Transcript Document
Collaboration and Cooperation on
Emergency Healthcare Issues in
Central and South Asia
Jim Holliman, M.D., F.A.C.E.P.
Program Manager
Afghanistan Health Care Sector Reconstruction Project
Center for Disaster and Humanitarian Assistance Medicine
(CDHAM)
Professor of Military and Emergency Medicine
Uniformed Services University of the Health Sciences (USUHS)
Clinical Professor of Emergency Medicine
George Washington University School of Medicine
Bethesda, Maryland, U.S.A.
February 2009
Collaboration and Cooperation on
Emergency Healthcare Issues :
Lecture Goals
Describe the current status and practice of Emergency
Medicine (EM) and EMS (Emergency Medical Services
or prehospital care) in different countries
Discuss the advantages and disadvantages of different
EM systems
Discuss methods for EM system and EM faculty
development
Stimulate interest in participating in International EM
activities and in solving problems in EM common to all
countries
Encourage medical systems collaborations among the
Central and South Asian countries
Why is There Increasing Interest in the
Specialty of Emergency Medicine (EM) ?
Recent awakening by many countries that they
should develop EM, partly because of public
demand for better EM services
EM in several countries has fully matured as a
specialty and can act as a role model for other
countries
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 few years
Reasons for Increased Interest in
Developing EM Within Other Countries
Improved overall medical system development in most countries
Rapid urbanization
–Resultant "demographic transition" from infectious diseases to
trauma & cardiorespiratory diseases
Increasing outpatient visits
Demonstrated success of EM in the U.S. and U.K.
–Increased public expectations
–International exposure from television shows like "E.R.", "Rescue
911", and "Casualty"
Increased international travel
Increased incidence of terrorist events
Increased incidence and severity of natural disasters
Expected Benefits of
Collaboration and Cooperation on
Emergency Healthcare Issues
• Improve patient care outcomes, particularly for
trauma
• Standardize medical personnel training
• Provide more effective response to disasters
• Decrease support for insurgencies
• Better trans-border infectious disease control
• Provide assistance for system development in
Afghanistan
Health Issues in Central and South
Asia Which Can Be Effectively
Addressed by Improved EM
• Trauma
– Also involves injury prevention programs
• Cardiac disease
• Respiratory illnesses
• Multisystem and complex illnesses,
particularly in the elderly
• Infectious illnesses
• Mass casualty events
Classification System for Stages
of National EM Development
This classification system proposed by Dr. Jeff
Arnold in 1999 (Ann. Emer. Med. 1999: 33: 97-103).
Places countries into one of 3 categories related to
their "stage" of national EM systems development :
–Underdeveloped (most African countries)
–Developing (some European and Middle Eastern
countries ; Iran for example probably fits here)
–Mature (U.S.A., U.K., Canada, Australia, Hong
Kong, Singapore)
Categories of Dr. Arnold's Classification
Scheme for National EM Development
Specialty systems
Academic EM
Patient care systems
Management systems
Comparison of EM
Specialty Systems
Country
Category :
UnderDeveloping
developed
Mature
Iran
National
EM
Organization
EM
Residency
Training
EM Board
Certification
No
Yes
Yes
Yes
No
Yes
Yes
Started
No
Yes / No
Yes
Yes
Official
Specialty
Status
No
Yes
Yes
Yes
Comparison of
Academic EM Features
Country
Category :
UnderDeveloping
developed
Mature
Iran
Specialty
Journal
No
Yes / No
Yes
No
Research
No
Yes / No
Yes
Starting
Databases
No
No
Yes
No
EM SubSpecialty
Training
No
No
Yes
No
Comparison of Patient
Care Systems
Country
Category :
UnderDeveloping
developed
Emergency
Physicians
E.D.
