Printed in the USA . Copyright 0 1992 Pergamon Press Ltd.
TheJournal of Emergency Medicine, Vol 10, pp 485-488,1992
A PERSPECTIVE ON EMERGENCY MEDICINE IN THE DEVELOPING WORLD Terrsnce D. Morton, Jr.,
MD,
FACEP
Clinical Instructor, Department of Emergency Medicine, Carolinas Medical Center, Charlotte, North Carolina Reprint Address: Terrence D. Morton, Jr., MD, FACEP, Piedmont Emergency Medicine Associates, P. A., 1332 East Morehead Street, Suite 200, Charlotte, NC 28204
Cl Abstract -Tbe author spent 6 months as director of a major university hospital accident and emergency department in Kuala Lumpur, Malaysia. A brief summary of this experience is provided, followed by a series of recommendations based on the experience that may provide some guidance in future efforts to establish emergency medicine in developing areas of tbe world. 0 Keywords-emergency third world
await the provision of basic public health measures, some of the developing areas of the world have good roads, ambulances, and functioning emergency departments. Based on the author’s experience in such a setting, it is proposed that the knowledge embodied in the specialty of emergency medicine could be of great benefit to the people of such areas.
medicine; developing countries;
MALAYSIAN INTRODUCTION
EXPERIENCE
While pursuing a residency in emergency medicine, the author began to investigate ways to work and travel overseas, particularly in the third world. Since opportunities to practice emergency medicine in this part of the world appeared to be nonexistent, efforts were being directed toward opportunities in the refugee camps of southeast Asia. By pure chance, the author met an American emergency physician who had spent time working in Malaysia. Through this chance meeting, contact was made with the Director and Deputy Director of the University Hospital in Kuala Lumpur, Malaysia. Arrangements were made for the author to work there for 6 months as a contract lecturer in the Department of Primary Care. His responsibility was to assume and expand upon the duties of the director of the Accident and Emergency Department (A & E). His hosts expressed a desire to learn more about the specialty of emergency medicine as practiced in the United States. Their hope is to eventually establish a postgraduate training program in emergency medicine based at the hospital. The role of acting director included a variety of responsibilities. Bedside teaching and supervision of
Interest in establishing emergency medicine as an international specialty is growing. Several organizations represent emergency physicians in other parts of the world, including the Canadian Association of Emergency Physicians, the Australasian College for Emergency Medicine, and the British Association for Accident and Emergency Medicine. Along with the American College of Emergency Physicians (ACEP), these organizations are organizing a World Federation of Emergency Medicine (1). The specialty has recently made its presence felt in disaster management (2), and international conferences are well attended. Recently the American College of Emergency Physicians advocated establishing emergency medicine as an international specialty (3). Much of the current effort is directed at establishing relationships between physicians practicing emergency medicine in areas of the world where the specialty exists in some form. There is little published experience or guidance for establishing emergency medicine in developing areas (4-9). Although in some areas the development of emergency medicine must
RECEIVED: 25 March 1991; FINALSUBMISSIONRECEIVED; 29October ACCEPTED: 16 December 1991 485
1991:
0736-4679/92 $5.00 + .OO
Terrence
house officers and medical students was provided, as was a weekly lecture series on topics pertaining to emergency medicine. Several projects meant to improve the daily operation of the department were initiated. For example, triage algorithms for common presenting complaints were designed for the nurses, and reference materials were provided in the department for the physicians. A very small part of the author’s time was spent in primary patient care, as none was expected in the position of acting director. Kuala Lumpur is the largest city in Malaysia, with a metropolitan area encompassing 1.5 million people. Several languages are spoken in Malaysia. All physicians and most other health care workers are fluent in English. A significant minority of patients do not speak English, but most of the physicians and nurses speak at least two languages and communication is not a problem. The University Hospital is one of two major teaching hospitals serving the area. The hospital has training programs in internal medicine, surgery, pediatrics, anesthesia, primary care, and psychiatry. The A & E saw over 58,000 patients in 1988. The spectrum of disease seen is remarkably like that of U.S. cities. The three most common presenting complains for the University Hospital A & E in 1988 were trauma of all types (29%), asthma and chronic obstructive pulmonary disease (90/o), and acute respiratory infections (8%) (10). The principal differences are that medical diseases often present in more advanced stages, and trauma is overwhelmingly blunt; penetrating trauma is rare. The A & E is staffed by 10 to 12 medical officers, assigned