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Emergency Medicine in Jordan
INTERNATIONAl. REPORT
Emergency Medicine in Jordan Prom the Department qf Emergency Medicine, KingHtcsseinMedical Center, Royal Medical Service, Amman, Jordan;* and Milton S HersheyMedical Center, PermsylvaniaState University, Hershey, PA.*
Suleiman Abbadi, MD* Abdel Karim Abdallah, MD* C James Holliman, MD*
R.eceivedfor publication December 16, 1996. Acceptedfor publkation March 12, 1997.
The kingdom of Jordan is well known in the Middle East for the high-quality health care it provides its citizens and other patients from throughout the region. The specialty of emergency medicine is developing in Jordan along unique lines, mainly as an outgrowth of family medicine. [Abbadi S, Abdallah AK, Holliman CJ: Emergencymedicine in Jordan. Ann EmergMedSeptember1997;30:319-321.]
Copyright Caby the American College of Emergency Physicians.
INTRODUCTION The Hashemite Kingdom of Jordan is a small country in the Middle East, about the size of Switzerland. Jordan borders Israel, Palestine, Syria, Iraq, and Saudi Arabia. The population, 90% Muslim, has increased sevenfold since 1952 to about 4.2 million (1994 census). One third of the population lives in the capital city, Amman, or its suburbs. Jordan is well-known in the Middle East for the highquality health care it provides its citizens and patients from throughout the region. The specialty of emergency medicine is developing m Jordan along unique lines, mainly as an outgrowth of family medicine.
HEALTH CARE SYSTEM Health care systems in Jordan are both publicly and privately operated. The Ministry of Health and the Royal Medical Service (RIDS), both government institutions, provide all levels of care to about 8-/% of the population and have at least one general hospital in every city. About one third of the population's health care expenses are covered by the military, and the government pays for care for most of the rest of the population. The fees paid by each person for health care coverage are significantly less than the government's expenditures for health care. The private health care system is based in Amman and operates with many highquality hospitals, some of which offer specialized services. Two medical schools graduate about 150 new physicians each year, and the physician/population ratio is currently
SEPTEMBER 1997
30:3
ANNALS OF EMERGENCY MEDICINE
3 19
JORDAN
Abbadi, Abdallah& HolI*man
1/500. In 1982 the Jordan Medical Council (JMC) was established as the only body officially responsible for accreditation of training programs, certification of physicians, and recognition of medical specialties in Jordan. The JMC has enabled subspecialty medical training to be conducted in Jordan. Before 1982 most Jordanian physicians had to tram out of the country The JMC has not yet recognized emergency medicine as a national specialty, although this recognition is anticipated in 1 to 2 years. PREHOSPITAL
EMERGENCY
CARE
Prehospital emergency care is the responsibility of the Civil Defence Directorate (CDD). The CDD provides ambulances with trained medics who provide first aid at the scene and transportation to the hospital. Most of the ambulances are dispatched from CDD departments, but some are dispatched directly from hospitals or family practice clinics. The Jordanian air force provides helicopters for air medical evacuations, staffed by military physicians (mostly family practitioners). Medics undergo a 2-year standardized national training course roughly equivalent to US paramedic training. Table.
