Taking emergency medicine international: What can we learn and teach?

Over the last several years, increasing numbers of Australian and New Zealand emergency doctors have been engaging in emergency medicine in other countries. In part this is as a consequence of an enlarging group with the accumulation of a ‘critical mass’ of experienced doctors. The numbers of Fellows of the Australasian College for Emergency Medicine (FACEM) has increased from 232 in 1995 to 872 in 2005, with the numbers of ACEM trainees increased from 220 to 1142. There is increasing awareness of the international arena, in particular with regard to our place in the Pacific and Asian regions. Australia and New Zealand and our College are increasingly multiethnic. Australasia is economically rich, while some of our neighbours are at the opposite end of the world’s wealth spectrum. It is time that we were looking beyond our own shores. Tables 1 and 2 show 43 places with which Australasian emergency physicians have made some connection. The list is incomplete and is expanding all the time. Our engagements span the range of disaster response, civil strife, rich relations and near neighbours. There are also connections with several major international medical agencies. The emergency medicine colleges of the wealthy English-speaking group of Australasia, USA, UK and Canada established the International Federation for Emergency Medicine in 1992 with the primary purpose of enhancing communication. There is therefore considerable exchange within this group.1-3 Another destination for the wealthy that is receiving increasing attention is Antarctica.4, 5 Recently, response to disasters has become the most visible arena of international activity, on account of the tsunami and earthquake in Aceh Indonesia in 2004 and 2005. With limited preparedness for an international effort of this scale, Australia mobilized a substantial response.6, 7 This experience brought to the fore the work of two FACEM in particular, and the concept of disaster response as a career. Rick Brennan leads the International Rescue Committee,8-10 and David Bradt has extensive experience in complex emergencies.11, 12 Strife involving large numbers of civilians is widespread and several international aid organizations are involved full time in responding. Australasians have contributed with the International Committee of the Red Cross, Médecins sans Frontières and other non-government organizations.13-16 Emergency doctors with the Australian Defence Forces have been involved from time to time.17 Civilian strife in East Timor led to emergency physician involvement with our near neighbour.18, 19 In Papua New Guinea (PNG) there is a long history of involvement of Australasian doctors,20 however, this did decline in the 1980s and 1990s. Since 2002 there has been a surge of activity by emergency physicians in particular to establish emergency medicine training, because of support by AusAID.21, 22 Interest in the PNG programme is expanding to the Solomon Islands.23 There is a need to attend to the highly populated regions of the tropics, where there is expanding interest in the provision of care to the acutely ill and injured. Working internationally requires learning while teaching. There is always much more to learn than we can teach. Cultural differences can be dramatic, with impact on attitudes to disease and to health care. PNG is an extreme illustration: more than 800 spoken languages representing at least as many cultural groups, each with their own distinct attitudes. A previously unknown group was ‘discovered’ as recently as 1988. Over the last 100 years missionaries and colonial administration have had a substantial impact, although tradition persists and sorcery can play a significant role in interpreting life events. Sorcerers and witches can be important players in dealing with health challenges. Long established and emerging tropical diseases, almost unseen in the protected enclave of Australasia, dominate the medical load. Malaria, tuberculosis and HIV/AIDS are increasing in prevalence and infectious diseases are the major cause of morbidity and mortality, particularly in children. In addition there is an explosion of the ‘lifestyle diseases’, with hypertension, diabetes, coronary artery disease, cerebrovascular disease and road trauma becoming major challenges. However, the level of resources available can be confronting for visitors from the rich world. Gloves and syringes might be reused, shortages of pharmaceuticals and equipment might be commonplace, supplies and services that we take for granted – even demand as a right – might not be available at all. Hospitals might be unable to supply linen or food and relatives might have to provide much of the nursing care. Pathways by which the neophyte might expand understanding and competence include the diploma courses in tropical medicine and hygiene available in Liverpool and London, UK.24 Masters streams are offered by the School of Public Health and Tropical Medicine at James Cook University, Queensland, Australia. Involvement in teaching can span the entire range of medical and allied health training. Short courses are the easiest in terms of output for time away, however, they allow limited attention to cultural and resource nuances. Simon Young et al. have introduced the advanced paediatric life support course to Vietnam and are expanding to Cambodia and Laos.25 David Williams et al. have developed a course specifically for PNG for the management of snakebite.26 The establishment of a specific service is illustrated by George Braitberg’s contribution to toxicology in Hanoi.27 More extensive is the commitment to the development of an entire programme, such as the master of medicine, emergency medicine in PNG.22 Emergency physicians can also advise about particular targets, such as management of road crashes. Mark Fitzgerald et al. are advisors to India on this huge challenge.28 Conferences in newly developing environments provide contacts through which Australasians may contribute. Emergency medicine is a theme for the 2006 Annual Medical Symposium in PNG (http://www.medsymp.org.pg), and a symposium on emergency medicine is planned for the 2006 College of Physicians Congress in Sri Lanka. Information relating to conferences is included in the International Emergency Medicine Special Interest Group Newsletters, available at the ACEM website, http://www.acem.org.au/infocentre. There are many opportunities for new and worthwhile challenges for those prepared to step outside the familiar, in countries with emerging interest in the delivery of care to the acutely ill and injured.

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