each month from the various departments within the hospital. There is little bedside supervision of medical officers while in the A & E, although consultation is readily available from medical officers on the in-house services. Patients who are treated and discharged are usually managed by the medical office on duty in the A & E. When the diagnosis is unclear or admission is a possibility, priority is usually given to obtaining consultation and not to extensive diagnostic workup or treatment. Several elements of emergency medical care common in the U.S. are not part of the armamentarium of Malaysian health care. There are a variety of reasons for this. Some examples are illustrative: In trauma, the principle of cervical immobilization is infrequently practiced simply because it has never been adequately stressed. Backboards are plentiful but are rarely used, in part because they are too heavy for the diminutive female nurses who staff the ambulances. In addition, the benefits of thoracic and lumbar spine immobilization have not been taught. Although femur fractures are very common, the use
D. Morton, Jr.
of traction splints for immobilization is considered expensive and inappropriate for the level of training of the available prehospital care providers. The same could be said of pneumatic antishock trousers, although only an occasional well-read physician is even aware of their existence. The management of poisoning has not benefited from the recent advances in the field of toxicology, despite the fact that overdoses, especially with paraquat, are common. For example, activated charcoal is unavailable in Malaysia. Prehospital care is primitive by western standards. All of Kuala Lumpur is served by ambulances dispatched by the city’s hospitals, but response times are long, often exceeding 20 minutes. Ambulances are staffed by a nurse and an attendant who has no formal medical training. The primary function of the ambulance is transport, with treatment limited to administration of oxygen, application of splints to fractures, and pressure to hemorrhage. Despite these differences, the practice of medicine at the University Hospital is not unlike that practiced in large cities in the United States. Malaysian physicians are trained in the British tradition and are generally astute clinicians. All common surgical, neurosurgical, and thoracic procedures are performed, and operating theaters are available for emergencies. Intensive care, coronary care, and burn units are in operation. The radiology suite is adjacent to A & E, offering CT scan, nuclear medicine studies, and 24-hour plain radiography. The hospital has a medical library with a large selection of texts and current journals. Indeed, a visitor would find more familiar than unfamiliar in this setting.
RECOMMENDATIONS Using the example of the Malaysian health care system, it is apparent that where the need exists emergency medicine will be practiced in some form. Although the idea of emergency medicine as a specialty is virtually unknown in Malaysia, there are functioning emergency departments in Kuala Lumpur providing care in circumstances very similar to those in emergency departments in the west. The director of the University Hospital in Kuala Lumpur and several senior faculty members there have expressed an interest in learning more about emergency medicine as practiced in the west. They feel that it may be practical and beneficial to establish a training program in Malaysia to train practitioners in the specialty. Many physicians in developed countries may be unaware of the potential impact of emergency medicine in developing countries. I believe that emergency
Emergency Medicine in the Developing World
medicine has a great deal to offer selected areas of the developing world. Obviously, not all areas are appropriate for efforts of this type. Where nutrition, basic public health measures, and prenatal care are poor, for example, emergency medicine cannot be a priority. Some countries will not have urban centers of the size necessary for the development of the specialty. Each country, and in fact individual areas within a country, will differ in their suitability. It is not the purpose of this paper to propose criteria with which to select those areas that will be fertile for the development of emergency medicine. To my knowledge no such criteria exist, and decisions on this matter will be complex and will benefit from future experience. As a starting point, it would seem logical to concentrate attention on those areas where local authorities request outside help in the establishment of the specialty. Based on my experience, suggestions are offered that may be useful in such efforts. The goal of our efforts should be to establish postgraduate training programs in emergency medicine in selected areas. The graduates of these programs will provide a cadre of teachers who will continue the development of the specialty without the necessity of outside support for survival. The obstacles to the establishment of such programs are significant, but with sustained effort they can be overcome. Any effort to establish emergency medicine in the developing world will be faced with the necessity of developing a formal mechanism for the placement of personnel overseas. ACEP has recently