care

without transport. EM physicians playimportant roles in supervising prehosddpital care systems, training prehospitalcare proviers an proviing prehospitalcare themselves.

EM care on arrival at a receivingfacilityOnce a patient arrives at the emergencyepartment (ED), the care process conddsists o the ollowing components: triage;resuscitation an stabilization; establishddment o a preliminary iagnosis an

proviing treatment; observation anconsultation; communication o resultsan ocumentation o care; an makingprovisions or ollowdup care.12,14,15

When a specic indhospital intervenddtion is available an inicate, patientsmay be brought by the prehospital careteam irectly to an inpatient specialtyunit. For example, unstable patients withpenetrating trauma may be taken irectlyto the operating suite, or patients withan acute Sd elevation myocarial inarcddtion may be taken irectly to the cariac

catheterization laboratory. However, themore common practice is to provieemergency care in a hospital ED.

riage is necessary to ientiy thosewho nee immeiate care an thosewho may eteriorate; to prioritize careor the remaining patients; an to isddtribute nite resources in the best way.Since patients may use the ED or conddvenience an or seldene emergenddcies, predestablishe triage guielines oralgorithms help ientiy those most innee o immeiate care an can minidd

mize morbiity.12 ED triage is usuallyperorme by specially traine nurses.

Resuscitation is the process o recdd

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an restoring critical organ unction.Emergency physicians have the knowlddege, skills an experience in areas suchas airway management, volume anbloo replacement, containment o acutehaemorrhage, paeiatric an obstetric redd

suscitation, an mastery o the therapiesor acute myocarial inarction, cariacarrhythmias an stroke.14,15 Other speddcialists may possess the knowlege, skillan experience to provie emergencycare or patients with problems in theirspecialty omain. However, it is neitherpractical nor costdeective to sta hospiddtal EDs aroun the clock with the rangeo specialists necessary to provie initialemergency care or all types o patients

when EM physicians are able to play thisrole eectively.

Te majority o patients who seekemergency care present with complaintsor symptoms but not iagnoses. riageprioritizes patients an enables the timeddliest evaluation to establish a preliminaryiagnosis an institute treatment.

I initial iagnostic an therapeuticmeasures are inconclusive, observationan/or consultation with another speddcialist may be inicate. It is also necesddsary to communicate results to otherphysicians an the patient, ocumentthe care given, an make provisions or

ollowdup care. Te emergency phaseo care is conclue once the patient isamitte, ischarge or transerre to ahigher level o care.

The roles of EM in public healthIn aition to the central public healthrole playe by clinical EM care systemsin seconary isease prevention, EMcare systems an EM physicians are alsoimportant or primary prevention. EDsprovie primary interventions such asvaccination against iphtheria, tetanus

an pertussis; postdexposure prophylaxisor iseases such as rabies an hepatitis;an ientication o asymptomatichypertension uring routine assessmento vital signs. EM physicians provietargete crisis intervention an reerralor conitions such as substance abuse,epression an interpersonal violence,16as well as eucation about use o helmetsan seatdbelts. EM physicians can alsoserve as powerul avocates or socialchange by lobbying or legislation orinjury prevention.

EDs are sources o ata or popuddlationdbase epiemiological surveilddlance.17,18 ED ata systems capture clinidd

only on patients who are hospitalize,but rom the even larger numbers opatients ischarge rom the ED whoare never hospitalize.

EDs are also important sites orenrolling patients in clinical research

trials which ocus on acute intervenddtions. Examples inclue stuies on acutestroke, acute myocarial inarction, acuteasthma an acute seizures.

