Emergency medicine and the developing world

The Evolution of Emergency Medicine

Objective

Emergency Medicine as an independent medical specialty has a history of only about 30 years. However, emergency medical care has been practised ever since human civilization. As emergency physicians, it is necessary to know the evolution of Emergency Medicine throughout the centuries and its development in different parts of the World. Lessons learned in the past may guide our future development.

Methods

Medical literature on evolution, development and history of Emergency Medicine were searched from the Medline, HealthSTAR and EMBASE. Relevant full text articles were retrieved through hospital library network. Information was also obtained through Internet and books on history of medicine.

Results

Most of the articles were contained in the International Report Section of the Annals of Emergency Medicine. The historical development, the catalysts for change and the different models of modern emergency care were found to be interesting and enlightening.

Conclusion

Emergency Medicine is still at its formative stage. Different models exist in different parts of the World. The specialty is rapidly changing and moving in different directions, both locally and internationally.

Advanced training in trauma life support for ambulance crews

BACKGROUND

There is an increasing global burden of injury especially in low- and middle-income countries (LMICs). To address this, models of trauma care initially developed in high income countries are being adopted in LMIC settings. In particular, ambulance crews with advanced life support (ALS) training are being promoted in LMICs as a strategy for improving outcomes for victims of trauma. However, there is controversy as to the effectiveness of this health service intervention and the evidence has yet to be rigorously appraised.

OBJECTIVES

To quantify the impact of ALS-trained ambulance crews versus crews without ALS training on reducing mortality and morbidity in trauma patients.

SEARCH METHODS

The search for studies was run on the 16th May 2014. We searched the Cochrane Injuries Group's Specialised Register, the Cochrane Central Register of Controlled Trials (CENTRAL, The Cochrane Library), Ovid MEDLINE(R), Ovid MEDLINE(R) In-Process & Other Non-Indexed Citations, Ovid MEDLINE(R) Daily and Ovid OLDMEDLINE(R), Embase Classic+Embase (Ovid), ISI WOS (SCI-EXPANDED, SSCI, CPCI-S & CPSI-SSH), CINAHL Plus (EBSCO), PubMed and screened reference lists.

SELECTION CRITERIA

Randomised controlled trials, controlled trials and non-randomised studies, including before-and-after studies and interrupted time series studies, comparing the impact of ALS-trained ambulance crews versus crews without ALS training on the reduction of mortality and morbidity in trauma patients.

DATA COLLECTION AND ANALYSIS

Two review authors assessed study reports against the inclusion criteria, and extracted data.

MAIN RESULTS

We found one controlled before-and-after trial, one uncontrolled before-and-after study, and one randomised controlled trial that met the inclusion criteria. None demonstrated evidence to support ALS training for pre-hospital personnel. In the uncontrolled before-and-after study, 'a priori' sub-group analysis showed an increase in mortality among patients who had a Glasgow Coma Scale score of less than nine and received care from ALS trained ambulance crews. Additionally, when the pre-hospital trauma score was taken into account in logistic regression analysis, mortality in the patients receiving care from ALS trained crews increased significantly.

AUTHORS' CONCLUSIONS

At this time, the evidence indicates that there is no benefit of advanced life support training for ambulance crews on patient outcomes.

Advanced trauma life support training for ambulance crews

BACKGROUND

There is an increasing global burden of injury especially in low- and middle-income countries (LMICs). To address this, models of trauma care initially developed in high income countries are being adopted in LMIC settings. In particular, ambulance crews with advanced life support (ALS) training are being promoted in LMICs as a strategy for improving outcomes for victims of trauma. However, there is controversy as to the effectiveness of this health service intervention and the evidence has yet to be rigorously appraised.

OBJECTIVES

To quantify the impact of ALS-trained ambulance crews versus crews without ALS training on reducing mortality and morbidity in trauma patients.

SEARCH STRATEGY

Searches were not restricted by date, language or publication status. We searched the Cochrane Injuries Group Specialised Register, CENTRAL (The Cochrane Library 2009, Issue 3), MEDLINE (Ovid SP), EMBASE (Ovid SP), CINAHL (EBSCO) and PubMed in all years up to July 2009. We also searched the reference lists of relevant studies and reviews in order to identify unpublished material.

SELECTION CRITERIA

Randomised controlled trials, quasi-randomised controlled trials and non-randomised studies, including before-and-after studies and interrupted time series studies, comparing the impact of ALS-trained ambulance crews versus crews without ALS training on the reduction of mortality and morbidity in trauma patients.