approved in concept the development of an “information clearinghouse” to answer requests from abroad concerning the development of emergency medicine (11). This is an important step, and such an idea could be expanded to include actual placement of personnel. Several factors must be taken into account in order for the clearinghouse concept to be successful in the developing world. As discussed above, only selected areas will be fertile ground for the establishment of emergency medicine. Such areas may consist of a single city or institution while much of the rest of the country is unsuitable. It should also be appreciated that in many parts of the developing world the idea of emergency medicine as a specialty will be an unfamiliar concept. This may lead to difficulty in identifying the appropriate person or persons with whom to coordinate efforts. In addition, language differences or cultural impediments may exist that inhibit the transfer of unfamiliar ideas and techniques. It is likely that the time required to facilitate change in such places may be considerably longer than in developed countries whose medical, political, and cultural milieu are closer to our own. Thus, for
487 example, lasting changes in emergency medical care in Kuala Lumpur are unlikely in the time that any single individual would spend there. For these reasons I have concluded that the efficient establishment of emergency medicine in developing areas will require attention to the concept of prolonged continuity of service to selected “target” hospitals. A more prolonged and continuous investment of resources in relatively few places could satisfy the medical, political, and cultural prerequisites for success in developing areas. I suggest a system in which selected hospitals are targeted for a prolonged effort to develop training programs in emergency medicine. The selection of specific hospitals could be accomplished by an organization or standing committee, developed from existing sources of leadership in the international community of emergency medicine, which evaluates requests for this service from prospective host governments, medical organizations, or hospitals. Specific predetermined criteria would be developed to aid in the evaluation process, and a site visit would be necessary. After selection of a site, a customized plan and timetable would be needed, taking into account the specific needs and resources of the site. An ongoing rotation at the director or faculty level could then be initiated (in many cases such an individual would become a member of an existing department in the host institution, such as medicine or surgery). Such continuity of service would require coordination on a national or international scale. Existence of an established plan would ensure continuity of purpose between successive participants. If we accept the need for prolonged and continuous effort to establish emergency medicine abroad, specific issues must be addressed. One such issue is financial support for physicians who undertake such efforts. Material compensation in developing areas of the world is considerably below that in the United States, making a prolonged stay all but impossible for many, especially the more experienced members of our specialty. While some loss of income is inevitable in an endeavor of this type, establishing a fund to partially offset this loss could do a great deal to encourage experienced leaders in emergency medicine to participate, to the benefit of host and participant. With a concerted effort, it may be possible to obtain grants from outside sources for this purpose. A closely related consideration is the need for professional and academic recognition for work done abroad. Many emergency physicians whose aspirations lie in the academic arena will hesitate to spend a year working to promote emergency medicine
488
Terrence
abroad if such a year is considered squandered by their colleagues at home. If such work is under the auspices of a recognized and organized effort, it should be appreciated as contributing to the professional growth of the physician and the specialty. Another idea that deserves consideration is the involvement of emergency nurses and paramedics in this process. In Kuala Lumpur the nurses are a dedicated group, eager to improve their skills. Because in many areas the emergency department nursing staff will be more stable than the physician staff, the potential for making a lasting impact is great. While it is the ideas shared with others that are most important, there is a need for books, equipment, and technologies that are unavailable in other areas. Whatever mechanism is established to provide people and ideas should also attempt to provide such items. Examples of items that would have been useful in Kuala Lumpur include emergency medicine textbooks and Micromedex systems. In many cases older models or editions that have been replaced will function very well in these settings.
D. Morton, Jr.
A final issue closely related to this discussion is the desire of foreign physicians to study the delivery of emergency medical care in countries where emergency medicine is established. A discussion of this issue is beyond the scope of this paper. The reader is referred to a recently published summary and discussion of this issue (12).