Te concentration o illness ounin an ED makes it an ieal setting ortraining health care proviers. EDs inteaching hospitals are esirable sites orteaching an training. In less evelopecountries, EM physicians can provieeucation an training or communityhealthdcare proviers, who may proviemuch o the EM care or the populadd

tion.5,7National an international systems

or response to isasters invariably reddquire time to mobilize an eploy, anare rarely operational until several aysater the event. As a result, the responsiddbility or the initial meical response toa isaster will all on local EM systemsan care proviers.19 Te global outbreako severe acute respiratory synrome(SARS)17 emonstrate the importanceo EM systems an EDs or early ientiddcation an management o the isease.

Much work certainly remains to be oneto optimize isaster response capacities

worlwie; however the central role orobust EM systems an care proviers ineective isaster planning an responsehas never been clearer.

Challenges and opportunitiesfor global development of EMcare systemsEducation and training

Te principles an concepts o EM areunerrepresente in or absent romthe curricula o many meical schoolsaroun the worl. Te traitional setddting or clinical eucation o meicalstuents is on the inpatient wars o terddtiary care hospitals where the emphasisis place on making the right iagnosis,not on the recognition an managemento meical emergencies.12 Health caredproviers rom countries without postddgrauate resiency programmes in EM,or without a critical mass o EMdtraine

proviers, may not have access to traindding in emergency care. Steps that can betaken by healthdcare policydmakers an

an training opportunities in EM withina given country or region inclue:

encouraging local universities to inddtrouce EM concepts into the unerddgrauate meical curriculum;supporting eorts to start prodd

grammes or training postgrauatephysicians in EM; ansupporting eorts to introuce EMcourses or physicians an nurses inthe community.

Recruitment of talentedindividualsIn countries where EM is not an ofciallyrecognize specialty, there is a relativeisincentive or talente iniviuals tochoose EM as a career, because they willbe unable to attain positions o acaemic,

clinical an aministrative authority.alente iniviuals rom unerdevelddope countries who go abroa to train inEM have little incentive to return homei there is no opportunity or avanceddment. By supporting or introucinginitiatives to aopt EM as an ofcial speddcialty, healthdcare policydmakers can helpcreate incentives that will attract talenteiniviuals to EM an retain them, who

will in turn rive the improvement olocal elivery o EM care.

Understanding the role of EMMisconceptions about the role o EMmay stem rom outate views or lacko amiliarity with current EM systemsan practice. Whatever their source,these misconceptions limit the extent to

which health care systems an the publicmay benet rom EM systems an careproviers by hinering their evelopddment an implementation.

One misconception is that theEM care system is only or the care opatients with known liedthreatening

emergencies an that all other patientsare manage by the primary care system.Rapi etermination o which patientshave true or potential emergencies is nota uniormly simple task. o minimizeelays in recognition an treatment,the unctions or triage an resuscitationmust be tightly integrate within thehealth care system.

Another misconception is that EMcare systems are ocuse only on the careo patients with injuries an that those

with meical emergencies are care or

by other segments o the health caresystem. By narrowly ocusing on traumacare, health system planners overlook

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using resources an optimizing the qualddity o emergency care.

A thir misconception is that EM caretakes place primarily in the prehospitalsetting. Prehospital care is an importantelement o the continuum o EM care, but

hospital EDs can treat ar greater numberso emergency patients. In the majority ocountries at all levels o socioeconomicevelopment, emergency care is elivereprimarily in a hospitaldbase ED ratherthan in the prehospital setting.9

By working with national an interddnational EM proessional organizations,healthdcare policydmakers an publichealth organizations can promote the creddation o guielines or the evelopment oEM care systems that take ull avantageo the potential o EM or serving public

health. Public health organizations areencourage to stuy an track the evelddopment an eects o EM care systems tobetter unerstan their role an potentialor promoting public health.

