- Email: [email protected]
Emergency Medicine in Peru
The Journal of Emergency Medicine, Vol. 29, No. 3, pp. 353–356, 2005 Copyright © 2005 Elsevier Inc. Printed in the USA. All rights reserved 0736-4679/05 $–see front matter
doi:10.1016/j.jemermed.2005.02.013
International Emergency Medicine
EMERGENCY MEDICINE IN PERU Robert C. Swanson,
DO,*
Nelson R. Morales Soto,
MD,†
and Abel Garcia Villafuerte,
MD†
*Department of Emergency Medicine, Medical College of Wisconsin, Milwaukee Wisconsin, and †Department of Emergency Medicine and Disasters, Universidad Nacional de San Marcos, Lima, Peru Reprint Address: Robert Chad Swanson, 16265 West Mayflower Drive, New Berlin, WI 53151
e Abstract—Emergency Medicine (EM) is a developing specialty in Peru, as is the case in many other countries around the world. The nation’s first residency training program was started in 1993 at the Universidad Nacional Mayor de San Marcos (UNMSM). This description of the development, organization, challenges, and goals of the EM specialty in Peru is based on personal experience and communication with other specialists in the country. © 2005 Elsevier Inc.
system provides care to those who pay into it, either through the employer or privately. Medical care through the social security system is generally the highest quality in the country and is comprehensive, covering patients’ prehospital, emergency, obstetric, inpatient, and surgical needs. The Ministry of Defense and Police sponsors health care facilities as well. Similarly, all care is provided free of charge for those who have served in the armed forces or police. The Ministry of Health regulates and provides funding for all other Peruvians, which is approximately 70% of the population. Currently, all health care for these uninsured patients is received after paying a fee that is subsidized by the government. It is common for patients who do not have access to the social security or military health facilities to be hospitalized for days until relatives gather enough money to pay for diagnostic procedures or imaging. Some health services, including emergencies, are provided free of charge. In addition, women and children of low socioeconomic status receive free health care in public hospitals.
e Keywords—Peru; emergency medicine development; international emergency medicine; descriptive report
INTRODUCTION Peru is a Spanish-speaking country located on the northwest coast of South America. It has an extremely variable topography, with western coastal plains, central rugged Andean mountains, and eastern lowlands with tropical Amazonian forests. This diverse geography lends itself to a wide range of diseases, including malaria, tuberculosis, brucellosis, and leishmaniasis. In addition, challenges of recent urbanization, widespread poverty, and terrorism contribute to Peru’s vulnerability to disasters and trauma (1). The population in 2003 was 27.1 million, with nearly one-third living in the capital and largest city, Lima (2).
EMERGENCY MEDICINE AS A SPECIALTY As in many other countries, Emergency Medicine is a developing specialty in Peru (3). The Peruvian Society of Emergency Medicine and Disasters (SPMED) was founded in 1984, partially in response to the need for physicians capable of stabilizing victims of violent terrorist attacks. The society has since strived for national dissemination and specialty recognition. The first residency training program in Emergency Medicine was started in Peru in 1993. It was not until 1999, however, that the specialty was fully recognized by being inscribed
HEALTH CARE DELIVERY SYSTEM Three national government ministries regulate funding and policies for health care in Peru, each functioning independent of the others. The Ministry of Labor funds and manages the social security health care system. This 353
354
R. C. Swanson et al.
into the Peruvian Medical College. In March of 2004, a plan for an organized national emergency medical system was presented to the Peruvian Ministry of Health by SPMED. This plan included a unified emergency system within the three ministries of health, a standardized Emergency Medicine (EM) educational curriculum, and one nationally standardized emergency response telephone number. The society recently sponsored the highly successful First Peruvian Congress of Emergency and Disasters. The leaders of the society recognize the need for a uniform approach to the challenges of emergency medical care and responding to disasters. Another goal is to include nurses, paramedics, and technicians in the society. SPMED is also very interested in collaborating with EM organizations around the world; its members are active in the recently formed Latin-American Association of Cooperation in Medical Emergencies and Disasters (ALACED) (4). The presidents of the respective national EM specialty organizations in Venezuela, Ecuador, Columbia, Argentina, Cuba, and other countries keep in regular contact by email. Society planning meetings are held biweekly, with educational courses held every other month. SPMED has also recently published the journal, Revista de la Sociedad Peruana de Medicina de Emergencias y Desastres (Journal of the Peruvian Society of Emergency Medicine and Disasters) (5).