Director
Housestaff,
Mature
Iran
other doctors
Some EM residency trained
All EM residency trained
Housestaff,
other doctors
Other
specialty
EM
physician
EM certified
physician
Other
specialty
Prehospital
care
private car,
taxi
BLS or EMT
ambulance
paramedic
or doctor
varies by
area
Transfer
system
Trauma
system
No
No
Yes
No
No
No
Yes
No
Comparison of
Management Systems
Country
UnderDeveloping
Category : developing
Quality
Assurance
programs
Peer
Review
programs
Specialty
C.M.E.
required
Mature
Iran
No
No
Yes
No
No
No
Yes
No
No
Yes / No
Yes
No
Countries in Which EM is a Well Established Specialty
In these countries EM is an official well- established
("mature") specialty with its own training programs,
board exam, subspecialty fellowships, & operational
stature equivalent to the "traditional" specialties :
–U.S.A.
–United Kingdom
–Australia
–Canada
–Hong Kong
–Singapore
Countries Which Have Graduated
Residents from EM Residency
Training Programs
Costa Rica (1)
Barbados (1)
Turkey (58)
Jordan (2)
Belgium (5)
Hungary (1)
Bosnia (1)
Iran (3)
Israel (5)
Nicaragua (1)
South Korea (55)
China (5)
Taiwan (2)
Estonia (1)
Poland (5)
Bulgaria (1)
Qatar (1)
(number of programs in parentheses)
Countries with EM Residency
Programs in Development
India
Panama
Mexico
Chile
Guatemala
Colombia
Argentina
Egypt
Oman
Italy
Netherlands
Sweden
Romania
Philippines
Czech Republic
Saudi Arabia
South Africa
Brazil
Potential Difficulties in Establishing
EM in Some Countries
Fear by other specialties of "loss" of patients or
revenue
Lack of understanding of the true breadth of the
specialty
Cultural resistance to adopting something
perceived as "American" in origin
Perception that it is hard work and low-paying
relative to other specialties
Lack of exposure to role models for interested
students & residents
The Two General Types of 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 from the "field" to
inpatient specialist services
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 really is not 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) and a relative shortage
of available physicians
Background Reasons for Development
of Paramedic-Based EMS in the U.S.
It costs less and takes less time to train
paramedics compared to physicians
Paramedics are paid less money than physicians
Physicians are "mal-distributed" with
concentrations in urban areas
The number of available residency training
positions exceeds the number of graduating U.S.
medical students (so there are not many
"unemployed" medical school graduates available
for work in the EMS systems)
Countries Utilizing the "AmericanAnglo" EMS System Type
U.S.A.
Canada
United Kingdom
Australia
Ireland
Mexico
Hong Kong
South Korea
Iran
Countries In Which Physicians
Provide Most Prehospital Care
Germany
Croatia
France
Austria
Switzerland
Hungary
Russia
Ukraine
Czech Republic
Slovakia
Estonia
Portugal
Slovenia
Latvia
Spain
Poland
Italy
Belarus
Countries Using a "Mixed" EMS System
with Both Physician and Non-physician
Staffed EMS Units
Belgium
Norway
Sweden
Israel
Argentina
Turkey
Note that the Netherlands
mainly uses a nurse-staffed
EMS system
Theoretical Advantages of
Physician-Based EMS Systems
Allows use of greater medical knowledge and
perhaps more advanced procedural skills by
the doctor
Can treat more patients at home without
transport to hospital
Potential for more accurate prehospital triage
or referral decisions
Improved communication ability with inhospital doctors
Status of Emergency Medicine as a
Specialty in the "Franco-German"
System
"Emergency physicians "are prehospital only
Emergency Medicine not recognized as a
separate or unique specialty
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 U.K.
