Jim Holliman, M.D., F.A.C.E.P . Professor of Emergency Medicine

1. International Emergency Medicine : What is it and How has it Developed ? 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 Medicine Uniformed Services University Bethesda, Maryland, U.S.A.

2. 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

3. 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

4. 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.)

5. 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 visits • Demonstrated 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 travel • Terrorist and other mass casualty events

6. 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

7. 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)

8. 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

9. 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

10. 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

11. 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

12. 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

13. 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

14. 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

15. 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

16. The Six ACGME Core Competencies Addressed by International EM Rotations • Patient care • Medical knowledge • Interpersonal skills • Professionalism • System based practice • Practice based learning

17. 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

18. Comparative Milestone Years for EM Development in the Countries with "Mature" EM Aust- ralia Hong Kong Singa- pore Can- ada U.K. U.S.A. 1973 (1979) 1986 1981 1980 1983 1984 Recognized specialty 1968 1967 1981 1984 1985 1993 National Organization 1970 1989 (1988) (1988) 1994 (1993) Academic Society 1979 1983 1986 1985 1997 1994 National certification exam

19. Organizations Which Have Been Involved in International Emergency Medicine • International Federation for EM (I.F.E.M.) • American College of Emergency Physicians (A.C.E.P.) • Society for Academic Emergency Medicine (S.A.E.M.) • World Association of Disaster & EM (W.A.D.E.M.) • American Academy of EM (A.A.E.M.) • European Society for EM (EuSEM) • Asian Society for EM • Emergency International • International Medical Corps (I.M.C.) • Doctors Without Borders (M.S.F.) • Pan-Arab Society of Trauma and EM

20. History of I.F.E.M.'s Involvement in International EM • Represents a consortium of national EM organizations • Founded by A.C.E.P., B.A.E.M., A.C.E.M., C.A.E.P. in 1989 • Operated the International Conference on EM (I.C.E.M.) every other year since 1986 • First held in London, then in 1988 in Brisbane, Australia • Original rotating host cycle for the I.C.E.M. : U.K. -- Australia -- Canada -- U.S.A. • Average about 1000 registrants per conference • Full membership extended to national organizations from other countries with developed EM in 1998 • Developing policy statements on international health issues and international core curriculum for EM • Voted to "open up" the host site for the I.C.E.M. to countries other than the original 4 founders starting in 2010

21. Earliest Members of the I.F.E.M. (and year the organization joined) • A.C.E.P. (1989) • B.A.E.M. (1989) • C.A.E.P. (1989) • A.C.E.M. (1989) • Hong Kong (1998) • Mexico (1999) • China (1999) • Korea (2000) • Czech (2000) • Taiwan (2000) • Singapore (2000) • Israel (2000) • Turkey (2002) • Poland (2002) • Now (2009) 11 other full members • 10 affiliate members • 3 “ex-officio” members (other multinational societies)

22. History of A.C.E.P.'s Involvement in International EM • For many years A.C.E.P.'s only international work was the International Meetings Subcommittee helping with the I.C.E.M. (and 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 international EM activities • The Section on International EM was founded in 1998 and has become the largest section in A.C.E.P. (over 1000 members) • The Task Force on International EM (1999 to 2002) developed a long term plan for further A.C.E.P. support of international EM • In the mid to late 1990's the Annals of EM published a series of articles describing EM development in different countries • A.C.E.P. leaders have been increasingly active with other countries' EM organizations • Has started formally endorsing other international conferences

23. History of S.A.E.M.'s Involvement with International EM • Had an International Committee from 1991 to 1996, then an International Interest Group (which quickly became the biggest interest group within S.A.E.M.) ; now the Committee has been reinstated • Developed reference databases on international EM rotations (since transferred to A.C.E.P.) and fellowships (listed on the SAEM website) • Published standard curricula for different types of international EM fellowship programs & a "generic national EM development plan" (AEM August 2000 issue) • The sum of the articles produced by the Interest Group constituted the "academic underpinning" for international EM work • Conducted business meetings at annual meetings of A.C.E.P. and S.A.E.M. since 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 1998 • Interested in promoting international research projects

24. History of W.A.D.E.M.'s Involvement in International EM • Founded in 1976 as the "Club of Mainz" • Has conducted an international conference every 2 years since 1987 (next in May 2009 in Victoria, British Columbia)) • Concerned mainly with Disaster Medicine discussions, and not so much with EM system development • Many of members are physicians from non-EM specialties • Prehospital and Disaster Medicine is the official journal of the organization