EM RESIDENCY TRAINING The residency program in Emergency Medicine and Disasters at the Universidad Nacional Mayor de San Marcos in Lima was the first EM training program in the country. The 3-year program, founded in 1993, graduates 15 to 16 residency-trained emergency physicians (EPs) each year. Two years ago another program was started in Trujillo, a city in northwestern Peru with a population of 650,000. Four residents are accepted yearly to the Trujillo program. There are two more residency programs that plan to accept residents in the near future, one in Lima (at the San Martin de Porres hospital) and one in Arequipa. The residency-training curriculum at Universidad Nacional Mayor de San Marcos (UNMSM) is similar to 3-year programs in the United States. Four months of the first year are spent in the emergency department (ED), 5 months in the second year, and 4 months in the third year. The remaining rotations consist of experiences in intensive care medicine, obstetrics, pediatrics, surgery, trauma, and emergency medical services. Graduate courses in advanced resuscitation, disaster management, health services management, and research methodology are also required. During their training, residents often
spend 1 month in either Colombia or the United States for more exposure to organized trauma systems.
EMERGENCY MEDICAL SERVICES SYSTEM The type of prehospital care provided in Peru ranges from ambulances in Lima with ventilators, defibrillators, and oxygen for patients with health insurance to no designated medical transportation for many other Peruvians. Emergency medical services (EMS) systems are supported by respective government ministries, so there are at least four separate EMS systems. Firefighters are often the first to reach those in need, and, as in the United States, many are trained as paramedics. The social security health care system, sponsored by the Ministry of Labor, provides free transportation to ill or injured members of its plan. The system follows a European model, with three levels of ambulances. Those that respond to the highest acuity patients are staffed by physicians and have advanced life support equipment, including ventilators. The Ministry of Defense and Police also provides ambulance services. The Health Ministry’s EMS system is extremely variable, ranging from a dedicated emergency hospital with ambulances in Lima to vast rural areas outside Lima where prehospital care is not available. Each of these four EMS providers has a different emergency telephone number. As mentioned earlier, SPMED is working to develop a national, unified emergency response system that includes one emergency number.
EMERGENCY DEPARTMENT PRACTICE As noted previously, the level of emergency medical care and services provided to Peruvian patients is highly dependent on many variables, especially possession of health insurance and geographic location. Computed tomography (CT) scanners, oxygen saturation monitors, intensive care support with ventilators, cardiac catheterization laboratories, and 24-h in-hospital surgical support are available in Lima’s larger academic centers, Social Services Hospitals, and Hospitals of the Armed Services. In the majority of Lima’s other hospitals and nearly all hospitals outside of Lima, such services are rarely available. Specialists provide medical care in most Peruvian EDs, apart from the EM training hospitals in Lima. An internist, a general surgeon, an orthopedic surgeon, or a pediatrician treats patients after triage, depending on chief complaint and physical findings. We performed an informal survey of 39 physicians practicing in Peruvian EDs in 2002. Ten of the respondents were residency-trained in Emergency Medicine.
Emergency Medicine in Peru
Our findings suggest that EM-trained physicians are more comfortable with emergent procedures than those trained in other specialties. We found few residencytrained EPs practicing outside of Lima. It is yet to be seen how residency-trained EM physicians will be received in many hospitals not familiar with the specialty of Emergency Medicine.