DATA COLLECTION AND ANALYSIS

One review author applied eligibility criteria to trial reports for inclusion and extracted data.

MAIN RESULTS

We found one controlled before-and-after trial, one uncontrolled before-and-after study, and one randomised controlled trial that met the inclusion criteria. None demonstrated evidence to support ALS training for pre-hospital personnel. In the uncontrolled before-and-after study, 'a priori' sub-group analysis showed an increase in mortality among patients who had a Glasgow Coma Scale score of less than nine and received care from ALS trained ambulance crews. Additionally, when the pre-hospital trauma score was taken into account in logistic regression analysis, mortality in the patients receiving care from ALS trained crews increased significantly.

AUTHORS' CONCLUSIONS

At this time, the evidence indicates that there is no benefit of advanced life support training for ambulance crews.

An attempt to measure the spread of emergency medicine internationally

OBJECTIVE

To determine the feasibility of using the internet to track the spread of emergency medicine internationally.

OVERVIEW

This was an attempt to perform a descriptive cross-sectional study employing a web-based survey.

SUBJECTS

Potential respondents were identified from multiple sources.

OBSERVATIONS

The primary outcome was the response to 16 questions about EM care and the setting in which it was delivered for acute cardiac, paediatric, obstetrical illnesses and trauma. The questions were divided into six general areas and elicited for urban, semi-urban and rural settings. A series of four e-mails soliciting completion of the survey were sent to potential respondents.

ANALYSIS

Simple descriptive statistics.

RESULTS

We identified 358 potential respondents with valid e-mail addresses over a period of three years. Overall, 145 (41%) responded and 117 (33% 95% CI 28-38%) of them were complete and interpretable. There was one response from 54 and two responses from 29 countries, representing an overall response rate by country surveyed of 65% (95% CI 57-73%), but of all existing countries of only 43% (95% CI 36-50%). Based on sparse data, it appears that in urban areas, 47% (obstetrics) to 65% (paediatric) of acutely sick or injured patients are taken to an ED-equivalent. For rural areas, this range was 19% (obstetrical) to 40% (trauma). CT scans are available in 78% of urban ED-equivalents but 12% of rural ones. Haematocrits are available in 72% of rural settings. In 60% of responding nations, some type of EM training was available, and in 42% physicians went abroad to study EM.

CONCLUSIONS

A survey of international EM is challenging to achieve because of difficulty in both identifying and in contacting potential respondents. Based on sparse data, population density (urban, rural) appears to be related to both the location to which acutely ill patients are taken for their care and to the level of technology available. The specialty of EM is now recognised internationally and education in EM is common.

Lessons learned from international emergency medicine development

The lessons learned from development of EM around the world span several key areas including general development, systems comparisons, models of EM practice, and education and training. Neither definitive nor exhaustive, these lessons learned are intended to be viewed as sign posts along the road traveled at this point in international EM development. It is hoped that future participants in international EM development can assimilate these lessons learned, adopt the most relevant ones, and add their own insight and wisdom to this growing list. Most importantly, it is hoped that by whichever path future development takes, we all reach the same destination of providing the best possible emergency medical care for the people of the world.

International emergency medicine: recent trends and future challenges

In the past two decades, emergency physicians have increasingly looked beyond their national borders to examine how emergency medicine is practised elsewhere in the world. A major result of their efforts is international emergency medicine, which can be defined as the area of emergency medicine concerned with the development and delivery of emergency medical care in the world. Several international trends are currently occurring in emergency medicine, including an increasing number of venues for information exchange, the spread of emergency medicine practice guidelines, an increasing number of international collaborations, and an increasing number of transnational special interest groups in emergency medicine. A closely related trend is the spread of the specialty model of emergency medicine, a key organizational system in which emergency medicine is viewed as a uniquely integrated horizontal body of medical knowledge and skills concerning the acute phases of all types of disease and injury. Multiple challenges await those involved in international emergency medicine, including the need for internationally accepted definitions, a 'systems approach' to analysing emergency medicine systems, and more useful and affordable information. A related challenge is the need for effective consensus-based processes, including international standardization processes. Many of these challenges may be met through the effective leadership of international emergency medicine organizations.

International pediatric emergency care: establishment of a new specialty in a developing country

BACKGROUND

Emergency medicine is being established as a unique and independent specialty throughout the world. Pediatric emergency medicine, however, is a relatively new subspecialty in the United States and a newer subspecialty in the rest of the world. In most of Europe and Asia, this specialty has yet to be developed.

OBJECTIVE

To analyze the establishment of a new pediatric emergency care system in a developing country and identify areas of need and potential collaboration.