EM residencies (only 80 hours postgraduate
training required for ambulance doctors in
Germany)
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 speciality hospitals
complicates this
Results of the Operational Problems
of the Franco-German System
Mortality for major or combined systems trauma is poor
( > 14 %, versus 4 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 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
System
Very long on-scene time despite nonentrapment
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 that her only injury was a small
pulmonary vein tear
Features Making Paramedic System
Implementation Difficult In Some Countries
Legal system restrictions on non-physicians
performing medical care or doing certain
procedures (such as defibrillation)
–Thus in Germany paramedics may not utilize some
procedural skills until the doctor is physically
present on-scene
Surplus of physicians due to excessive medical
school graduation rates
–Italy, Spain, Turkey, Argentina
Other Problems with EMS System
Implementation in Europe
Non-standardization of the emergency
telephone number in different countries
Economic problems in some ex-Communist
countries
Lack of regional trauma system coordination
Public expectation to always demand to have
a doctor respond for house calls
Features of the EMS System in the
United Kingdom
Closest to U.S. in structure
Paramedic training and protocols similar to U.S.
Less use of "on-line" command
Most administrators are non-physicians
Physicians staff ALS vehicles in a few big cities
(London, Edinburgh)
–General practice physicians staff rural first response
vehicles
Daytime helicopter service available non-uniformly
Current Problems with Emergency
Medicine in Great Britain
Lack of physician oversight & control of
prehospital paramedic care
Usually only 2 Consultants (EM faculty) per E.D.
–Housestaff not directly supervised at night
–Higher admission for observation rate
–Less able to do research
Residency education loosely structured
Trauma care systems not regionalized
EMS Development Trends
Underway in Europe
Specifying training standards
–New EM residency programs starting
Coordinated dispatch centers
Standard emergency phone number (112)
Critical care protocols
International conferences
Privatization of services and payments
Expansion of helicopter services
Trauma systems regionalization
Relationship of Disaster Medicine
(DM) to Emergency Medicine (EM)
DM is really a small subset of EM
The 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
Northridge California quake ; California has good EM
whereas Japan does not)
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 care
Training 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
problems
So 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 EM
Governmental support
Support from other physician specialties
Infrastructure 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
How Can Countries Develop Their
Initial Cadre of EM Physicians (the
"Core Faculty") ?
Complete an EM residency in a country with wellestablished EM training programs
Complete a non-residency fellowship training
program
Obtain local clinical EM experience & supplement
this with :
–On-site clinical training by experienced EM
physicians from other countries
–In-country or out-of-country short training courses
How Many "Core" EM
Faculty Are Needed ?
2 per hospital is minimum to supervise a training
program
5 or 6 is minimum if 24 hour per day E.D.
supervision is to be provided
Minimum required ratio of 1 "core" faculty to 3
residents is current U.S. requirement
If > 5 faculty available, then assignment of specific
program responsibility to each faculty is useful
(such as one is Residency Director, etc.)
Specific Program Responsibilities To
Consider Assigning to Core Faculty
(Overall) Department Director
EM Residency Program Director
E.D. Clinical Operations Director
Research Director
Medical Student Programs Director
Quality Improvement Programs Director
EMS (Prehospital) Coordinator or Director
Coordinator for residents from other specialties
Liaisons with other departments (such as Trauma,
Pediatrics, etc.)
Types of International EM
Fellowship Programs
"Observational Type"
–For physicians from other countries to study in U.S., U.K., or Australia
–National medical license not required
–Operational at George Washington, Stanford, Loma Linda, and Harvard
Universities in the U.S.
"Clinical Experience Type"
–For physicians from other countries to work in U.S., or U.K.
–Could be funded from the "source" country
–Operational in Washington state and at Harvard Univ. in the U.S.