EMERGENCY MEDICINE CONFERENCES AND CONTINUING EDUCATION There are no nationally required Emergency Medicine certification courses in Peru. Advanced Trauma Life Support (ATLS) and Advanced Cardiac Life Support (ACLS) courses are periodically offered, although they are too expensive for most practicing surgeons and emergency physicians. Courses in trauma management, medical emergencies, emergencies in obstetrics and gynecology, etc. are occasionally offered in Lima and other large cities. As noted, SPMED sponsored the first Peruvian Conference on Emergencies and Disasters, which was held on November 4 –7, 2004. Over 1200 participants from more than seven countries attended the lectures, research presentations, and panel discussions. Those present included specialty leaders from Cuba, Argentina, Venezuela, Colombia, and the United States. In 2006, the second Peruvian Conference on Emergencies and Disasters will be held in Lima, jointly with the second ALACED conference.
355
physicians in Emergency Medicine. Population-based disparities in emergency physicians have also been recognized in the United States, though not to the same extent (6). There are only two EM residency training programs in Peru, which do not graduate enough specialists to meet the country’s needs. The need and role for EM specialists in a developing country like Peru, especially in rural areas, is highly dependent on the health system infrastructure and available resources. In Iquitos, for example, there were few functioning ventilators in the public hospital for a population of over 100,000. An EM specialist practicing in Iquitos, then, might better serve the population by focusing on basic first aid public education, disaster management, and general health care resource procurement, rather than advanced airway management. The value of advocating public health measures in the emergency department is recognized, and specific interventions have been analyzed in the United States (7,8).
CONCLUDING COMMENTS The specialty of Emergency Medicine in Peru is at an important point in its development. Individual EPs are developing their skills and furthering their education, and the specialty is becoming better organized. With a wellestablished specialty organization, new residency programs, a scientific journal, and a successful national conference, it is an exciting time for the specialty of Emergency Medicine. The future of the specialty depends in large part on the role that the recently graduated Emergency Medicine specialists play in Peru.
FUTURE DIRECTIONS The Emergency Medicine and Disasters specialty in Peru has made considerable strides in development over the past 20 years. As mentioned, the professional society, SPMED, is recognized nationally and is active, a residency-training program is more than 10 years old, new residency programs are being developed, and re-certification courses are offered. However, many challenges face the specialty. Recognition of emergency trained physicians in Peru is, for the most part, limited to certain hospitals in Lima. Most of the graduates of the residency-training program have stayed in Lima to practice. None of the 15 physicians surveyed outside of Lima was residency trained in Emergency Medicine. In hospitals where the EM residents are not trained, ED chiefs often are chosen based on years of experience, as opposed to type of residency training. Some of the physicians surveyed in cities outside of Lima had not even heard of residency-trained
Acknowledgments—We thank all of the physicians who provided comments regarding Emergency Medicine in Peru, especially Wilfredo Galvez Rivero, MD, the EM residency program coordinator at UNMSM. We also thank Jane Johnson for her statistical contributions, and Tom Aufderheide, MD and Stephen Hargarten, MD, MPH for suggestions on revisions.
REFERENCES 1. Hernandez DH, Church A. Terrorism in Peru. Prehop Disast Med 2003;18:123– 6. 2. World Bank website. Available at: http://devdata.worldbank.org/ external/CPProfile.asp?SelectedCountry⫽PER&CCODE⫽brPER& CNAME⫽Peru&PTYPE⫽CP. Accessed November 11, 2004. 3. Arnold JL. International emergency medicine and the recent development of emergency medicine worldwide. Ann Emerg Med 1999; 33:97–103. 4. ALACED website. Available at: http://www.sld.cu/eventos/sium/ juntaALACED.htm. Accessed November 11, 2004.
356 5. SPMED website. Available at: http://www.spmed.org/fotos% 20congreso.htm. Accessed November 11, 2004. 6. Williams JM, Ehrlich PF, Prescott JE. Emergency medical care in rural America. Ann Emerg Med 2001;38:323–7. 7. Rhodes KV, Gordo JA, Lowe RA for the Society for Academic Emergency Medicine Public Health and Education Task Force Preventive Services Work Group. Preventive care in the emergency department, Part I: clinical preventive services—are they
R. C. Swanson et al. relevant to emergency medicine? Acad Emerg Med 2000; 7:1036 – 41. 8. Irwin CB, Wyer PC, Gerson LW, for the Society for Academic Emergency Medicine Public Health and Education Task Force Preventive Services Work Group. Preventive care in the emergency department, Part II: clinical preventive services—an emergency medicine evidence-based review. Acad Emerg Med 2000; 7:1042–54.
