Ch 2. Global Emergency Medicine
Global Emergency Medicine
Global Emergency Medicine
Evolution from International Emergency Medicine to Global Emergency Medicine
International emergency medicine as a subspecialty of emergency medicine primarily started in the mid 1990’s and had two primary aims: to promote emergency medicine as a recognized specialty in other countries and to provide humanitarian assistance.2 It has been most commonly defined as “the area of emergency medicine concerned with the development of emergency medicine in other countries."1
The term global emergency medicine has emerged in the past several years, much in line with the distinctions drawn between the terms global and international health. More and more people refer to what previously was called international emergency medicine as global emergency medicine because it 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.
For the purposes of this book, we will be using the term “global emergency medicine” as it is most inclusive with the understanding that this term may include international emergency medicine.
What is Global Emergency Medicine?
Global emergency medicine (GEM) encompasses a diverse array of initiatives, settings, approaches, and objectives that center on health care system capacity building, and the delivery of healthcare (specifically acute care) worldwide. GEM activities and competencies can be categorized into 3 major areas: emergency medicine development, delivery of acute care in resource limited settings, and disaster and humanitarian response. GEM research has also become a specialty itself due to unique challenges inherent to global research, and it intersects with the three major areas. Below are brief overviews of each category. There is, of course, a lot of overlap between parts of these areas, but for the sake of clarity we have created distinct categories.
Emergency Medicine Development
As countries improve their economies and healthcare systems, their burden of disease changes from infectious disease, sanitation, and
nutrition to trauma (particularly motor vehicle), heart disease, and cancer. These new burdens require a new type of system and provider that specializes in delivery of this care. Emergency medicine development (EMD) focuses on the development of emergency medicine globally, both at the health-systems level and individual training level. It seeks to strengthen public health systems and emergency medical systems into ones that that are organized, integrated, equitable, and accessible to anyone needing acute care. Endeavors include, but are not limited to, establishing pre-hospital medical and trauma care systems, creating culturally appropriate emergency departments within hospitals, and training providers to staff those departments.
EMD also encompasses EM specialty development (including advocacy for EM at the national level), development of collective national organizations that unite, inform and educate their members, and the initiation and expansion of residency/graduate level training programs. In addition, EMD aims to improve and advance emergency medicine education and training through propagation of structured training programs (e.g. Advanced Cardiac Life Support, Advanced Trauma Life Support, and other resuscitation programs). Other strategies include specific education about topics relevant to a region (e.g. infectious diseases, sanitation, and injuries), tele-simulation, and public/community education. The goal of an EMD program is collaboration and local capacity building which are essential for the sustainability and the longevity of EM in any region.
Acute/Emergency Care in Resource-Limited Settings
This aspect of GEM focuses on the actual delivery of care: diagnosis, management, and prevention of diseases in low- and middle- income countries to improve the overall health of the population. The inherent uncertainty and challenges of medicine multiply exponentially in resource-limited settings due to limited infrastructure, staff, and diagnostic and therapeutic resources. This area focuses on optimizing the use of resources available, examining the efficacy of treatment regimens for diseases seen primarily in these settings (e.g. rehydration methods for diarrheal illnesses), and improving bedside skills (e.g. diagnostic algorithms, physical exam skills). Traditional areas of interest include vulnerable populations, maternal and child mortality, and infectious diseases (e.g. diarrheal illnesses, pneumonia, TB, malaria, and HIV). Given that injury and diseases of old age now exceed communicable diseases as leading causes of death in many resource-limited countries, there has also been a surge in stroke, heart disease, and trauma-related illnesses in these settings. Research has therefore also expanded to injury prevention and heart disease/stroke prevention. In addition to the delivery of care, this area of GEM seeks to address the inherent challenges in conducting research in low-resource settings.
Disaster and Humanitarian Response
Disaster and humanitarian response (DHR) focuses on care of those affected by natural disasters, armed conflict, disease epidemics, mass migrations, political/economic instability, and other potentially reversible situations. DHR not only encompasses disaster response, mitigation, and assessment, but also prevention, preparedness, and rebuilding. The care for the populations involved includes attention to the short term problems of food, water, sanitation, healthcare, shelter, and safety in the acute phase of a disaster as well as attention to the long-term problems of rebuilding damaged health and social infrastructure and addressing psychological and emotional distress of affected people.
In recent years, humanitarianism has seen rapid expansion and undergone professionalization with the development of its own standards, ethics, training, and research. This advancement is based upon two important principles. The first is that the limited resources available must be allocated to provide the greatest benefit to the greatest number of people. The second is that disease prevention and health promotion (e.g. nutrition, sanitation, communicable disease control) should be emphasized over complex medical care. By utilizing these strategies, morbidity/mortality rates have been reduced during complex humanitarian disasters. A large area of focus in DHR is developing skilled communication and coordination of resource allocation rather than on improving the actual healthcare delivery. In addition to the above topics, improving the training of aid workers has increased their effectiveness, allowing them to deliver aid more effectively in complex political and social climates in which they have to operate. A seminal publication in the field came out of the 'Sphere Project' entitled "Humanitarian Charter and Minimum Standards in Disaster Response", which outlines the core principles and minimum standards for humanitarian programs during emergencies.