Family medicine and emergency medicine curricula. Rotation
Duration (Months)
Family medicine
Generalmedicine Generalsurgery Pediatrics Obstetrics/gynecology Otolaryngology Ophthalmology Psychiatry Dermatology Anesthesiology Radiology Emergencymedicine Familymedicine Total
6 6 6 6 1 1 2 1 1 1 4 12 48
Emergency medicine
CCU Neurosurgery Orthopedics EMS
ICU Anesthesiology Radiology Air evacuation ED Total
2 1 1 4 1 1 1 1 24 36
Higher training
United Kingdom/UnitedStates
320
12
CDD fire fighters are trained as first responders and provide coverage for most prehospital cases. Despite the available ambulance system, self-transport of patients to EDs is much more prevalent than it is in the United States. ROYAL M E D I C A L
SERVICE
The RMS comprises physicians and other health care personnel employed by the army. The RMS provides health care for about 36% of the population and for many reasons took the lead in establishing and maintaining quality health care. The RMS developed all needed specialties and established the facilities necessary to meet the needs of cases requiring highly specialized care. The recognized specialties with board certification include family practice, internal medicine, general surgery, pediatrics, and obstetrics/gynecology In addition, several subspecialty certifications are recognized within each of these basic specialties. Specialized hospital centers such as Queen Alia Heart Institute and Farah Rehabilitation Center have been developed. FAMILY MEDICINE MEDICINE
AS A BASE FOR E M E R G E N C Y
In 1981 the RMS started a 4-year postgraduate training program in family medicine. Two years later, the Ministry of Health and the two medical schools started similar programs. The new specialty of family medicine proved to successful and much needed, not only to provide quality primary and prehospital health care but to lay the groundwork for a strong emergency care service. The family medicine residency training program includes rotations in surgery, medicine, pediatrics, and obstetrics/gynecology for 6 months each and a 4-month rotation in the EDs of the larger hospitals (Table). Currently the RMS has 95 board-certified family medicine physicians and the Ministry of Health has 45, 25 of them board-certified. CREATION OF E M E R G E N C Y SPECIALTY
MEDICINE
AS A
Initially, EDs in Jordan were staffed by rotating residents in
general medicine and surgery. In 1987 the RMS reviewed emergency care in its hospitals and decided that emergency care should be provided by full-time physicians trained in emergency medicine. With the help of an American emergency physician consultant, a training course in emergency medicine--including Advanced Trauma Life Support, Advanced Cardiac Life Support, and other emergency medicine topics--was started. This course was attended by a group
ANNALS OF EMERGENCYMEDICLNE 30:3 SEPTEMBER1997
JORDAN
Abbadi, Abdallah & HoIliman
of board-certified family practitioners. The course has been repeated three times since 1988, and its components are now encompassed in emergency medicine residency training. Three physicians and three nurses from the initial training group were sent to the United States for further training and to study the American experience in starting emergency medicine as a specialty This group spent 3 months at Brooke Army Medical Center in San Antonio, TX, and undertook clinical and didactic experience in the ED and ICU. This study group proved helpful in starting the Jordanian emergency medicine program. In 1988 this group staffed the first model ED at Queen Alia Hospital in Amman, A year later, the operation of this ED was reviewed by a group of visiting American emergency physicians. These physicians pronounced the ED a success, and this report was used to encourage and continue the process of training and to prepare emergency medicine faculty for the future. TRAINING
thusiasm of a few family practitioners, and the support of the RMS have made it possible to develop the much-needed specialty of emergency medicine in Jordan. The path of the development of emergency medicine in Jordan has been different than in many countries, having been mainly an outgrowth of family medicine. The extended EM residency training program is producing the core of faculty needed to further develop the specialty for the future. Reprint no. 47/1/83294 Address for reprints: SuleimanAbbadi,MD POBox960940 Amman11196 Jordan 962-6-677-335 Fax962-6-551-4157
IN E M E R G E N C Y M E D I C I N E
Since 1989 a training program in emergency medicine has been operating for family physicians who wish to make emergency medicine their career. After completing the 7year domestic training program, these physicians are sent for 1 year of training in the United Kingdom (Royal Infirmary of Edinburgh and University College Hospital, London) or the United States. The American experience has been developed as a fellowship in emergency medicine at Pennsylvania State University. The purpose of the lengthy traimng is to prep;are faculty for the training of residents in emergency medicine as this specialty develops further in Jordan. The Jordanian portion of emergency medicine training for selected board-certified family practitioners (Table) takes place in the largest teaching hospital ED in the country: King Hussein Medical (;enter in Amman. This ED sees about 65,000 patients each year, a large proportion of whom have cardiac or trauma emergencies. The ED is supervised by 10 emergency medicine faculty, five of whom have completed the entire 8-year emergency medicine training program. These faculty provide weekly didactic conferences on emergency medicine for the resident trainees. One goal is to train enough emergency physicians to fully staff all the EDs in Jordan. PAST AND FUTURE
The experience of emergency medicine colleagues in the United States in the development of this specialty, the en-
SEPTEMBER 1997
30:3
ANNALS OF EMERGENCY MEDICINE
32 2
Emergency Medicine in Jordan Prom the Department qf Emergency Medicine, KingHtcsseinMedical Center, Royal Medical Service, Amman, Jordan;* and Milton S HersheyMedical Center, PermsylvaniaState University, Hershey, PA.*
Suleiman Abbadi, MD* Abdel Karim Abdallah, MD* C James Holliman, MD*
R.eceivedfor publication December 16, 1996. Acceptedfor publkation March 12, 1997.