doi:10.1016/j.jemermed.2005.02.013
International Emergency Medicine
EMERGENCY MEDICINE IN PERU Robert C. Swanson,
DO,*
Nelson R. Morales Soto,
MD,†
and Abel Garcia Villafuerte,
MD†
*Department of Emergency Medicine, Medical College of Wisconsin, Milwaukee Wisconsin, and †Department of Emergency Medicine and Disasters, Universidad Nacional de San Marcos, Lima, Peru Reprint Address: Robert Chad Swanson, 16265 West Mayflower Drive, New Berlin, WI 53151
e Abstract—Emergency Medicine (EM) is a developing specialty in Peru, as is the case in many other countries around the world. The nation’s first residency training program was started in 1993 at the Universidad Nacional Mayor de San Marcos (UNMSM). This description of the development, organization, challenges, and goals of the EM specialty in Peru is based on personal experience and communication with other specialists in the country. © 2005 Elsevier Inc.
system provides care to those who pay into it, either through the employer or privately. Medical care through the social security system is generally the highest quality in the country and is comprehensive, covering patients’ prehospital, emergency, obstetric, inpatient, and surgical needs. The Ministry of Defense and Police sponsors health care facilities as well. Similarly, all care is provided free of charge for those who have served in the armed forces or police. The Ministry of Health regulates and provides funding for all other Peruvians, which is approximately 70% of the population. Currently, all health care for these uninsured patients is received after paying a fee that is subsidized by the government. It is common for patients who do not have access to the social security or military health facilities to be hospitalized for days until relatives gather enough money to pay for diagnostic procedures or imaging. Some health services, including emergencies, are provided free of charge. In addition, women and children of low socioeconomic status receive free health care in public hospitals.
e Keywords—Peru; emergency medicine development; international emergency medicine; descriptive report
INTRODUCTION Peru is a Spanish-speaking country located on the northwest coast of South America. It has an extremely variable topography, with western coastal plains, central rugged Andean mountains, and eastern lowlands with tropical Amazonian forests. This diverse geography lends itself to a wide range of diseases, including malaria, tuberculosis, brucellosis, and leishmaniasis. In addition, challenges of recent urbanization, widespread poverty, and terrorism contribute to Peru’s vulnerability to disasters and trauma (1). The population in 2003 was 27.1 million, with nearly one-third living in the capital and largest city, Lima (2).
EMERGENCY MEDICINE AS A SPECIALTY As in many other countries, Emergency Medicine is a developing specialty in Peru (3). The Peruvian Society of Emergency Medicine and Disasters (SPMED) was founded in 1984, partially in response to the need for physicians capable of stabilizing victims of violent terrorist attacks. The society has since strived for national dissemination and specialty recognition. The first residency training program in Emergency Medicine was started in Peru in 1993. It was not until 1999, however, that the specialty was fully recognized by being inscribed
HEALTH CARE DELIVERY SYSTEM Three national government ministries regulate funding and policies for health care in Peru, each functioning independent of the others. The Ministry of Labor funds and manages the social security health care system. This 353
354
R. C. Swanson et al.
into the Peruvian Medical College. In March of 2004, a plan for an organized national emergency medical system was presented to the Peruvian Ministry of Health by SPMED. This plan included a unified emergency system within the three ministries of health, a standardized Emergency Medicine (EM) educational curriculum, and one nationally standardized emergency response telephone number. The society recently sponsored the highly successful First Peruvian Congress of Emergency and Disasters. The leaders of the society recognize the need for a uniform approach to the challenges of emergency medical care and responding to disasters. Another goal is to include nurses, paramedics, and technicians in the society. SPMED is also very interested in collaborating with EM organizations around the world; its members are active in the recently formed Latin-American Association of Cooperation in Medical Emergencies and Disasters (ALACED) (4). The presidents of the respective national EM specialty organizations in Venezuela, Ecuador, Columbia, Argentina, Cuba, and other countries keep in regular contact by email. Society planning meetings are held biweekly, with educational courses held every other month. SPMED has also recently published the journal, Revista de la Sociedad Peruana de Medicina de Emergencias y Desastres (Journal of the Peruvian Society of Emergency Medicine and Disasters) (5).
