R E F L E C T I O N S F R O M O U R G R A N T E E S 
P A K I S T A N:
“Emergency rooms have existed in Pakistan since the mid 1950s. However emergency medicine is just now beginning to get recognition as a specialized branch of internal medicine. At present time, all emergency rooms are completely staffed and run by Senior Medical Officer (SMOs), i.e. medical residency graduates from surgery, internal medicine or pediatrics who are waiting to take their specialty licensing exams. There is a consulting attending physician on call, but is usually not present in the Emergency Department for the duration of the 24 hours. Rather, there are am and pm rounds for which this consultant physician rounds on active patients, advises as he/she sees fits and moves on to other academic duties. Majority of SMOs running the ERs, move on to their specialty of training on acquiring licenses. A small minority stay on in the emergency department, and take on the positions of “Consulting physicians” (equivalent of attending physicians in US). Patients are seen according to their level of emergencies.
Unlike the our standard patient population, the acuity level of the patients seen in the emergency rooms is very high with up to 60% admission. In terms of the patient disease pathology the one major difference is the percentage of infectious disease patients – almost 40% of critical care cases are serious tropical infections such as malaria, dengue and the like. A very significant number of patients are trauma patients however trauma codes are not run by emergency physicians, rather general surgery residents direct these codes. Unfortunately the concept of ABCDE (ATLS) has not been inculcated into the practice norms as yet. Trauma is very much a new and practically non-existent field in Pakistan and definitely needs direction for development. The county equivalent of hospitals in Karachi is Jinnah Postgraduate Medical Centre (JPMC), where majority of the traumas and those unable to afford medical care go to. Patients are expected to pay what they can out of pocket at JPMC, however they are typically admitted to inpatient services if their illness is severe enough. At Agha Khan University Hospital (AKU), like at most other private hospitals, patients are evaluated in the emergency department, but their admissions are held until families are able to provide up to 50% of their total hospital visit expenses at triage. This leads to a significant number of patients being transferred to other hospitals with lesser facilities and therefore contributes to patient morbidity and mortality.
AKU is in the process of graduating its first batch of emergency medicine residents this year. The push to recognize emergency medicine as an independent specialty was initiated by Dr. Junaid Razzak who happens to be a graduate of the Yale emergency medicine residency on his arrival at AKU 6 years ago. To date he remains the only ABEM certified emergency physician practicing in Pakistan.
To date there is only one official emergency medicine training residency in Pakistan, the one at AKU. It has sixteen residents at present. The residency is structured such that all residents rotate through the following departments in blocks of 8-12 weeks: medicine, intensive care unit, surgical intensive care unit, surgery floor, ob/gyn, anesthesia, orthopedics, emergency department, electives, pediatrics. ER rotation time percentage increases according to post graduate level, however the experience of all residents is not uniform and there appears to be a month to month adjustment with some of the residents being “fit into” other departments subject to availability of positions. Weekly didactics are held in the shape of 5 hours of lectures over 2 days. Pediatric didactics are held separately but attendance is optional. All residents are expected to engage in “scholarly activity” in the form of basic clinical or bench-side research. Residents work 5 12 hour shifts/week while in the emergency department and run the emergency department rooms alongside the SMOs. There is an abundance of procedures like intubations, central lines and thoracentesis. However surgical procedures like tube thoracostomies, cricithyrodotimes are strictly surgery domain. Residents are not required to be BLS/ACLS or ATLS certified, yet the principles of each of these courses is imparted through conferences.
With regards to the proper licensure for practice of emergency medicine, at present there is none specific to EM. All residents in general are required to take Pakistan medical and dental council (PMDC) mediated National licensing exam Parts A (undergraduate- general medicine) and B (post graduate- specialty specific). This year there has been a resolution to introduce an emergency medicine specific Part B into the system for the benefit of those training in EM. In the meanwhile SMOs that are practicing in emergency departments (at least in AKU) are offered twice monthly didactics in the specifics of emergency medicine practice. This was an area of curriculum development that I was asked to develop while in Pakistan.
I was able to interview operations officers from EDHI and AMMAN foundation and was able to obtain a better understanding of their collective contributions to EMS, their current challenges and the plans for the future. EDHI is considered a “traditional” ambulance service, with 70% of their vehicles operated by a lone driver and basic equipment such as oxygen, a stretcher, lights and sirens and personal protective equipment. This service is accessible via dialing 1515 perhaps the current equivalent of 911 in the US. It is the most utilized ambulance service in Karachi. The ambulances are arranged according to several ambulance stations all across Karachi and calls are directed to the closest station from a central station at Tower road, where the dispatch service is located. EDHI ambulance did not start out requiring any kind of training for their staff hence at the present time they are in the process of having their drivers and EMT trained in basic life support equivalent classes. In addition they are attempting to coordinate with the more technically advanced AMMAN foundation for training in Advanced life support training for their “emergency ambulances” i.e. those ambulances equipped with medications, straight boards, collars, intubation equipment and defibrillators.
Amman foundation is considered one of the newer more technically advanced EMS services, with 30 % of their fleet functioning as Advanced/Emergency ambulances with a traveling physician on board. They are well organized with a central station and ten surrounding substations, with all calls being dispatched appropriately to the nearest location. In addition dispatchers are trained to provide basic life support instructions over the phone. All calls and ambulance runs are recorded, along with any medical interventions provided, deaths etc.
At the present time there is no formal unified coordination between the various services, especially in response to disasters. They keep in communication informally via telephones and personal contacts. There is also a lack of formal ambulance to hospital communication so typically very critical patients such as mass casualty victims are often brought in without any prior notifications. There is a very palpable competition for patients between the various non-profit organizations since all these organizations benefit from donations from the patients as well as families."
-DR. NUR-AIN NADIR
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