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 MedicineUniformed Services University

Bethesda, Maryland, U.S.A.

International Emergency Medicine :

What is it and How has it Developed ?

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 visitsDemonstrated 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 travelTerrorist 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 Comparative Milestone Years for EM Development in the Countries with Development in the Countries with "Mature" EM"Mature" EM

1973 (1979)

1986 1981 1980 1983 1984

1968 1967 1981 1984 1985 1993

1970 1989 (1988) (1988) 1994 (1993)

1979 1983 1986 1985 1997 1994

U.S.A. U.K.Aust-ralia

Can-ada

HongKong

Singa-pore

Recognizedspecialty

National Organization

Academic Society

Nationalcertificationexam

Organizations Which Have Been Organizations Which Have Been Involved in International Emergency Involved in International Emergency MedicineMedicine

International Federation for EM (I.F.E.M.)International Federation for EM (I.F.E.M.)American College of Emergency Physicians (A.C.E.P.)American College of Emergency Physicians (A.C.E.P.)Society for Academic Emergency Medicine (S.A.E.M.)Society for Academic Emergency Medicine (S.A.E.M.)World Association of Disaster & EM (W.A.D.E.M.)World Association of Disaster & EM (W.A.D.E.M.)American Academy of EM (A.A.E.M.) American Academy of EM (A.A.E.M.) European Society for EM (EuSEM)European Society for EM (EuSEM)Asian Society for EMAsian Society for EMEmergency InternationalEmergency InternationalInternational Medical Corps (I.M.C.)International Medical Corps (I.M.C.)Doctors Without Borders (M.S.F.)Doctors Without Borders (M.S.F.)Pan-Arab Society of Trauma and EMPan-Arab Society of Trauma and EM

History of I.F.E.M.'s Involvement in History of I.F.E.M.'s Involvement in International EMInternational EM

Represents a consortium of national EM organizationsRepresents a consortium of national EM organizationsFounded by A.C.E.P., B.A.E.M., A.C.E.M., C.A.E.P. in 1989Founded by A.C.E.P., B.A.E.M., A.C.E.M., C.A.E.P. in 1989Operated the International Conference on EM (I.C.E.M.) every Operated the International Conference on EM (I.C.E.M.) every other year since 1986other year since 1986–First held in London, then in 1988 in Brisbane, AustraliaFirst held in London, then in 1988 in Brisbane, Australia–Original rotating host cycle for the I.C.E.M. : U.K. -- Australia Original rotating host cycle for the I.C.E.M. : U.K. -- Australia -- Canada -- U.S.A.-- Canada -- U.S.A.–Average about 1000 registrants per conferenceAverage about 1000 registrants per conference

Full membership extended to national organizations from other Full membership extended to national organizations from other countries with developed EM in 1998countries with developed EM in 1998

Developing policy statements on international health issues Developing policy statements on international health issues and international core curriculum for EMand international core curriculum for EM

Voted to "open up" the host site for the I.C.E.M. to countries Voted to "open up" the host site for the I.C.E.M. to countries other than the original 4 founders starting in 2010other than the original 4 founders starting in 2010

Earliest Members of the I.F.E.M.Earliest Members of the I.F.E.M.(and year the organization joined)(and year the organization joined)

A.C.E.P. (1989)A.C.E.P. (1989)B.A.E.M. (1989)B.A.E.M. (1989)C.A.E.P. (1989)C.A.E.P. (1989)A.C.E.M. (1989)A.C.E.M. (1989)Hong Kong (1998)Hong Kong (1998)Mexico (1999)Mexico (1999)China (1999)China (1999)Korea (2000)Korea (2000)Czech (2000)Czech (2000)Taiwan (2000)Taiwan (2000)

Singapore (2000)Singapore (2000)Israel (2000)Israel (2000)Turkey (2002)Turkey (2002)Poland (2002)Poland (2002)Now (2009) 11 other Now (2009) 11 other full membersfull members

10 affiliate members10 affiliate members3 “ex-officio” members 3 “ex-officio” members (other multinational (other multinational societies)societies)

History of A.C.E.P.'s Involvement in History of A.C.E.P.'s Involvement in International EMInternational EM

For many years A.C.E.P.'s only international work was the For many years A.C.E.P.'s only international work was the International Meetings Subcommittee helping with the I.C.E.M. (and International Meetings Subcommittee helping with the I.C.E.M. (and conducting the 2 worst I.C.E.M.'s in 1992 and 2000)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 In the late 1990's the A.C.E.P. leadership started to directly support international EM activitiesinternational EM activities–The Section on International EM was founded in 1998 and has The Section on International EM was founded in 1998 and has become the largest section in A.C.E.P. (over 1000 members)become the largest section in A.C.E.P. (over 1000 members)–The Task Force on International EM (1999 to 2002) developed a The Task Force on International EM (1999 to 2002) developed a long term plan for further A.C.E.P. support of international EMlong term plan for further A.C.E.P. support of international EM