The kingdom of Jordan is well known in the Middle East for the high-quality health care it provides its citizens and other patients from throughout the region. The specialty of emergency medicine is developing in Jordan along unique lines, mainly as an outgrowth of family medicine. [Abbadi S, Abdallah AK, Holliman CJ: Emergencymedicine in Jordan. Ann EmergMedSeptember1997;30:319-321.]
Copyright Caby the American College of Emergency Physicians.
INTRODUCTION The Hashemite Kingdom of Jordan is a small country in the Middle East, about the size of Switzerland. Jordan borders Israel, Palestine, Syria, Iraq, and Saudi Arabia. The population, 90% Muslim, has increased sevenfold since 1952 to about 4.2 million (1994 census). One third of the population lives in the capital city, Amman, or its suburbs. Jordan is well-known in the Middle East for the highquality health care it provides its citizens and patients from throughout the region. The specialty of emergency medicine is developing m Jordan along unique lines, mainly as an outgrowth of family medicine.
HEALTH CARE SYSTEM Health care systems in Jordan are both publicly and privately operated. The Ministry of Health and the Royal Medical Service (RIDS), both government institutions, provide all levels of care to about 8-/% of the population and have at least one general hospital in every city. About one third of the population's health care expenses are covered by the military, and the government pays for care for most of the rest of the population. The fees paid by each person for health care coverage are significantly less than the government's expenditures for health care. The private health care system is based in Amman and operates with many highquality hospitals, some of which offer specialized services. Two medical schools graduate about 150 new physicians each year, and the physician/population ratio is currently
SEPTEMBER 1997
30:3
ANNALS OF EMERGENCY MEDICINE
3 19
JORDAN
Abbadi, Abdallah& HolI*man
1/500. In 1982 the Jordan Medical Council (JMC) was established as the only body officially responsible for accreditation of training programs, certification of physicians, and recognition of medical specialties in Jordan. The JMC has enabled subspecialty medical training to be conducted in Jordan. Before 1982 most Jordanian physicians had to tram out of the country The JMC has not yet recognized emergency medicine as a national specialty, although this recognition is anticipated in 1 to 2 years. PREHOSPITAL
EMERGENCY
CARE
Prehospital emergency care is the responsibility of the Civil Defence Directorate (CDD). The CDD provides ambulances with trained medics who provide first aid at the scene and transportation to the hospital. Most of the ambulances are dispatched from CDD departments, but some are dispatched directly from hospitals or family practice clinics. The Jordanian air force provides helicopters for air medical evacuations, staffed by military physicians (mostly family practitioners). Medics undergo a 2-year standardized national training course roughly equivalent to US paramedic training. Table.