EM RESIDENCY TRAINING The residency program in Emergency Medicine and Disasters at the Universidad Nacional Mayor de San Marcos in Lima was the first EM training program in the country. The 3-year program, founded in 1993, graduates 15 to 16 residency-trained emergency physicians (EPs) each year. Two years ago another program was started in Trujillo, a city in northwestern Peru with a population of 650,000. Four residents are accepted yearly to the Trujillo program. There are two more residency programs that plan to accept residents in the near future, one in Lima (at the San Martin de Porres hospital) and one in Arequipa. The residency-training curriculum at Universidad Nacional Mayor de San Marcos (UNMSM) is similar to 3-year programs in the United States. Four months of the first year are spent in the emergency department (ED), 5 months in the second year, and 4 months in the third year. The remaining rotations consist of experiences in intensive care medicine, obstetrics, pediatrics, surgery, trauma, and emergency medical services. Graduate courses in advanced resuscitation, disaster management, health services management, and research methodology are also required. During their training, residents often
spend 1 month in either Colombia or the United States for more exposure to organized trauma systems.
EMERGENCY MEDICAL SERVICES SYSTEM The type of prehospital care provided in Peru ranges from ambulances in Lima with ventilators, defibrillators, and oxygen for patients with health insurance to no designated medical transportation for many other Peruvians. Emergency medical services (EMS) systems are supported by respective government ministries, so there are at least four separate EMS systems. Firefighters are often the first to reach those in need, and, as in the United States, many are trained as paramedics. The social security health care system, sponsored by the Ministry of Labor, provides free transportation to ill or injured members of its plan. The system follows a European model, with three levels of ambulances. Those that respond to the highest acuity patients are staffed by physicians and have advanced life support equipment, including ventilators. The Ministry of Defense and Police also provides ambulance services. The Health Ministry’s EMS system is extremely variable, ranging from a dedicated emergency hospital with ambulances in Lima to vast rural areas outside Lima where prehospital care is not available. Each of these four EMS providers has a different emergency telephone number. As mentioned earlier, SPMED is working to develop a national, unified emergency response system that includes one emergency number.
EMERGENCY DEPARTMENT PRACTICE As noted previously, the level of emergency medical care and services provided to Peruvian patients is highly dependent on many variables, especially possession of health insurance and geographic location. Computed tomography (CT) scanners, oxygen saturation monitors, intensive care support with ventilators, cardiac catheterization laboratories, and 24-h in-hospital surgical support are available in Lima’s larger academic centers, Social Services Hospitals, and Hospitals of the Armed Services. In the majority of Lima’s other hospitals and nearly all hospitals outside of Lima, such services are rarely available. Specialists provide medical care in most Peruvian EDs, apart from the EM training hospitals in Lima. An internist, a general surgeon, an orthopedic surgeon, or a pediatrician treats patients after triage, depending on chief complaint and physical findings. We performed an informal survey of 39 physicians practicing in Peruvian EDs in 2002. Ten of the respondents were residency-trained in Emergency Medicine.
Emergency Medicine in Peru
Our findings suggest that EM-trained physicians are more comfortable with emergent procedures than those trained in other specialties. We found few residencytrained EPs practicing outside of Lima. It is yet to be seen how residency-trained EM physicians will be received in many hospitals not familiar with the specialty of Emergency Medicine.
EMERGENCY MEDICINE CONFERENCES AND CONTINUING EDUCATION There are no nationally required Emergency Medicine certification courses in Peru. Advanced Trauma Life Support (ATLS) and Advanced Cardiac Life Support (ACLS) courses are periodically offered, although they are too expensive for most practicing surgeons and emergency physicians. Courses in trauma management, medical emergencies, emergencies in obstetrics and gynecology, etc. are occasionally offered in Lima and other large cities. As noted, SPMED sponsored the first Peruvian Conference on Emergencies and Disasters, which was held on November 4 –7, 2004. Over 1200 participants from more than seven countries attended the lectures, research presentations, and panel discussions. Those present included specialty leaders from Cuba, Argentina, Venezuela, Colombia, and the United States. In 2006, the second Peruvian Conference on Emergencies and Disasters will be held in Lima, jointly with the second ALACED conference.
