Международная медицина неотложной помощи: развитие и вызовы

Subspecialty of emergency medicine

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.

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. 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.

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. 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. 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.

There are two primary models of emergency medicine: the Anglo American model, which relies on "bringing the patient to the hospital", and the Franco German model, which operates through "bringing the hospital to the patient". Instead, Arnold and Holliman have proposed that other groupings be used, such as classifying emergency medical systems as following a specialty or multidisciplinary model. 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. An example of a developing nation establishing its own model of emergency medicine may be seen in southern Brazil. Elements of both of the major conventional models have been incorporated, with the EMS system following French influences and the ambulances being staffed by physicians, while an American approach to emergency medical residency training is also present.

In developed counties, training programs specifically relating to the international practice of emergency medicine are now available within many emergency medicine residencies. The curriculum that should be covered by such programs has been the subject of much discussion. Patient care, medical knowledge, practice 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, but the application of these goals can take many forms. Such exchanges can be mutually beneficial. For instance, 23 to 28 percent of all physicians in Australia, the United States, the United Kingdom and Canada received their training at medical schools outside of the country in which they currently practice.

[[File:Africa satellite plane. jpg|thumb|According to Alagappan et al., Africa is the continent most in need of developing emergency medical systems. Given the limited resources of many developing nations, funding vitally effects how emergency medicine fits into the health system. Preventive care is 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 particular problem for poorer nations such as Zambia, which had a per capita health expenditure of 23 US dollars in 2003.

Hobgood et al. argue that one key component in equipping nations to develop emergency medical systems is to identify the aspects of training that are essential for health care providers. In their view, a standard curriculum is useful for identifying core issues, even if countries have very different needs and resources. To address this goal, the International Federation for Emergency Medicine developed a model curriculum in 2009. 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. Another conduit for the transfer of knowledge is the International Conference on Emergency Medicine, a conference held every two years for worldwide emergency physicians by the International Federation for Emergency Medicine (IFEM). In 2012, the conference took place in Dublin, Ireland. The organization was founded in 1991 by four national emergency physician organizations: the American College of Emergency Physicians, the British Association for Emergency Medicine, the Canadian Association of Emergency Physicians, and the Australasian College for Emergency Medicine. The conference rotated between the founding members until 2010, when it was held in Singapore. Many new members have been accepted since the mid 1990s, when the IFEM decided to open up membership to other nations' emergency medicine organizations; the conference will rotate to them as well. There are other conferences on international emergency medicine as well, including the one that the World Association for Disaster and Emergency Medicine (WADEM) has held every two years since 1987. However, WADEM focuses more on disaster medicine than emergency medicine system development, and many of its member physicians are not specialists in emergency medicine. Additionally, the European Society for Emergency Medicine (EuSEM) has hosted an annual conference since 1998. EuSEM also publishes The European Journal of Emergency Medicine, develops recommendations for emergency medicine standards for European countries, and supports a disaster medicine training center and degree program in San Marino. The Asian Society for Emergency Medicine (Asian Society), which was founded in 1998, holds its own biennial conference. In addition to that, the Asian Society, like the EuSEM, develops curriculum recommendations for Asian countries. An alternate route for developing emergency medicine is to provide additional training for other specialists to equip them to practice in emergency medicine. This has the benefit of being more rapid to implement, as physicians already trained in other areas can add the necessary emergency skills to their repertoire. However, after the initial expansion it is difficult for emergency medicine to progress further in nations that adopt this strategy, as the retrained practitioners identify more with their original specialty and have less incentive to continue to press for further innovations in emergency medicine.

The limitations on resources available in developing countries are 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, there may be no roads at all. 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 that year, Rescue 1122 was launched as a professional pre hospital 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. A new dimension of thought is that of the isolated subject of technology for trauma care as published in the World Journal of Surgery by Mihir Shah et al. 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.

Despite the thought that increasing availability to emergency medicine will improve patient outcomes, little empirical evidence exists to directly support that claim, even in developed countries. 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. A similar lack of direct proof exists for the effectiveness of international assistance in promoting emergency medicine in other countries. Although it may seem that such efforts must 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 to 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. Jeffrey Arnold argues that its application worldwide could lead to the boon of sharing best practices between emergency medicine practitioners in various countries, thus advancing the current standard of emergency care.