CONCLUSION There appears to be interest in the United States and abroad in establishing emergency medicine in areas of the world where it does not exist. Some areas of the developing world could benefit greatly from the knowledge embodied in the specialty of emergency medicine. A customized approach will be necessary, based on the principle of prolonged effort in carefully selected locations. Attention to other issues such as financial support, academic recognition, and participation by other health care providers will improve the chances of success.
REFERENCES 1. New horizons abound for EPs in foreign countries. Emergency Medicine News. 1991 May:6. 2. ACEP physicians receive commendations for Armenian earthquake relief mission. ACEP News (American College of Emergency Physicians). 1989 February;8(2). 3. Podgomy G. Emergency medicine now an international specialty. ACEP News (American College of Emergency Physicians). 1989 February;8(2). 4. Berk WA. Emergency medicine in the third world: two years as director of the Kingston, Jamaica, Public Hospital Casualty Department. Ann Emerg Med. 1989;18:567-72. 5. Ali J, Naraysingh V. Potential impact of the advanced trauma life support (ATLS) program in a third world country. Int Surg. 1987;72:179-84. 6. Berk WA, Osbourne DD, Taylor DD. Evaluation of the “golden period” for wound repair: 204 cases from a third world emergency department. Ann Emerg Med. 1988;17:496500.
7. Barber SG. Aeromedical evacuations in Papua New Guineaa case for routine oxygen supplementation in developing countries. P N Cl Med J. 1983;26(3-4):203-6. 8. Wood AM. Flying doctor service. Injury. 1979;10:170-4. 9. Gish 0, Walker G. Alternative forms of transport and their use in the health services of developing countries. Int J Health Serv. 1978;8:633-51. 10. Annual report, 1988. University Hospital, University of Malaya, Kuala Lumpur, Malaysia. 11. Information Clearinghouse for International Emergency Medicine. ACEP News (American College of Emergency Physicians). 1990 July. 12. Sivertson K. International fellowships. Academic News and Views (Newsletter of the ACEP Academic Affairs Committee). 199OApril:l.
TheJournal of Emergency Medicine, Vol 10, pp 485-488,1992
A PERSPECTIVE ON EMERGENCY MEDICINE IN THE DEVELOPING WORLD Terrsnce D. Morton, Jr.,
MD,
FACEP
Clinical Instructor, Department of Emergency Medicine, Carolinas Medical Center, Charlotte, North Carolina Reprint Address: Terrence D. Morton, Jr., MD, FACEP, Piedmont Emergency Medicine Associates, P. A., 1332 East Morehead Street, Suite 200, Charlotte, NC 28204
Cl Abstract -Tbe author spent 6 months as director of a major university hospital accident and emergency department in Kuala Lumpur, Malaysia. A brief summary of this experience is provided, followed by a series of recommendations based on the experience that may provide some guidance in future efforts to establish emergency medicine in developing areas of tbe world. 0 Keywords-emergency third world
await the provision of basic public health measures, some of the developing areas of the world have good roads, ambulances, and functioning emergency departments. Based on the author’s experience in such a setting, it is proposed that the knowledge embodied in the specialty of emergency medicine could be of great benefit to the people of such areas.