25. History of A.A.E.M.'s Involvement in International EM • Have had an international committee since 2000 • Co-sponsor with the European Society of EM (EuSEM) of the Mediterranean Congress on EM since 2001 (in odd-number years) • Co-sponsor with EuSEM for EuSEM Congresses since 2002 in even-numbered years • Co-sponsor with the Argentine EM Society for the InterAmerican EM Congress every other year since 2006 • Co-sponsor for the Caribbean EM Conference in Barabados January 2009

26. History of the European Society of EM (EuSEM) Involvement in International EM • Founded at the I.C.E.M. in London in 1994 • Conducted First European Congress on EM in San Marino in 1998 (dropped out of sponsoring the original Second Congress which was held in Wroclaw, Poland in 2000, but resumed with Congress in Slovenia in Sept. 2002) • Conducted Mediterranean Congress on EM since 2001 • Published European Journal of EM since 1994 • Published Manifesto for EM in Europe • Interested in developing standardization of training and certification for EM • Supports Disaster Medicine training center and degree program in San Marino • Membership both for individuals and for national EM societies

27. History of the Asian Society of EM • Founded in 1998 at the First Asian Conference on EM in Singapore • Has conducted multinational conferences in Singapore (1999), Taiwan (2001), Hong Kong (2003), Japan (2005), and next in Busan, Korea, May 16 to 19, 2009 • Starting to develop curriculum recommendations and exchange programs • Societal members include Hong Kong, Singapore, Malaysia, Taiwan, Japan, Korea, Bahrain, Thailand, and India

28. History of Emergency International's Involvement in International EM • Started in the late 1980's as the "Society for the International Advancement of Emergency Medical Care" • Early on mainly conducted medical tour trips, but later developed into a "grass roots" organization devoted to assisting EM development in other countries • Nonprofit organization ; was headquartered in Maryland • Had regional based projects in Asia, Middle East, and Latin America • Had conducted business meetings at the annual meetings of A.C.E.P. and S.A.E.M. • Unfortunately dissolved in late 2003

29. History of I.M.C.'s and M.S.F.'s Involvement in International EM • I.M.C. started by Dr. Bob Simon in the 1980's to provide medical care for Afghan refugees • M.S.F. was dominated by French non-emergency physicians until the mid-1990's when it started to utilize more real EM physicians • Both organizations are mainly interested in providing emergency clinical care for disaster and refugee situations & have not done much EM system development • Both are independent private N.G.O.'s • I.M.C. has had prominent programs in Afghanistan, Pakistan, and Bosnia • M.S.F. has been prominent in Africa • M.S.F. won the Nobel Peace Prize in 1999

30. History of the Center for International EMS • Founded in 1991 by Dr. (?) Eelco Dykstra • First headquartered in Weisbaden, then in the Netherlands • Organized a series of good international networking conferences (the "Pan-European Conferences on EMS") : • Budapest, Hungary 1992, AbanoTerme, Italy 1994, Prague, Czech. Rep. 1996, Opatija, Croatia 1998 • Fizzled out after failing to continue the conference series in Turkey in 2000

31. History of the Pan-Arab Society of Trauma and Emergency Medicine • Founded in 2002 • Headquartered in Doha, Qatar • Conducted Qatar International Trauma & EM Conference in Doha every other year since 2002 (over 800 attendees annually) • Published Middle Eastern Journal of EM since 2001 (recently renamed Journal of Emergency Medicine, Trauma, and Acute Care or JEMTAC)

32. History of the American Academy for EM in India (A.A.E.M.I.) • Started in 2000 • Represents an organization focused on helping EM develop in a single country (India) • Has cosponsored international conferences in India every other year since 2002 with the Society for EM in India (S.E.M.I.) and has helped SEMI with its national conference each odd-numbered year

33. 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) • Mature (U.S.A., U.K., Canada, Australia, Hong Kong, Singapore)

34. Categories of Dr. Arnold's Classification Scheme for National EM Development • Specialty systems • Academic EM • Patient care systems • Management 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)

35. Comparison of EM Specialty Systems Country Class : Under- developed Developing Mature Middle East Countries National EM Organization 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

36. Comparison of Academic EM Features 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

37. Comparison of Patient Care Systems 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

38. Comparison of Management Systems 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

39. 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

40. 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 Committee • Join 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

41. Regularly Held International EM Conferences • W.A.D.E.M. : Biennial, odd # years • I.F.E.M. I.C.E.M. : Biennial, even # years • Eu.S.E.M. : biennial, even # years • Mediterranean Congress, biennial, odd # years • Asian Society of EM : Biennial, odd # years • InterAmerican 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

42. 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

43. 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

44. 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)

45. 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

46. 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)

47. Practical Things to Remember Prior to Undertaking International EM Work • If you don't have a passport, then get one • If 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)

48. 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

49. 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"

50. 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