Family medicine and emergency medicine curricula. Rotation
Duration (Months)
Family medicine
Generalmedicine Generalsurgery Pediatrics Obstetrics/gynecology Otolaryngology Ophthalmology Psychiatry Dermatology Anesthesiology Radiology Emergencymedicine Familymedicine Total
6 6 6 6 1 1 2 1 1 1 4 12 48
Emergency medicine
CCU Neurosurgery Orthopedics EMS
ICU Anesthesiology Radiology Air evacuation ED Total
2 1 1 4 1 1 1 1 24 36
Higher training
United Kingdom/UnitedStates
320
12
CDD fire fighters are trained as first responders and provide coverage for most prehospital cases. Despite the available ambulance system, self-transport of patients to EDs is much more prevalent than it is in the United States. ROYAL M E D I C A L
SERVICE
The RMS comprises physicians and other health care personnel employed by the army. The RMS provides health care for about 36% of the population and for many reasons took the lead in establishing and maintaining quality health care. The RMS developed all needed specialties and established the facilities necessary to meet the needs of cases requiring highly specialized care. The recognized specialties with board certification include family practice, internal medicine, general surgery, pediatrics, and obstetrics/gynecology In addition, several subspecialty certifications are recognized within each of these basic specialties. Specialized hospital centers such as Queen Alia Heart Institute and Farah Rehabilitation Center have been developed. FAMILY MEDICINE MEDICINE
AS A BASE FOR E M E R G E N C Y
In 1981 the RMS started a 4-year postgraduate training program in family medicine. Two years later, the Ministry of Health and the two medical schools started similar programs. The new specialty of family medicine proved to successful and much needed, not only to provide quality primary and prehospital health care but to lay the groundwork for a strong emergency care service. The family medicine residency training program includes rotations in surgery, medicine, pediatrics, and obstetrics/gynecology for 6 months each and a 4-month rotation in the EDs of the larger hospitals (Table). Currently the RMS has 95 board-certified family medicine physicians and the Ministry of Health has 45, 25 of them board-certified. CREATION OF E M E R G E N C Y SPECIALTY
MEDICINE
AS A
Initially, EDs in Jordan were staffed by rotating residents in
general medicine and surgery. In 1987 the RMS reviewed emergency care in its hospitals and decided that emergency care should be provided by full-time physicians trained in emergency medicine. With the help of an American emergency physician consultant, a training course in emergency medicine--including Advanced Trauma Life Support, Advanced Cardiac Life Support, and other emergency medicine topics--was started. This course was attended by a group
ANNALS OF EMERGENCYMEDICLNE 30:3 SEPTEMBER1997
JORDAN
Abbadi, Abdallah & HoIliman
of board-certified family practitioners. The course has been repeated three times since 1988, and its components are now encompassed in emergency medicine residency training. Three physicians and three nurses from the initial training group were sent to the United States for further training and to study the American experience in starting emergency medicine as a specialty This group spent 3 months at Brooke Army Medical Center in San Antonio, TX, and undertook clinical and didactic experience in the ED and ICU. This study group proved helpful in starting the Jordanian emergency medicine program. In 1988 this group staffed the first model ED at Queen Alia Hospital in Amman, A year later, the operation of this ED was reviewed by a group of visiting American emergency physicians. These physicians pronounced the ED a success, and this report was used to encourage and continue the process of training and to prepare emergency medicine faculty for the future. TRAINING
thusiasm of a few family practitioners, and the support of the RMS have made it possible to develop the much-needed specialty of emergency medicine in Jordan. The path of the development of emergency medicine in Jordan has been different than in many countries, having been mainly an outgrowth of family medicine. The extended EM residency training program is producing the core of faculty needed to further develop the specialty for the future. Reprint no. 47/1/83294 Address for reprints: SuleimanAbbadi,MD POBox960940 Amman11196 Jordan 962-6-677-335 Fax962-6-551-4157
IN E M E R G E N C Y M E D I C I N E
Since 1989 a training program in emergency medicine has been operating for family physicians who wish to make emergency medicine their career. After completing the 7year domestic training program, these physicians are sent for 1 year of training in the United Kingdom (Royal Infirmary of Edinburgh and University College Hospital, London) or the United States. The American experience has been developed as a fellowship in emergency medicine at Pennsylvania State University. The purpose of the lengthy traimng is to prep;are faculty for the training of residents in emergency medicine as this specialty develops further in Jordan. The Jordanian portion of emergency medicine training for selected board-certified family practitioners (Table) takes place in the largest teaching hospital ED in the country: King Hussein Medical (;enter in Amman. This ED sees about 65,000 patients each year, a large proportion of whom have cardiac or trauma emergencies. The ED is supervised by 10 emergency medicine faculty, five of whom have completed the entire 8-year emergency medicine training program. These faculty provide weekly didactic conferences on emergency medicine for the resident trainees. One goal is to train enough emergency physicians to fully staff all the EDs in Jordan. PAST AND FUTURE
The experience of emergency medicine colleagues in the United States in the development of this specialty, the en-
SEPTEMBER 1997
30:3
ANNALS OF EMERGENCY MEDICINE
32 2