medicine; developing countries;
MALAYSIAN INTRODUCTION
EXPERIENCE
While pursuing a residency in emergency medicine, the author began to investigate ways to work and travel overseas, particularly in the third world. Since opportunities to practice emergency medicine in this part of the world appeared to be nonexistent, efforts were being directed toward opportunities in the refugee camps of southeast Asia. By pure chance, the author met an American emergency physician who had spent time working in Malaysia. Through this chance meeting, contact was made with the Director and Deputy Director of the University Hospital in Kuala Lumpur, Malaysia. Arrangements were made for the author to work there for 6 months as a contract lecturer in the Department of Primary Care. His responsibility was to assume and expand upon the duties of the director of the Accident and Emergency Department (A & E). His hosts expressed a desire to learn more about the specialty of emergency medicine as practiced in the United States. Their hope is to eventually establish a postgraduate training program in emergency medicine based at the hospital. The role of acting director included a variety of responsibilities. Bedside teaching and supervision of
Interest in establishing emergency medicine as an international specialty is growing. Several organizations represent emergency physicians in other parts of the world, including the Canadian Association of Emergency Physicians, the Australasian College for Emergency Medicine, and the British Association for Accident and Emergency Medicine. Along with the American College of Emergency Physicians (ACEP), these organizations are organizing a World Federation of Emergency Medicine (1). The specialty has recently made its presence felt in disaster management (2), and international conferences are well attended. Recently the American College of Emergency Physicians advocated establishing emergency medicine as an international specialty (3). Much of the current effort is directed at establishing relationships between physicians practicing emergency medicine in areas of the world where the specialty exists in some form. There is little published experience or guidance for establishing emergency medicine in developing areas (4-9). Although in some areas the development of emergency medicine must
RECEIVED: 25 March 1991; FINALSUBMISSIONRECEIVED; 29October ACCEPTED: 16 December 1991 485
1991:
0736-4679/92 $5.00 + .OO
Terrence
house officers and medical students was provided, as was a weekly lecture series on topics pertaining to emergency medicine. Several projects meant to improve the daily operation of the department were initiated. For example, triage algorithms for common presenting complaints were designed for the nurses, and reference materials were provided in the department for the physicians. A very small part of the author’s time was spent in primary patient care, as none was expected in the position of acting director. Kuala Lumpur is the largest city in Malaysia, with a metropolitan area encompassing 1.5 million people. Several languages are spoken in Malaysia. All physicians and most other health care workers are fluent in English. A significant minority of patients do not speak English, but most of the physicians and nurses speak at least two languages and communication is not a problem. The University Hospital is one of two major teaching hospitals serving the area. The hospital has training programs in internal medicine, surgery, pediatrics, anesthesia, primary care, and psychiatry. The A & E saw over 58,000 patients in 1988. The spectrum of disease seen is remarkably like that of U.S. cities. The three most common presenting complains for the University Hospital A & E in 1988 were trauma of all types (29%), asthma and chronic obstructive pulmonary disease (90/o), and acute respiratory infections (8%) (10). The principal differences are that medical diseases often present in more advanced stages, and trauma is overwhelmingly blunt; penetrating trauma is rare. The A & E is staffed by 10 to 12 medical officers, assigned each month from the various departments within the hospital. There is little bedside supervision of medical officers while in the A & E, although consultation is readily available from medical officers on the in-house services. Patients who are treated and discharged are usually managed by the medical office on duty in the A & E. When the diagnosis is unclear or admission is a possibility, priority is usually given to obtaining consultation and not to extensive diagnostic workup or treatment. Several elements of emergency medical care common in the U.S. are not part of the armamentarium of Malaysian health care. There are a variety of reasons for this. Some examples are illustrative: In trauma, the principle of cervical immobilization is infrequently practiced simply because it has never been adequately stressed. Backboards are plentiful but are rarely used, in part because they are too heavy for the diminutive female nurses who staff the ambulances. In addition, the benefits of thoracic and lumbar spine immobilization have not been taught. Although femur fractures are very common, the use
D. Morton, Jr.
of traction splints for immobilization is considered expensive and inappropriate for the level of training of the available prehospital care providers. The same could be said of pneumatic antishock trousers, although only an occasional well-read physician is even aware of their existence. The management of poisoning has not benefited from the recent advances in the field of toxicology, despite the fact that overdoses, especially with paraquat, are common. For example, activated charcoal is unavailable in Malaysia. Prehospital care is primitive by western standards. All of Kuala Lumpur is served by ambulances dispatched by the city’s hospitals, but response times are long, often exceeding 20 minutes. Ambulances are staffed by a nurse and an attendant who has no formal medical training. The primary function of the ambulance is transport, with treatment limited to administration of oxygen, application of splints to fractures, and pressure to hemorrhage. Despite these differences, the practice of medicine at the University Hospital is not unlike that practiced in large cities in the United States. Malaysian physicians are trained in the British tradition and are generally astute clinicians. All common surgical, neurosurgical, and thoracic procedures are performed, and operating theaters are available for emergencies. Intensive care, coronary care, and burn units are in operation. The radiology suite is adjacent to A & E, offering CT scan, nuclear medicine studies, and 24-hour plain radiography. The hospital has a medical library with a large selection of texts and current journals. Indeed, a visitor would find more familiar than unfamiliar in this setting.