In the mid to late 1990's the In the mid to late 1990's the Annals of EMAnnals of EM published a series of published a series of articles describing EM development in different countriesarticles describing EM development in different countries

A.C.E.P. leaders have been increasingly active with other countries' A.C.E.P. leaders have been increasingly active with other countries' EM organizationsEM organizations

Has started formally endorsing other international conferencesHas started formally endorsing other international conferences

History of S.A.E.M.'s Involvement with History of S.A.E.M.'s Involvement with International EMInternational EM

Had an International Committee from 1991 to 1996, then an International Had an International Committee from 1991 to 1996, then an International Interest Group (which quickly became the biggest interest group within Interest Group (which quickly became the biggest interest group within S.A.E.M.) ; now the Committee has been reinstatedS.A.E.M.) ; now the Committee has been reinstated

Developed reference databases on international EM rotations (since Developed reference databases on international EM rotations (since transferred to A.C.E.P.) and fellowships (listed on the SAEM website)transferred to A.C.E.P.) and fellowships (listed on the SAEM website)

Published standard curricula for different types of international EM Published standard curricula for different types of international EM fellowship programs & a "generic national EM development plan" (fellowship programs & a "generic national EM development plan" (AEMAEM August 2000 issue)August 2000 issue)

The sum of the articles produced by the Interest Group constituted the The sum of the articles produced by the Interest Group constituted the "academic underpinning" for international EM work"academic underpinning" for international EM work

Conducted business meetings at annual meetings of A.C.E.P. and S.A.E.M. Conducted business meetings at annual meetings of A.C.E.P. and S.A.E.M. since 1993since 1993

Held conjoint meetings with the U.K. Faculty of A&E Medicine in 1990, 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 1998and 1998, and with EuSEM in San Marino in 1998

Interested in promoting international research projectsInterested in promoting international research projects

History of W.A.D.E.M.'s Involvement in History of W.A.D.E.M.'s Involvement in International EMInternational EM

Founded in 1976 as the "Club of Mainz"Founded in 1976 as the "Club of Mainz"Has conducted an international conference Has conducted an international conference every 2 years since 1987 (next in May 2009 every 2 years since 1987 (next in May 2009 in Victoria, British Columbia))in Victoria, British Columbia))

Concerned mainly with Disaster Medicine Concerned mainly with Disaster Medicine discussions, and not so much with EM discussions, and not so much with EM system developmentsystem development

Many of members are physicians from non-Many of members are physicians from non-EM specialtiesEM specialties

Prehospital and Disaster MedicinePrehospital and Disaster Medicine is the is the official journal of the organizationofficial journal of the organization

History of A.A.E.M.'s Involvement in History of A.A.E.M.'s Involvement in International EMInternational EM

Have had an international committee since 2000Have had an international committee since 2000Co-sponsor with the European Society of EM Co-sponsor with the European Society of EM (EuSEM) of the Mediterranean Congress on EM (EuSEM) of the Mediterranean Congress on EM since 2001 (in odd-number years)since 2001 (in odd-number years)

Co-sponsor with EuSEM for EuSEM Congresses Co-sponsor with EuSEM for EuSEM Congresses since 2002 in even-numbered yearssince 2002 in even-numbered years

Co-sponsor with the Argentine EM Society for Co-sponsor with the Argentine EM Society for the InterAmerican EM Congress every other year the InterAmerican EM Congress every other year since 2006since 2006

Co-sponsor for the Caribbean EM Conference in Co-sponsor for the Caribbean EM Conference in Barabados January 2009Barabados January 2009

History of the European Society of EM History of the European Society of EM (EuSEM) Involvement in International EM(EuSEM) Involvement in International EM

Founded at the I.C.E.M. in London in 1994Founded at the I.C.E.M. in London in 1994Conducted First European Congress on EM in San Marino in Conducted First European Congress on EM in San Marino in 1998 (dropped out of sponsoring the original Second Congress 1998 (dropped out of sponsoring the original Second Congress which was held in Wroclaw, Poland in 2000, but resumed with which was held in Wroclaw, Poland in 2000, but resumed with Congress in Slovenia in Sept. 2002)Congress in Slovenia in Sept. 2002)

Conducted Mediterranean Congress on EM since 2001Conducted Mediterranean Congress on EM since 2001Published Published European Journal of EMEuropean Journal of EM since 1994 since 1994Published Manifesto for EM in EuropePublished Manifesto for EM in EuropeInterested in developing standardization of training and Interested in developing standardization of training and certification for EMcertification for EM

Supports Disaster Medicine training center and degree program Supports Disaster Medicine training center and degree program in San Marinoin San Marino

Membership both for individuals and for national EM societiesMembership both for individuals and for national EM societies

