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 postgraduate 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 antiglobalization 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 viceversa 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 antiglobalization movements.
Dr Khalid Abu Haimed