Global Emergency Medicine Research
Conducting research in culturally distinct and often resource-limited settings provides challenges that are unique to GEM. Therefore, GEM research has become a specialty in itself, and has grown rapidly over the recent years. Some of the unique challenges to research in GEM are:
1. Lack of adequate funding
2. Lack of appropriate resources
3. Lack of healthcare infrastructure
4. Cultural/Societal differences between patients, local researchers, and foreign researchers
5. Feasibility of integration of advancements into the present healthcare system
6. Historical studies in which the ethical standard of a sponsoring country was not applied to research in the host country
These challenges have led to the formation of specific fundamentals of GEM research. In addition, the growing body of “grey literature” produced by governmental agencies and nongovernment organizations reflects the widespread interest in developing and enhancing emergency medicine systems in different countries.
The four fundamentals of GEM research are:
1. Capacity building - utilizing local members of a region in a project
2. Health care improvement domains – helping develop standards of care by changing structure, process, or outcome
3. Implementation – consideration of the efficacy, feasibility, and cost effectiveness of proposed interventions
4. Methodology – addressing specific challenges of design and data collection, pushing utilization of epidemiological data
As mentioned above, the focus of GEM research has changed recently and now includes domains such as trauma, injury, preventive care, and a focus on chronic disease in addition to infectious disease and malnutrition. For example, cardiovascular diseases are now the number one cause of death globally. In the United States, the development of observation units and intensive care units has reduced rates of missed diagnoses of myocardial infarctions. However, these interventions might not be translatable globally due to cultural and economic differences. Thus, research is needed to find the best management plans for this ever-growing cohort of patients in a variety of care environments.
Global Emergency Medicine is an ever-growing field that is becoming more specialized each year. Skills and competencies for those interested in a career in GEM expand beyond the necessary EM competencies to provide clinical care in a variety of settings. As described above, there are many different aspects of GEM. In the following pages, we hope to provide you with the fundamentals needed to explore GEM as a specialty or part of your career as a whole. There are many different ways to become involved as a student, a resident, or as a practicing physician. Thank you for reading, and welcome to the world of Global Emergency Medicine.
1. Arnold, Jeffrey L. (January 1999). "International Emergency Medicine and the Recent Development of Emergency Medicine Worldwide". Annals of Emergency Medicine 33 (1): 97–103
2. Sistenich, Vera (August 2012). "International Emergency Medicine: How to Train for It". Emergency Medicine Australasia 24 (4): 435–41
3. Arnold LK, Razzak J. Research agendas in global emergency medicine. Emergency Medicine Clinics of North America 2005; 23:231-257.
4. Becker T, Jacquet G, March R, et al. Global emergency medicine: a review of the literature from 2013. Academic Emergency Medicine 2014; 21(7):810-817.
5. Brennan R, Nandy R. Complex humanitarian emergencies: a major global health challenge. Emergency Medicine 2001; 13:147-156.
6. Cardiovascular diseases. World Health Organization website. http://www.who.int/mediacentre/factsheets/fs317/en/. Accessed June 20, 2015.
7. GEMLR Procedures Manual 2013. Available at: http://www.gemlr.org/uploads/1/4/6/4/14642448/2012_
gemlr_procedures_manual_abridged.doc. Accessed June 20, 2015.
8. Hogan D, Burstein J. Disaster Medicine. 2nd ed. Philadelphia: Lippincott Williams Wilkins; 2007.
9. Hsia R, Razzak J, Tsai A, et al. Placing emergency care on the global agenda. Annals of Emergency Medicine 2010; 56(2): 142-149.
10. Humanitarian Charter and Minimum Standards in Disaster Response. Available at: http://www.sphereproject.org/resources/download-publications/?search=1&keywords=&language=English&category=22. Accessed June 20, 2015.
11. Jacquet G, Foran M, Bartels S, et al. Global emergency medicine: a review of the literature from 2012. Academic Emergency Medicine 2013; 20(8):835-843.
12. Schroeder E, Jacquet G, Becker TK, et al. Global emergency medicine: a review of the literature from 2011. Academic Emergency Medicine 2012; 19(10):1196-1203.
13. Smith J, Haile-Mariam T. Priorities in global emergency medicine development. Emergency Medicine Clinics of North America 2005; 23:11-29.
14. Sphere Project. Available at: http://www.sphereproject.org/. Accessed June 20, 2015.