SETTING

Pristina University Hospital, the main academic medical center in Kosovo, Federal Republic of Yugoslavia.

METHODS

Data were collected using convenience sample surveys of all emergency visits in 2001, hospital admissions, health department statistics, and interviews with government officials and healthcare providers.

RESULTS

Emergency care of children in Kosovo is provided by three parallel 24-hour clinic systems. During 2001, approximately 31,000 children sought emergency care (10,000 in the pediatric clinic, 5000 in an emergency facility, and 16,000 in the infectious disease clinic). There was no coordination or cooperation between these different facilities. No attempt was made to diagnose acute otitis media or urinary tract infection in young children. No records were kept. No physician in this study had pediatric emergency medicine and/or emergency medicine training. Prehospital providers had limited equipment and training.

CONCLUSIONS

Hospital clinic systems in this environment provide high-volume and often a high level of acute care. Barriers to improved care include limited specialized training, lack of coordination between departments, and failure to establish a medical records system.

Advanced trauma life support training for ambulance crews

BACKGROUND

There is an increasing global burden of disease from injuries. Models of trauma care initially developed in high-income countries are also being adopted in low and middle-income countries (LMIC). Amongst these ambulance crews with Advanced Life Support (ALS) training are being promoted in LMIC as a strategy for improving outcomes for victims of trauma. However there is controversy as to the effectiveness of this health service intervention, and the evidence has yet to be rigorously appraised.

OBJECTIVES

To quantify the effectiveness of ambulance crews with ALS training versus crews with any other level of training in reducing mortality and morbidity in trauma patients.

SEARCH STRATEGY

We searched the Cochrane Controlled Trial Register (CCTR), the specialised register of the Cochrane Injuries Group, MEDLINE, EMBASE, CINAHL, PubMed and the National Research Register. We checked references of background papers and contacted authors to identify additional published or unpublished data.

SELECTION CRITERIA

Randomised controlled trials, quasi-randomised controlled trials and controlled before-and-after studies comparing effectiveness of ambulance crews with ALS training versus crews with any other levels of training in reducing mortality and morbidity in trauma patients. Studies which compared crews staffed by physicians versus others were excluded.

DATA COLLECTION AND ANALYSIS

Two reviewers independently applied eligibility criteria to trial reports for inclusion and extracted data.

MAIN RESULTS

We found one randomised controlled trial, which included 16 trauma cases. However, outcome data were added to the main non-randomised cohort in the analysis, and data on these 16 cases are not yet available.

REVIEWER'S CONCLUSIONS

In the absence of evidence of the effectiveness of advanced life support, strong argument could be made that it should not be promoted outside the context of a properly concealed and otherwise rigorously conducted randomised controlled trial.

International emergency medicine and the recent development of emergency medicine worldwide

Emergency medicine is being established as a unique and independent specialty throughout the world. Two major models of emergency care delivery exist in the world today: the Anglo-American and the Franco-German model. Most countries developing new systems of emergency care are following the Anglo-American model and are recapitulating the sequence of steps taken to establish the systems of emergency medicine in the United States. The most important step in the development of emergency medicine in other countries is the recognition that emergency medicine incorporates a unique body of knowledge requiring specialized practitioners or emergency physicians. A global network of international emergency medicine is assisting the development of emergency medicine worldwide and now includes international organizations, academic institutions, and individuals in countries where emergency medicine is mature and their counterparts in countries where emergency medicine is developing. The multilevel exchange of information through various modalities, such as international conferences, physician exchange programs, and print or electronic media, is playing a vital role in the search for internationally applicable systems of emergency care.

Epidemiology and practice of emergency medicine in a developing country

STUDY OBJECTIVE

To analyze the emergency medicine system in a developing country and identify areas of need and potential collaboration.

DESIGN

Convenience sample surveys of all emergency visits over a 2-week period, hospital admission and health department statistics, and interviews with government officials, health providers, and EMS managers.

SETTING

Port of Spain General Hospital, Trinidad and Tobago.

RESULTS

The ED has more than 100,000 visits per year. No records are kept. No physician in this study had emergency medicine training; only one had completed any residency. The survey included 3,710 patients: 40.5% were admitted, and .3% died. Injuries accounted for 41.6% of all visits, asthma 7.8%. The mean time elapsed before a patient was seen was .5 hour; mean time to discharge, 1.9 hours. In only 9% of patients were laboratory tests performed. Prehospital providers had limited equipment and training.

CONCLUSION

The ED and prehospital systems provide high-volume and often high-acuteness care. Barriers to improved care include limited specialized training and lack of medical records.