Emergency Medicine as a Global Organization by

Khalid A. Abu-Haimed MBBS. FRCPC. FAAEM

Consultant, Emergency Medicine

Chairman, Department of Emergency Medicine King Faisal Specialty Hospital and Research Center

Riyadh, Saudi Arabia

Globalizing emergency medicine specialty is a concept that was injected in my life and career as a North American board certified emergency consultant on 30 September 1999, three months before Y2K. From 1990 until that day I was lucky, like many other north American trained board certified practicing emergency physician, to have the opportunity to work, train and practice with certified trained emergency medicine consultants. I started my career as practicing emergency physician during the first gulf war. I was working shoulder to shoulder with US and Canadian certified emergency medicine specialist and consultants. That experience made me learn and believe in the specialty. I was able to digest the value of the specialty and how much it positively adds to the emergency medicine patient management and outcome. From that time I worked hard to acquire the long list of exams, paper works, and other logistics to be able to be trained in emergency medicine in North America. At that time, I was one of few if not the only foreign medical graduate undergoing residency training in the area of emergency medicine in North America. Actually, I was the first foreign medical graduate who successfully completed residency training in Emergency Medicine from Toronto University in Canada. During which I was trained by and practiced with the best and the pioneers of emergency medicine in all areas of the specialty including EMS, ambulance and medivac, trauma, cardiovascular, respiratory, pediatric, toxicology, critical care, administration and others.

I was fortunate to acquire the fundamentals of the specialty from those who were classified among the best, conducted within the best academic education and training system and environment. I was also fortunate to practice in few of the best emergency department and centers in Canada. From that time and until 30 September 1999, I believed anything but such a standard of emergency care is not acceptable. Therefore, I continued to practice only in emergency department that follow a North American emergency medicine specialty standard. Not until 30 September 199 where I was appointed as a head of a 21 bed orphan emergency department in the middle of nowhere. The closest North American standard definitive care facilities are about 2 hours of driving away from my emergency department. My staffs were MDs without any post-graduate training. Their only experience is practicing in primitive emergency department. Their only drive for engagement was their love to emergency medicine and the desire to save lives. None of them had the opportunity that you or I have had, i.e. to be trained and mentored by and practice with trained certified emergency medicine consultants. Despite the fact that emergency departments in that place and many other developing and under developing nations are considered the hospital graveyard, majority of them did have the desire and the will to develop and learn the specialty from the right source. Unfortunately, they were deprived by many political, financial, and logistical barriers that stood between them and where emergency medicine specialty training programs are offered. The first three months of my job were extremely difficult and very depressive as I was conducting a thorough operation reviews and observational studies. The closest description of the department I could have given at that time was an urgent care unit. Only stable and mildly sick patients were seen and managed. Real emergency medicine sick patients used to detour through the department without any or minimal intervention to the back of an ambulance to be transferred to the nearest capable definitive care hospital. This journey could last up to two hours were many of those patients die on the road or on the corridor of another primitive emergency department when the transferring staff is forced to go to as the patient condition deteriorated during transport. All my department beds were urgent care with minimal specialty required pharmaceutical, equipments and supplies.

