Collaboration and Cooperation on Emergency Healthcare Issues in Central and South Asia

1. 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

2. 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

3. 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

4. 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

5. 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

6. 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

7. 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)

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

9. Comparison of EM Specialty Systems Country Category : Under- developed Developing Mature Iran National EM Organization No Yes Yes Yes EM Residency Training No Yes Yes Started EM Board Certification No Yes / No Yes Yes Official Specialty Status No Yes Yes Yes

10. Comparison of Academic EM Features Country Category : Under- developed Developing Mature Iran Specialty Journal No Yes / No Yes No Research No Yes / No Yes Starting Databases No No Yes No EM Sub- Specialty Training No No Yes No

11. Comparison of Patient Care Systems Country Category : Under- developed Developing Mature Iran Emergency Physicians Housestaff, other doctors Some EM res- idency trained All EM resi- dency trained Housestaff, other doctors E.D. Director 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 No No Yes No Trauma system No No Yes No

12. Comparison of Management Systems Country Category : Under- developing Developing Mature Iran Quality Assurance programs No No Yes No Peer Review programs No No Yes No Specialty C.M.E. required No Yes / No Yes No

13. 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

14. 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)

15. 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

16. 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

17. 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

18. 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"

19. 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

20. 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)

21. Countries Utilizing the "American-Anglo" EMS System Type • U.S.A. • Canada • United Kingdom • Australia • Ireland • Mexico • Hong Kong • South Korea • Iran

22. Countries In Which Physicians Provide Most Prehospital Care • Germany • France • Austria • Russia • Ukraine • Estonia • Slovenia • Spain • Italy • Croatia • Switzerland • Hungary • Czech Republic • Slovakia • Portugal • Latvia • Poland • Belarus

23. 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

24. 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 in-hospital doctors

25. 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)

26. 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

27. 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

28. 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

29. Features of the Princess Diana Debacle Showing Deficiencies in the Franco-German System • Very long on-scene time despite non-entrapment • 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

30. 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

31. 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

32. 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 • Mostadministrators 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

33. 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

34. 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

35. 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)

36. 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)

37. 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

38. 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

39. How Can Countries Develop Their Initial Cadre of EM Physicians (the "Core Faculty") ? • Complete an EM residency in a country with well-established 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

40. 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.)

41. 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.)

42. 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

43. 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)

44. 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

45. 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

46. 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

47. 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.)

48. 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

49. 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

50. 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