RECOMMENDATIONS Using the example of the Malaysian health care system, it is apparent that where the need exists emergency medicine will be practiced in some form. Although the idea of emergency medicine as a specialty is virtually unknown in Malaysia, there are functioning emergency departments in Kuala Lumpur providing care in circumstances very similar to those in emergency departments in the west. The director of the University Hospital in Kuala Lumpur and several senior faculty members there have expressed an interest in learning more about emergency medicine as practiced in the west. They feel that it may be practical and beneficial to establish a training program in Malaysia to train practitioners in the specialty. Many physicians in developed countries may be unaware of the potential impact of emergency medicine in developing countries. I believe that emergency
Emergency Medicine in the Developing World
medicine has a great deal to offer selected areas of the developing world. Obviously, not all areas are appropriate for efforts of this type. Where nutrition, basic public health measures, and prenatal care are poor, for example, emergency medicine cannot be a priority. Some countries will not have urban centers of the size necessary for the development of the specialty. Each country, and in fact individual areas within a country, will differ in their suitability. It is not the purpose of this paper to propose criteria with which to select those areas that will be fertile for the development of emergency medicine. To my knowledge no such criteria exist, and decisions on this matter will be complex and will benefit from future experience. As a starting point, it would seem logical to concentrate attention on those areas where local authorities request outside help in the establishment of the specialty. Based on my experience, suggestions are offered that may be useful in such efforts. The goal of our efforts should be to establish postgraduate training programs in emergency medicine in selected areas. The graduates of these programs will provide a cadre of teachers who will continue the development of the specialty without the necessity of outside support for survival. The obstacles to the establishment of such programs are significant, but with sustained effort they can be overcome. Any effort to establish emergency medicine in the developing world will be faced with the necessity of developing a formal mechanism for the placement of personnel overseas. ACEP has recently approved in concept the development of an “information clearinghouse” to answer requests from abroad concerning the development of emergency medicine (11). This is an important step, and such an idea could be expanded to include actual placement of personnel. Several factors must be taken into account in order for the clearinghouse concept to be successful in the developing world. As discussed above, only selected areas will be fertile ground for the establishment of emergency medicine. Such areas may consist of a single city or institution while much of the rest of the country is unsuitable. It should also be appreciated that in many parts of the developing world the idea of emergency medicine as a specialty will be an unfamiliar concept. This may lead to difficulty in identifying the appropriate person or persons with whom to coordinate efforts. In addition, language differences or cultural impediments may exist that inhibit the transfer of unfamiliar ideas and techniques. It is likely that the time required to facilitate change in such places may be considerably longer than in developed countries whose medical, political, and cultural milieu are closer to our own. Thus, for
487 example, lasting changes in emergency medical care in Kuala Lumpur are unlikely in the time that any single individual would spend there. For these reasons I have concluded that the efficient establishment of emergency medicine in developing areas will require attention to the concept of prolonged continuity of service to selected “target” hospitals. A more prolonged and continuous investment of resources in relatively few places could satisfy the medical, political, and cultural prerequisites for success in developing areas. I suggest a system in which selected hospitals are targeted for a prolonged effort to develop training programs in emergency medicine. The selection of specific hospitals could be accomplished by an organization or standing committee, developed from existing sources of leadership in the international community of emergency medicine, which evaluates requests for this service from prospective host governments, medical organizations, or hospitals. Specific predetermined criteria would be developed to aid in the evaluation process, and a site visit would be necessary. After selection of a site, a customized plan and timetable would be needed, taking into account the specific needs and resources of the site. An ongoing rotation at the director or