"Clinical-Based" for U.S. EM residency graduates
–Part of year in U.S. & part overseas
–17 programs now operational in the U.S. and one in Canada
Some of the Modular Courses of
Potential Value in Initial EM Training
E.T.C. (Emergency Trauma Care)
B.T.L.S. (Basic Trauma Life Support)
A.T.L.S. (Advanced Trauma Life Support)
A.C.L.S. (Advanced Cardiac Life Support)
P.A.L.S. (Pediatric Advanced Life Support)
A.P.L.S. (Advanced Pediatric Life Support)
A.B.L.S. (Advanced Burn Life Support)
First Responder
E.M.T.-A (Emergency Medical Technician Ambulance)
Advantages of Modular Training
Courses
Can provide intense focused training
Inexpensive to conduct
Require only limited time away from work for the
participants
Allow standardization of training
Coordinated teaching materials readily available
Can be inserted into already established longer
curricula
Disadvantages (Limitations) of
Modular Training Courses
Participants might feel they are "experts" in the
subject after only a short course
Not equivalent to complete residency training
May focus on clinical problems not of local
relevance (such as ACLS in some areas)
Often do not include supervised clinical
experience to determine if the course material is
being correctly applied in practice
May not be part of a long term followup and
development plan
General Sequence of National
Emergency Medicine Development
Interested cadre of physicians forms
Initial physician cadre obtains EM training for
themselves
Model clinical departments set up
National professional society formed
Training standards & curricula set
Residency programs organized
National specialty journal published
Special exam established
Declared an officially recognized specialty
Organizations Involved in
International Emergency Medicine
A.C.E.P. Section on International EM
A.C.E.P. International Meetings Subcommittee
International Federation for EM (I.F.E.M.)
S.A.E.M. International Interest Group
American Academy for EM in India
A.A.E.M. International EM Committee
World Association of Disaster & EM (W.A.D.E.M.)
European Society for Emergency Medicine (EuSEM)
Asian Society for Emergency Medicine
International Medical Corps (I.M.C.)
Doctors Without Borders (M.S.F.)
Regularly Held International EM
Conferences
W.A.D.E.M.
–Biennial, odd # years
I.F.E.M. International Conference on EM
–Biennial, even # years
EuSEM European Congress on EM
–Biennial, even # years
EuSEM Mediterranean Congress of EM
–Biennial, odd # years
Asian Society of EM
– biennial, odd # years
Perhaps a Central Asian Conference on EM could be started
and the host site rotated among the Central Asian countries
Current Common Problems in EM
in All Countries
Overcrowding (high patient caseloads)
–Due to increasing populations, decreased
inpatient bed capacities, and increasing
complexity and severity of illnesses
High demand from the public
Obtaining appropriate reimbursement for services
Intermittent lack of support from other specialties
Coordinating prehospital and in-hospital patient
care
Current Common Challenges for
EM in All Countries
Fixing the emergency department (E.D.)
overcrowding crisis
–Most of the solutions involve larger aspects of
the health care system than just the E.D.
Getting the government to pass appropriate
legislation to support EM & illness prevention
Avoiding "burnout" in EM personnel
EM physicians from different countries must work
together & teach each other to effectively deal with
these challenges
Specific Recommendations for Physicians
to Assist in International EM Development
Develop linkages with other national EM
organizations or societies
Facilitate two-way exchange of physicians for
study tours and / or clinical or course work
Provide educational materials
Develop fellowship training programs
Act as system structure & training consultants
Promote international collaborative research
projects
Participate in international EM conferences
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 and resources, but
don't compromise quality or integrity
Ensure efforts are part of a coordinated and long
term plan and are supported by the government
Make the effort to formally evaluate outcome or
benefit of programs
Additional Longer Term Goals for
International EM Development
EM system integration with each country's
government & military
Education of all medical students in basic EM
Public education by EM :
–Appropriate use of the E.D.
–Injury & violence prevention
Collaboration with international societies &
research projects
–There is huge potential for international
collaboration on clinical EM research projects
Collaboration and Cooperation on
Emergency Healthcare Issues :
Summary
EM is just starting to develop in many countries
EM provides an extremely important component of a
national health care system
EM is most effective in a country when it is a defined
specialty with its own physician training programs
The clinical, political, and financial problems faced
by EM are largely the same in all countries
There is great potential for more collaborative
interaction between EM physicians from different
countries to solve these problems