355
physicians in Emergency Medicine. Population-based disparities in emergency physicians have also been recognized in the United States, though not to the same extent (6). There are only two EM residency training programs in Peru, which do not graduate enough specialists to meet the country’s needs. The need and role for EM specialists in a developing country like Peru, especially in rural areas, is highly dependent on the health system infrastructure and available resources. In Iquitos, for example, there were few functioning ventilators in the public hospital for a population of over 100,000. An EM specialist practicing in Iquitos, then, might better serve the population by focusing on basic first aid public education, disaster management, and general health care resource procurement, rather than advanced airway management. The value of advocating public health measures in the emergency department is recognized, and specific interventions have been analyzed in the United States (7,8).
CONCLUDING COMMENTS The specialty of Emergency Medicine in Peru is at an important point in its development. Individual EPs are developing their skills and furthering their education, and the specialty is becoming better organized. With a wellestablished specialty organization, new residency programs, a scientific journal, and a successful national conference, it is an exciting time for the specialty of Emergency Medicine. The future of the specialty depends in large part on the role that the recently graduated Emergency Medicine specialists play in Peru.
FUTURE DIRECTIONS The Emergency Medicine and Disasters specialty in Peru has made considerable strides in development over the past 20 years. As mentioned, the professional society, SPMED, is recognized nationally and is active, a residency-training program is more than 10 years old, new residency programs are being developed, and re-certification courses are offered. However, many challenges face the specialty. Recognition of emergency trained physicians in Peru is, for the most part, limited to certain hospitals in Lima. Most of the graduates of the residency-training program have stayed in Lima to practice. None of the 15 physicians surveyed outside of Lima was residency trained in Emergency Medicine. In hospitals where the EM residents are not trained, ED chiefs often are chosen based on years of experience, as opposed to type of residency training. Some of the physicians surveyed in cities outside of Lima had not even heard of residency-trained
Acknowledgments—We thank all of the physicians who provided comments regarding Emergency Medicine in Peru, especially Wilfredo Galvez Rivero, MD, the EM residency program coordinator at UNMSM. We also thank Jane Johnson for her statistical contributions, and Tom Aufderheide, MD and Stephen Hargarten, MD, MPH for suggestions on revisions.
REFERENCES 1. Hernandez DH, Church A. Terrorism in Peru. Prehop Disast Med 2003;18:123– 6. 2. World Bank website. Available at: http://devdata.worldbank.org/ external/CPProfile.asp?SelectedCountry⫽PER&CCODE⫽brPER& CNAME⫽Peru&PTYPE⫽CP. Accessed November 11, 2004. 3. Arnold JL. International emergency medicine and the recent development of emergency medicine worldwide. Ann Emerg Med 1999; 33:97–103. 4. ALACED website. Available at: http://www.sld.cu/eventos/sium/ juntaALACED.htm. Accessed November 11, 2004.
356 5. SPMED website. Available at: http://www.spmed.org/fotos% 20congreso.htm. Accessed November 11, 2004. 6. Williams JM, Ehrlich PF, Prescott JE. Emergency medical care in rural America. Ann Emerg Med 2001;38:323–7. 7. Rhodes KV, Gordo JA, Lowe RA for the Society for Academic Emergency Medicine Public Health and Education Task Force Preventive Services Work Group. Preventive care in the emergency department, Part I: clinical preventive services—are they
R. C. Swanson et al. relevant to emergency medicine? Acad Emerg Med 2000; 7:1036 – 41. 8. Irwin CB, Wyer PC, Gerson LW, for the Society for Academic Emergency Medicine Public Health and Education Task Force Preventive Services Work Group. Preventive care in the emergency department, Part II: clinical preventive services—an emergency medicine evidence-based review. Acad Emerg Med 2000; 7:1042–54.