History of the Asian Society of EMHistory of the Asian Society of EM

Founded in 1998 at the First Asian Conference on EM Founded in 1998 at the First Asian Conference on EM in Singaporein Singapore

Has conducted multinational conferences in Has conducted multinational conferences in Singapore (1999), Taiwan (2001), Hong Kong (2003), Singapore (1999), Taiwan (2001), Hong Kong (2003), Japan (2005), and next in Busan, Korea, May 16 to 19, Japan (2005), and next in Busan, Korea, May 16 to 19, 20092009

Starting to develop curriculum recommendations and Starting to develop curriculum recommendations and exchange programsexchange programs

Societal members include Hong Kong, Singapore, Societal members include Hong Kong, Singapore, Malaysia, Taiwan, Japan, Korea, Bahrain, Thailand, Malaysia, Taiwan, Japan, Korea, Bahrain, Thailand, and Indiaand India

History of Emergency International's History of Emergency International's Involvement in International EMInvolvement in International EM

Started in the late 1980's as the "Society for the International Started in the late 1980's as the "Society for the International Advancement of Emergency Medical Care"Advancement of Emergency Medical Care"

Early on mainly conducted medical tour trips, but later Early on mainly conducted medical tour trips, but later developed into a "grass roots" organization devoted to developed into a "grass roots" organization devoted to assisting EM development in other countriesassisting EM development in other countries

Nonprofit organization ; was headquartered in MarylandNonprofit organization ; was headquartered in MarylandHad regional based projects in Asia, Middle East, and Latin Had regional based projects in Asia, Middle East, and Latin AmericaAmerica

Had conducted business meetings at the annual meetings of Had conducted business meetings at the annual meetings of A.C.E.P. and S.A.E.M.A.C.E.P. and S.A.E.M.

Unfortunately dissolved in late 2003Unfortunately dissolved in late 2003

History of I.M.C.'s and M.S.F.'s History of I.M.C.'s and M.S.F.'s Involvement in International EMInvolvement in International EM

I.M.C. started by Dr. Bob Simon in the 1980's to provide medical I.M.C. started by Dr. Bob Simon in the 1980's to provide medical care for Afghan refugeescare for Afghan refugees

M.S.F. was dominated by French non-emergency physicians M.S.F. was dominated by French non-emergency physicians until the mid-1990's when it started to utilize more real EM until the mid-1990's when it started to utilize more real EM physiciansphysicians

Both organizations are mainly interested in providing Both organizations are mainly interested in providing emergency clinical care for disaster and refugee situations & emergency clinical care for disaster and refugee situations & have not done much EM system developmenthave not done much EM system development

Both are independent private N.G.O.'sBoth are independent private N.G.O.'sI.M.C. has had prominent programs in Afghanistan, Pakistan, I.M.C. has had prominent programs in Afghanistan, Pakistan, and Bosniaand Bosnia

M.S.F. has been prominent in AfricaM.S.F. has been prominent in AfricaM.S.F. won the Nobel Peace Prize in 1999M.S.F. won the Nobel Peace Prize in 1999

History of the Center for History of the Center for International EMSInternational EMS

Founded in 1991 by Dr. (?) Eelco DykstraFounded in 1991 by Dr. (?) Eelco DykstraFirst headquartered in Weisbaden, then in First headquartered in Weisbaden, then in the Netherlandsthe Netherlands

Organized a series of good international Organized a series of good international networking conferences (the "Pan-European networking conferences (the "Pan-European Conferences on EMS") :Conferences on EMS") :–Budapest, Hungary 1992, Abano Terme, Italy Budapest, Hungary 1992, Abano Terme, Italy

1994, Prague, Czech. Rep. 1996, Opatija, 1994, Prague, Czech. Rep. 1996, Opatija, Croatia 1998Croatia 1998

Fizzled out after failing to continue the Fizzled out after failing to continue the conference series in Turkey in 2000conference series in Turkey in 2000

History of the Pan-Arab Society of History of the Pan-Arab Society of Trauma and Emergency MedicineTrauma and Emergency Medicine

Founded in 2002 Founded in 2002 Headquartered in Doha, QatarHeadquartered in Doha, QatarConducted Qatar International Trauma & EM Conducted Qatar International Trauma & EM Conference in Doha every other year since Conference in Doha every other year since 2002 (over 800 attendees annually)2002 (over 800 attendees annually)

Published Published Middle Eastern Journal of EMMiddle Eastern Journal of EM since 2001 (recently renamed since 2001 (recently renamed Journal of Journal of Emergency Medicine, Trauma, and Acute Emergency Medicine, Trauma, and Acute CareCare or JEMTAC) or JEMTAC)

History of the American Academy History of the American Academy for EM in India (A.A.E.M.I.)for EM in India (A.A.E.M.I.)