faculty level could then be initiated (in many cases such an individual would become a member of an existing department in the host institution, such as medicine or surgery). Such continuity of service would require coordination on a national or international scale. Existence of an established plan would ensure continuity of purpose between successive participants. If we accept the need for prolonged and continuous effort to establish emergency medicine abroad, specific issues must be addressed. One such issue is financial support for physicians who undertake such efforts. Material compensation in developing areas of the world is considerably below that in the United States, making a prolonged stay all but impossible for many, especially the more experienced members of our specialty. While some loss of income is inevitable in an endeavor of this type, establishing a fund to partially offset this loss could do a great deal to encourage experienced leaders in emergency medicine to participate, to the benefit of host and participant. With a concerted effort, it may be possible to obtain grants from outside sources for this purpose. A closely related consideration is the need for professional and academic recognition for work done abroad. Many emergency physicians whose aspirations lie in the academic arena will hesitate to spend a year working to promote emergency medicine
488
Terrence
abroad if such a year is considered squandered by their colleagues at home. If such work is under the auspices of a recognized and organized effort, it should be appreciated as contributing to the professional growth of the physician and the specialty. Another idea that deserves consideration is the involvement of emergency nurses and paramedics in this process. In Kuala Lumpur the nurses are a dedicated group, eager to improve their skills. Because in many areas the emergency department nursing staff will be more stable than the physician staff, the potential for making a lasting impact is great. While it is the ideas shared with others that are most important, there is a need for books, equipment, and technologies that are unavailable in other areas. Whatever mechanism is established to provide people and ideas should also attempt to provide such items. Examples of items that would have been useful in Kuala Lumpur include emergency medicine textbooks and Micromedex systems. In many cases older models or editions that have been replaced will function very well in these settings.
D. Morton, Jr.
A final issue closely related to this discussion is the desire of foreign physicians to study the delivery of emergency medical care in countries where emergency medicine is established. A discussion of this issue is beyond the scope of this paper. The reader is referred to a recently published summary and discussion of this issue (12).
CONCLUSION There appears to be interest in the United States and abroad in establishing emergency medicine in areas of the world where it does not exist. Some areas of the developing world could benefit greatly from the knowledge embodied in the specialty of emergency medicine. A customized approach will be necessary, based on the principle of prolonged effort in carefully selected locations. Attention to other issues such as financial support, academic recognition, and participation by other health care providers will improve the chances of success.
REFERENCES 1. New horizons abound for EPs in foreign countries. Emergency Medicine News. 1991 May:6. 2. ACEP physicians receive commendations for Armenian earthquake relief mission. ACEP News (American College of Emergency Physicians). 1989 February;8(2). 3. Podgomy G. Emergency medicine now an international specialty. ACEP News (American College of Emergency Physicians). 1989 February;8(2). 4. Berk WA. Emergency medicine in the third world: two years as director of the Kingston, Jamaica, Public Hospital Casualty Department. Ann Emerg Med. 1989;18:567-72. 5. Ali J, Naraysingh V. Potential impact of the advanced trauma life support (ATLS) program in a third world country. Int Surg. 1987;72:179-84. 6. Berk WA, Osbourne DD, Taylor DD. Evaluation of the “golden period” for wound repair: 204 cases from a third world emergency department. Ann Emerg Med. 1988;17:496500.
7. Barber SG. Aeromedical evacuations in Papua New Guineaa case for routine oxygen supplementation in developing countries. P N Cl Med J. 1983;26(3-4):203-6. 8. Wood AM. Flying doctor service. Injury. 1979;10:170-4. 9. Gish 0, Walker G. Alternative forms of transport and their use in the health services of developing countries. Int J Health Serv. 1978;8:633-51. 10. Annual report, 1988. University Hospital, University of Malaya, Kuala Lumpur, Malaysia. 11. Information Clearinghouse for International Emergency Medicine. ACEP News (American College of Emergency Physicians). 1990 July. 12. Sivertson K. International fellowships. Academic News and Views (Newsletter of the ACEP Academic Affairs Committee). 199OApril:l.
