International emergency medicine is a subspecialty of emergency medicine that focuses not only on the global practice of emergency medicine but also on efforts to promote the growth of emergency care as a branch of medicine throughout the world. The term international emergency medicine generally refers to the transfer of skills and knowledge—including knowledge of ambulance operations and other aspects of prehospital care—from developed emergency medical systems (EMSs) to those systems which are less developed. However, this definition has been criticized as oxymoronic, given the international nature of medicine and the number of physicians working internationally. From this point of view, international emergency medicine is better described as the training required for and the reality of practicing the specialty outside of one's native country.
Emergency medicine has been a recognized medical specialty in the United States and other developed countries for nearly forty years, although these countries' EMSs did not become fully mature until the early 1990s. At that point, some of its practitioners turned their attention from developing the specialty at home to developing it abroad, leading to the birth of international emergency medicine. They began to support the growth of emergency medicine worldwide, doing so through conferences, national and regional emergency medicine organizations, relief and development organizations, international emergency medicine fellowships, physician exchanges, information transfer, and curriculum development.
Most developing countries are taking steps to develop emergency medicine as a specialty, to develop accreditation mechanisms, and to promote the development of emergency medicine training programs. Their interest is a result of improved healthcare, increasing urbanization, aging populations, the rising number of traffic fatalities, and heightened awareness of emergency medicine among their citizens. In addition, emergency medicine is useful in dealing with time-sensitive illnesses, as well as improving public health through vaccinations, interventions, training, and data collection. Countries that lack mature EMSs are developing emergency medicine as a specialty so that they will be able to set up training programs and encourage medical students to pursue residencies in emergency medicine.
Some challenges faced in international emergency medicine include immature or non-existent training programs, a lack of adequate emergency transport, a shortage of resources to fund emergency medicine development, and an absence of research that could inform developing countries how to best spend the resources they devote to emergency medicine. Additionally, the standards and methods used in countries with mature EMSs are not always suited for use in developing countries due to a lack of infrastructure, shortage of funds, or local demographics. Ambulances, the developed country standard, are costly and not practical for the road conditions present in many countries; instead, a variety of modes of transportation are used. Furthermore, in place of expensive medication and equipment, developing countries often opt for cheaper if slightly less effective alternatives. Although it may seem that increasing availability to emergency medicine must improve health, there is little empirical evidence to directly support that claim or to point out which methods are most effective in improving patient health. Evidence-based medicine seeks to address this issue by rigorously studying the effects of different interventions instead of relying on logic or tradition.
Background
Definition The most commonly accepted definition of international emergency medicine is that it is "the area of emergency medicine concerned with the development of emergency medicine in other countries." In that definition, "other countries" refers to nations that do not have a mature emergency care system (exemplified by board-certified emergency physicians and academic emergency medicine, among other things). Included in those nations are some that are otherwise quite developed but lack a complete emergency medical system, such as Armenia, China, Israel, Nicaragua, and the Philippines. Work in international emergency medicine can be broken down into two main categories: 1) the promotion of emergency medicine as a recognized and established specialty in other countries, and 2) the provision of humanitarian assistance.
William Burdick, Mark Hauswald, and Kenneth Iserson have criticized the above definition 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 and the reality of practicing the specialty outside of one's native country.
History
Emergency medicine
Emergency medicine is a specialty that was first developed in the United States in the 1960s. For the United States, the high number of traffic and other accident fatalities in the 1960s spurred a white paper from the National Academy of Sciences; it exposed the inadequacy of the current emergency medical system and led to the establishment of modern emergency medical services. The United Kingdom, Australia, Canada, Hong Kong, and Singapore followed shortly thereafter, developing their respective emergency medicine systems in the 1970s and 1980s.
Beginning of the subspecialty
By the early 1990s, the emergency medicine systems (EMSs) in the United States, the United Kingdom, Australia, Canada, Hong Kong, and Singapore were largely mature, leading some practitioners to focus on developing the specialty in other countries. Thus, international emergency medicine as a subspecialty began in the 1990s, although some isolated efforts to achieve some of its goals had taken place in the late 1980s. There were several reasons for the heightened interest these practitioners had in developing emergency medicine abroad. One was the contrast between the EMSs of their countries and the EMSs of other countries. Another was the revolutions of 1989, overthrowing authoritarian regimes, which facilitated spread of new ideas, such as emergency medicine.
Two international emergency medicine conferences were launched in the 1980s, the International Conference on Emergency Medicine (ICEM) and the World Association for Disaster and Emergency Medicine Conference (WADEM). ICEM was founded by the International Federation of Emergency Medicine, while WADEM was started by an organization of the same name. Additionally, in the 1990s various national and regional emergency medicine organizations began supporting the development of the specialty in other countries, including the American College of Emergency Physicians, the European Society for Emergency Medicine, and the Asian Society of Emergency Medicine.
Furthermore, countries without mature EMSs began taking more interest in developing them. One reason for this interest was the overall improvement in healthcare in these countries. Another was the increasing urbanization taking place worldwide and the corresponding shift of focus from infectious diseases to trauma and cardiorespiratory diseases, which are better managed by emergency medicine than prevention. In addition to these developments, the aging population in many countries has led to an increased need for emergency medical services. Also, American popular culture, particularly television shows, and "the demonstrated success of emergency medicine" in countries with mature EMSs both led the public in many countries to expect better emergency medical care.
International emergency medicine organizations, whether focused on relief or development, have also contributed to the growth of the subspecialty. Relief organizations, such as Doctors Without Borders or AmeriCares, serve countries that do not have mature EMSs when health catastrophes occur. These organizations also serve to "enhance [the specialty's] image in the international public eye". Some development organizations, such as Emergency International or the International Federation for Emergency Medicine, help establish and develop emergency care systems in other countries by providing "ongoing educational and organizational assistance."
Emergency medicine in the developing world Motor vehicle crashes were a major factor that led to the development of emergency medicine in the United States, the United Kingdom, Australia, Canada, Hong Kong, and Singapore, and they are a major factor leading countries to develop their own emergency medical systems today. Such 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 various reasons, including lower safety standards for vehicles. The lack of available emergency care in many developing countries only serves to exacerbate this problem. This higher rate of accident mortality per vehicle exists despite the fact that there are fewer cars in Asia and Africa than in the West. Odero et al. argue that this shows a need to improve emergency medical care.
Emergency medical care applies to other acute health problems as well. Many illnesses 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 potentially life-threatening conditions, yet effective treatment is often unavailable for much of the world's population.
For instance, a 2008 study of medical systems in Zambia published by the International Anesthesia Research Society found that only 50 percent of hospitals had an emergency medical system that transported patients. Just 24 percent of ambulances carried oxygen, with only 40 percent carrying drugs of any kind. Furthermore, only 29 intensive care beds were available in all of the hospitals surveyed, and these were only found in major hospitals. This implies that the majority of critically ill patients are receiving care in general hospital wards.
Anderson et al. argue that, 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, because of the high number of patients. Emergency medicine also improves public health by preventing secondary disease developing from an initial presentation (initial symptoms), and it serves as the first line of defense in disaster scenarios.
Models of emergency care