I used to drive for one hour to work on daily basis on a single lane, two way roads. It was a dramatic experience as you may encounter motor vehicle accidents with multiple victims lying on the floor waiting for an ambulance that may or may not arrive in less than an hour due to lack of strategic deployment of the ambulances and/or the distance that lack of ambulance support. When the ambulance arrives it has nothing but stretchers and two first aid or first respondents. Actually, there were stories about victims dying trapped in their cars in front of their families waiting for such limited capability ambulances. After the completion of my operation review and observational studies I was thinking for days and nights about what can be done to make things better. How can I plant a seed of what I was fortunate to learn and acquire practicing with the best in a high standard of care centers? During which the last 9 years of emergency medicine experience that includes my residency training passed in front of my eyes as a move only then I was able to recall the direction and advices that I learned from my mentors and colleagues. Finally, I was able to come with a plan. I mobilized resources towards recruiting board certified, trained and licensed staff including physicians, nurses and paramedics. I was able to restructure the department operations and functions. I revised the department missions, goals and objectives towards providing the best possible ethical, clinically sound and cost effective emergency medical care. My first step was to work with the leadership and agree on the new mission, goals and objectives and action plan. Immediately the plan was transferred to all the department staff with added incentives to ensure their engagement. Actually, we were able to build in the incentive within the action plan to ensure implementation on the ground. We build up a local training education program in the area of medical, surgical, trauma and critical care resuscitation, monitoring and transportation. The program was built with input from all key players in the emergency department to ensure success. Upon the completion of the program and within two years, our orphan ER became one of the best nationwide. We were able to develop an equipped resuscitation and critical care area that had one trauma, one ICU and one CCU bed. It had a portable digital x-ray, centralized monitoring capability including arterial lines, stat lab, ultrasound and portable dialysis machine. It was equipped and supplied with all what is needed as per JCIA and North American standards including

pharmaceuticals. The rest of the department rooms were changed into designated 8 medical, 6 surgical, 1 ENT and Eye, 1 orthopedic, 1 procedure and 1 isolation rooms. We were able to resuscitate, treat, stabilized, monitor and transport more than 250 critically ill, incubated, ventilated medical, surgical and trauma patients utilizing a locally build and modified level 1 ambulance with critical care ground transport capability. The transportations were over 2 hours period, 40% of which was conducted by the same 7 staff after completing our local training and education program mentioned above. Our morbidity and mortality in the emergency department dropped to zero. All of the patients we transported arrived well package and alive to the definitive care facility critical area at the other end. There was only one patient that required resuscitation within the designated hospital two minutes before entering the designated critical area. Therefore, the seed we planted in the middle of nowhere inflicted a significant change. From that time I made it a mission to conduct more operational reviews and observational studies in many other similar areas and emergency departments in developing and under developing nations and identified that there are millions of emergency medicine providers practicing in primitive ERs and /or EMS systems that undergo similar dramatic experience. Due to the scarcity of trained and certified and academic emergency medicine consultants as well as lots of political and financial restrictions majority will not be able to import the expertise. 9/11 unfortunate incident made the situation even extremely difficult if not impossible. We as leaders as well as being trained and certified consultants in this field have to come out with a solution if we do believe in our specialty and how much it could contribute to ease the suffering that those emergency medicine providers and their patients are going through. There are many examples but the one that stroked me was seeing an intubated patient connected directly to an oxygen tank without a ventilator and/or a bag valve mask apparatus. Half an hour later they discover that the tank was empty. Simple basic procedures are either not available or providers were not probably trained. Unfortunately at that time our emergency medicine literature had no or limited references and/or resources that could help or direct us towards a workable solution. How can we support those providers overcoming the multiple barriers between them and emergency medicine specialty education, training and other support programs and resources? How can we develop a