Administration of systems forthe delivery of EM careIn many countries it is common or theierent components o EM care systemsto be organize, operate, an uneby ierent government ministries or

agencies. For example, the alarm an isddpatch unctions may be controlle by thepolice (ministry o justice); prehospitalcare unctions may be controlle by there epartment (ministry o interior);an hospital EDs may be controlleby the ministry o health. For EM careto be eective an efcient, all o theseelements nee to work in close cooriddnation, which necessitates a commonunerstaning o the mission an opdderational strategies at all organizationallevels, an cooperation at the leaership

level. By avocating systemdbase elivddery o EM care as a core public healthunction, health care policydmakers anpublic health ofcials can promote uncddtional relationships between ierent

elements o the EM care system. Specicinitiatives can inclue the requiremento meical leaership or all elements othe EM care elivery system as well asesignating a lea agency to coorinateinteragency activities.

ConclusionWe have presente the global isciplineo EM rom a public health perspectiveto explain how it provies primary anseconary isease prevention. EM caresystems are potent public health toolsor reucing morbiity an mortalityrom acute illness an injury, or isasterresponse, epiemiological surveillancean selecte preventive health unctions.Tere remain, however, several chalddlenges an opportunities or health care

policydmakers an public health avoddcates to improve EM care or the beneto the health o the public. O

Competing interests: none eclare.

Rsum

Mondialisation de la mdecine durgence et importance de ce phnomne pour la sant publiqueLa mdecine durgence est une discipline mondiale, qui assure uneprvention des pathologies secondaires et constitue galementun outil de prvention primaire. Cest un systme intgr

horizontalement de soins durgence comprenant : laccs auxsoins, la dispensation de soins de mdecine durgence au seinde la collectivit et pendant le transport des patients, ainsi que ladispensation de soins dans lunit ou le service durgence.

La mdecine durgence peut ournir nombre doutils pouramliorer la sant publique, parmi lesquels la prvention despathologies primaires, les interventions pour aire ace aux abusde substances et aux violences interpersonnelles, la ormation etlentranement cliniques des prestateurs de soins et la participation

aux rponses locales et rgionales aux catastrophes doriginenaturelle et humaine.

Les denseurs de la sant publique et les dcideurs dans

ce domaine peuvent tirer parti des possibilits oertes par lamdecine durgence et aider surmonter les difcults quellerencontre. Promouvoir dans le monde entier la mise en place et lareconnaissance de la mdecine durgence en tant que spcialitmdicale peut bnfcier la ormation aux soins de sant,contribuer lincorporation de lventail complet des soins decette spcialit dans le systme de sant publique et tendre sescapacits de prvention primaire et secondaire au proft de lasant des populations.

Resumen

La mundializacin de la medicina de emergencia y su importancia para la salud pblicaLa medicina de emergencia (ME) es una disciplina mundial quecontempla la prevencin secundaria de enermedades y se utilizatambin como instrumento de prevencin primaria. Es un sistemade atencin de emergencia integrado horizontalmente que abarcala atencin ME; el suministro de servicios de ME en la comunidady durante el transporte de pacientes; y el suministro de atencinen el centro receptor o el servicio de urgencias del hospital.

La ME orece numerosas herramientas para mejorar lasalud pblica. Entre ellas cabe citar la prevencin primaria; lasintervenciones destinadas a combatir el abuso de sustanciasy la violencia interpersonal; la educacin sobre las prcticasde seguridad; la vigilancia epidemiolgica; el reclutamiento

de pacientes para ensayos de investigacin clnica centrados

en intervenciones agudas; la educacin y ormacin clnica dedispensadores de atencin sanitaria; y la participacin en lasrespuestas locales y regionales a los desastres naturales o causadospor el hombre.

Los deensores de la salud pblica y los responsablespolticos pueden benefciarse de las posibilidades que brinda laME y ayudar a superar los retos que plantea. Preconizando elestablecimiento y reconocimiento de la especialidad de ME entodo el mundo se puede contribuir a mejorar la enseanza de laatencin sanitaria, propiciar la incorporacin de todo el espectrode medidas de ME en el sistema de salud pblica, y ampliar lasopciones de la ME para la prevencin primaria y secundaria en

benefcio de la salud de la poblacin.

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