Global Emergency Medicine

The Academic Practice of Global Emergency Medicine

The GEM physician is a trained subspecialist who works to strengthen the practice of emergency medicine worldwide. In the United States (US), the subspecialty of GEM has been recognized by national professional associations including the American College of Emergency Physicians (ACEP), Society for Academic Emergency Medicine (SAEM), and the American Academy of Emergency Medicine (AAEM) through their respective GEM-oriented sections. Many GEM specialists have completed GEM fellowships: 1 to 2 years of additional post-residency training, often including a graduate degree focused on global health. A growing number of academic EM departments in the United States maintain a division of global emergency medicine which provides an academic home to GEM specialists.

Fellowship training programs in the United States coordinate their efforts through the Global Emergency Medicine Fellowship Consortium (GEMFC), which maintains a website describing active fellowships and facilitating the annual application process. Curricula vary based on an individual fellowship’s goals, which may be more heavily oriented to systems building, research, education, direct clinical care, or humanitarian work. Most fellowships incorporate a combination of these areas. Model curricula have been proposed, which include experiences in the following domains: EM systems, humanitarian relief, disaster medicine, public health, travel and field medicine, program administration, academic skills, and clinical skills ( Table e1.1 ). Approaches to meeting knowledge and skill goals may include a variety of educational programming, such as a Master of Public Health degree, short courses such as the International Committee for the Red Cross (ICRC) Health Emergencies in Large Populations, tropical medicine courses, and international field experiences. Proposed competency assessment frameworks for fellows training in GEM must adapt to the diverse fellowship curricula and focus on the following key domains: professionalism, communication, medical knowledge, patient care, research skills, quality improvement, and social accountability to partners and stakeholders.

History of Global Emergency Medicine

The first emergency medicine residencies in the United States began in the early 1970s and emergency medicine was formally recognized as a specialty by the American Board of Medical Specialties in 1979. In the following decades, emergency medicine grew both within the United States and globally. It was recognized as a specialty in Canada in 1980, Australia in 1981, soon followed by Hong Kong, Singapore, the United Kingdom (UK), and others.

The first emergency physicians building the specialty came together to form academic societies and advocacy groups to build collaboration, facilitate idea exchange, and advance the field. ACEP was formed in 1968, and similar organizations in other countries soon followed. In 1989, recognizing the need for international support in developing emergency medicine, the International Federation for Emergency Medicine (IFEM) was chartered by its founding members, ACEP, British Association for Accident and Emergency Medicine (UK; now the Royal College of Emergency Medicine), Australasian College for Emergency Medicine (Australia), and Canadian Association of Emergency Physicians (Canada). IFEM has grown to include over 50 full members and creates core standards, curricula, and policy briefs on emergency medicine through its committees and interest groups. ACEP created its section on international emergency medicine in 1998, reflecting the growing interest among emergency physicians to engage in global activities. As other societies followed with their own committees or interest groups focusing on emergency medicine development internationally, the specialty of GEM took its modern form.

Fellowship training in GEM arose from the combined need of trained emergency physicians practicing internationally who realized they had inadequate preparation and residents expressing increased interest in entering the field. The first fellowships in the United States were started in the mid-1990s with a curriculum largely based on a consensus panel of emergency physicians practicing GEM. As the specialty of GEM has matured, fellowships have grown significantly in number both in the United States and in other countries. The GEMFC was created in 2012 to bring GEM fellowship directors together to further define the specialty and agree on common curricular goals and assessment criteria.

The practice of GEM has grown in scope and quality. GEM research has raised awareness of the burden of emergency care amenable conditions, the economic value of emergency care, and the central role of emergency care systems in public health and health security. ^{, ,} In 2013, SAEM hosted the “Global Health and Emergency Care: A Research Agenda” Consensus Conference during which priorities were discussed and agreed upon across eight focus areas. These priorities formed a foundation for the currently maturing GEM research priorities. ^,

The World Health Organization (WHO) supported numerous efforts related to GEM in the early 2000s, including trauma care and prehospital care in low-resource settings, later forming the Emergency, Trauma, and Acute Care Programme in 2015 which is led by an emergency physician. This program has refined definitions of emergency care systems, essential functions, quality indicators, and emergency care itself ( Fig. e1.1 and Table e1.2 ). In 2019, the National Institutes of Health (NIH) Fogarty Center for Global Health Studies initiated the Collaborative for Enhancing Emergency Care Research in LMICs (CLEER), which has further defined the research agenda for GEM. ^,

Several resolutions related to emergency care have been issued by the World Health Assembly (WHA), the governing body of the WHO. Passed in 2019, WHA resolution 72.16, “Emergency care systems for universal health coverage: ensuring timely care for the acutely ill and injured,” calls for the strengthening of emergency care delivery through a detailed list of initiatives across the prehospital, facility, public health, and disaster preparedness fields. This resolution is aligned with the three Sustainable Development Goals (SDG) that are directly affected by emergency care: Goal 3 (Ensure healthy lives and promote well-being for all at all ages), Goal 11 (Make cities and human settlements inclusive, safe, resilient and sustainable), and Goal 16 (Promote peaceful and inclusive societies for sustainable development, promote access to justice for all and build effective, accountable and inclusive institutions at all levels). Prior resolutions have focused on surgical and anesthesia care, mental health, disaster management, emergency care systems, and road safety ( Table e1.3 ).

Global EM Organizations

Emergency medicine is represented globally by a variety of professional organizations whose objectives differ based on their core missions. A growing number of countries have a national professional society focused on the development and support of the practice of domestic emergency medicine. In the United States, ACEP is the largest organization, and analogous organizations exist in at least 50 other countries. The IFEM maintains a current list of these organizations on its website.

Regional societies are composed of several organizations representing the specific interests and needs of emergency medicine in a particular area of the world. An example is the African Federation for Emergency Medicine (AFEM), which has developed African context-specific educational material for emergency medicine and supports the development of the specialty across the continent. The Consortium of Universities for Global Health (CUGH) is based in Washington, DC, and brings together academic institutions from around the world that have a focus on global health. CUGH provides an important forum for discussion among academics working in the field of global health and is not limited in scope to health care or emergency medicine.

Areas of Focus in Global Emergency Medicine

GEM can be divided into development and humanitarian work. Development work is typically longer term and proactive with the goal of strengthening local systems in a sustainable manner. Humanitarian work tends to be more reactive, focused on the response to large-scale crises in which local resources are overwhelmed. These two subfields complement each other: an emergency care system strengthened through development work should be able to surge during a crisis to enhance humanitarian efforts, and an effective humanitarian response will include strengthening the local system to provide resilience against future crises. Humanitarian response is discussed in detail in Chapter e2. This chapter on GEM will focus on the development of EM systems globally.

Strengthening the specialty of emergency medicine globally is a large and complex task that requires efforts within the fields of education, research, and policy. For example, as an emergency care system is strengthened, provider training must be expanded to provide the level of care needed, while policy efforts must establish credentialing pathways for these new providers. Locally applicable processes and outcome measures must be defined, and interventions must be measured through research. These interdependent efforts are equally critical to GEM.