Started in 2000Started in 2000Represents an organization focused on Represents an organization focused on helping EM develop in a single country helping EM develop in a single country (India)(India)

Has cosponsored international conferences Has cosponsored international conferences in India every other year since 2002 with the in India every other year since 2002 with the Society for EM in India (S.E.M.I.)Society for EM in India (S.E.M.I.) and has and has helped SEMI with its national conference each helped SEMI with its national conference each odd-numbered yearodd-numbered year

Classification System for Stages of Classification System for Stages of National EM DevelopmentNational EM Development

This classification system proposed by Dr. This classification system proposed by Dr. Jeff Arnold in 1999 Jeff Arnold in 1999 ((Ann. Emer. MedAnn. Emer. Med. 1999; 33: 97-. 1999; 33: 97-103).103).

Places countries into one of 3 categories Places countries into one of 3 categories related to their "stage" of national EM related to their "stage" of national EM systems development :systems development :–Underdeveloped (most African countries)Underdeveloped (most African countries)–Developing (some European and Middle Developing (some European and Middle

Eastern countries)Eastern countries)–Mature (U.S.A., U.K., Canada, Australia, Hong Mature (U.S.A., U.K., Canada, Australia, Hong

Kong, Singapore)Kong, Singapore)

Categories of Dr. Arnold's Classification Categories of Dr. Arnold's Classification Scheme for National EM DevelopmentScheme for National EM Development

Specialty systemsSpecialty systemsAcademic EMAcademic EMPatient care systemsPatient care systemsManagement systemsManagement 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 SpecialtyComparison of EM Specialty

SystemsSystems

Country Class :

Under- developed

Developing Mature Middle East Countries

National EMOrganization

No Yes Yes Some

EM Residency Training

No Yes Yes Some

EM Board Certification

No Yes/No Yes No

Official Specialty Status

No Yes Yes Some

Comparison of Academic EMComparison of Academic EM

FeaturesFeatures

Country Class :

Under- developed

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 Sub- Specialty Training

No No Yes No

Comparison of Patient CareComparison of Patient Care

SystemsSystems Country Class :

Under- developed

Developing Mature Middle East Countries

Emergency Physicians

Housestaff, other doctors

Some EM residency trained

All EM residency trained

GP's, some residency trained

E.D. Director

Other specialty

EM physician

EM certified physician

Some EM

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 ManagementComparison of Management

SystemsSystems

Country Class :

Under- developed

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 CommitteeJoin 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 ConferencesW.A.D.E.M. : Biennial, odd # yearsI.F.E.M. I.C.E.M. : Biennial, even # yearsEu.S.E.M. : biennial, even # years –Mediterranean Congress, biennial, odd # years

Asian Society of EM : Biennial, odd # yearsInterAmerican 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.ama-assn.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 oneIf 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 "American-Anglo" EMS System Type

U.S.A.CanadaUnited KingdomAustraliaIrelandMexicoHong KongSouth KoreaIran

Countries In Which Physicians Provide Most Prehospital CareGermanyFranceAustriaRussiaUkraineEstoniaSloveniaSpainItaly

CroatiaSwitzerlandHungaryCzech RepublicSlovakiaPortugalLatviaPolandBelarus

Countries Using A "Mixed" EMS System (with both Physician & Non-physician Staffed EMS Units)

BelgiumNorwaySwedenIsraelArgentinaTurkey

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 EMThe 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 careTraining 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 multi-system problemsSo 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 EMGovernmental supportSupport from other physician specialtiesInfrastructure 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–SingaporeEM 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)Barbados (1)Turkey (33/19)Jordan (3)Hungary (1)Bosnia (1)Belgium (5)Iran (3)Mexico (3)

Nicaragua (1)South Korea (55)

China (6)Taiwan (2)Estonia (1)Israel (7)Bulgaria (1)Qatar (1)

Countries with EM Residency Programs in Development

IndiaIrelandParaguayChileGuatemalaColombiaArgentinaEgyptSouth AfricaBrazil

ItalyNetherlandsSwedenRomaniaPhilippinesPolandCzech RepublicOmanSaudi ArabiaPeru

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 & curriculumU.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 low-paying 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 materialsAct 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 nucleusPhysicians obtain local clinical experience in EM (perhaps with on-site U.S. or Canadian physician co-workers) & then start a training programPhysicians come to the U.S. or Canada for various short-term training courses, & then return to their home countryU.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 restrictionsRestrictions 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 formsInitial physician cadre obtains EM training for themselves

Model clinical departments set upNational professional society formedTraining standards & curricula setResidency programs organizedNational specialty journal publishedSpecialty exam establishedDeclared 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 DevelopmentDevelop 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 materialsDevelop fellowship training programsAct 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 EMPublic 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 systemU.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 helicoptersExcessive documentation

International Emergency Medicine SummaryEM 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