global emergency medicine system that works for all despite the financial and other multiple variations? In 2005, myself and one of my colleagues, Dr Fahad Ali, Consultant, Emergency Medicine, who is a US trained and certified started to think out of the box and looked at how industries other than medical were able to efficiently globalize. Finally we came to a very valuable 2005 published resource in globalization that provides the foundation for a reasonable feasible approach. It is the Book The World is Flat by Thomas Friedmen who identified that globalization is the way to the future. Free market-oriented governance is dominating and those who are advocating centrally planned economies are going to be lucked in history. Open sourcing through private networks and latter the internet will allow people to pool brain power and share the insight in all areas, business, academic, science and others. The existing infrastructure, including fibro optics and satellite communications, made open source news room a reality. The book emphasized on the need to present ideas and point of views in a neutral way so that supporters and oppositions can agree and start talking to each other. World trade organization by it self was build up based on globalization concept. People today understand and believe that anti-globalization movement and culture diversity proponents will be isolated. Y2k was the major driving force towards reducing the boundaries between the east and the west. Changing the two digit time and date code to multi digit in every computer forced corporate to outsource as such a step required a huge network of expensive human resources working under European and north American standards. Dramatic reduction of the cost was accomplished by outsourcing such service who through the existing above-mentioned communication infrastructure were able to run the business support operation and knowledge of work from the east not to forget that today the majority of north American corporate service call centers are operated remotely i.e. you dial 800 number in the USA and a service call center in India will take your call. This step gradually migrated to outsourcing complete partial or complete factories. Y2k was also the engine for another globalizing concept. Off sourcing i.e. factories moved from the west to the east and vice-versa. North American and Japanese products or their spare parts are manufactured in China, Malaysia and/or Taiwan and assembled and/or displayed in Tokyo and Washington, DC. This could not have been possible without China forced

to drop communism and join the world trade organization and the dramatic development of global supply chain management. In sourcing, i.e. adapting a synchronized commerce solutions utilizing corporate like UPS and Federal Express further augmented the outsourcing and off sourcing process. The dramatic development of what is called informing concept i.e. the ability to search a googol (1 with 100 zeros), people can search millions and trillions of files by pre-set define key words or IPs. This capability augmented by the dramatic improvement in the computer processors and storage capability, the digital data and the ability to visualize it, personalize it and mobilize it, and the data input and output speed dramatically amplified the globalization concepts. Today, through sophisticated applications, engines are talking to computers, and vice-versa, computers are talking to people and vice-versa, people are talking to engines and vice-versa and people are talking to people and vice-versa from anywhere to anywhere. Therefore, we identified that globalization is possible and cost effective i.e. saving money. We believe that looking at emergency medicine as a global organization will not only save money but also will save lives and improve patient outcome. Utilizing the same concept and infrastructure, the practicing emergency medicine provider in the middle of nowhere will be able to attend a training session conducted at Harvard University in Boston, ask questions and lively interact with the speakers. That practicing emergency medicine staff who can not afford the travel cost will also be able to attend similar conferences at his home town center or from home. Similar to that, an incident commander in Iran can consult the best expertise in disaster management or any disaster control center in the world which by visualizing the scene, analyzing the data, defining the risk can work with the incident commander in building up the appropriate action plan. A practicing emergency physician in Bangladesh can seek the advice of a trained board certified emergency medicine consultant in Massachusetts Medical Center in Boston where he or she can visualize and directly exchange information with the practicing emergency physician, the patient and/or his family and directly give the best advice. We have no doubt that Emergency medicine as a global organization can be a reality. This idea was shared and discussed with some of AAEM emergency medicine leaders during the 2nd World Congress in Emergency Medicine and Disasters, Cancun, Mexico, November 19th 241h 2008 where all agreed on the importance of such a resource and the magnitude of contribution it is going to add to the specialty worldwide.

Despite the fact that it is unethical to deprive emergency medicine providers from having an access to all human knowledge and resources, few questions were put down for discussion. If everyone contributes his or her intellectual, capital for free, where will the resources for new renovation come from? How we can end up the endless legal wrangles over which part of the innovation is made community free and made to stay the way and which part is added by some individuals and/or corporate for profit and had to be paid to drive further innovation? Other questions might also surface during this presentation that we might not be able to address within the presentation allotted time. Therefore, our first step is to announce the development of a website with free electronic registration and e-mail service for all registrants of this conference to put forward their feelings and ideas. This topic then can be revisited during coming emergency medicine conferences where we will officially launched the website www.globem.org and the services it can provide. We believe that this website is going to be an important base for a vital program that will inflict a significant change in the emergency medicine specialty arena and will open ground to unify and augment the global emergency medicine community beyond all self influential centralized anti-globalization movements. Dr Khalid Abu Haimed