as the president of the international federation for emergency medicine ( ifem ) wrote in a 2007 editorial , emergency medicine is rapidly becoming a global specialty . increasing numbers of countries
every country has its own unique aspects , but in the development of em all have more that is common than is unique .
the author spent 10  years in new zealand building em and has been contributing over 7  years to the development of em in papua new guinea ( png ) . in new zealand he borrowed from australia , who had learned from the uk , usa and canada .
developing countries can learn from how things have happened in other places , extracting what might be useful for their own circumstances .
this article offers some selected observations and invites the reader to see if there are any parallels to their own circumstances that they can make use of .
the author s first exposure to emergency medicine was as a student in 1978 at the kenyatta national hospital in nairobi .
the most junior doctors did the best they could with a huge workload without any guidance . in 1979 as a new graduate at the royal perth hospital in western australia , he started in a busy emergency department supervised by a former anesthetist where often the most senior doctor on the floor was in their 2nd year post graduation from medical school ( pgy2 ) .
there were aspects that were appreciated : it was hospital , generalist , unpredictable , often exhausting , sometimes terrifying , and from time to time exciting and enormously satisfying .
but there was no career pathway to continue doing it . in the uk in 1962 an orthopedic surgeon , harry platt , had recommended that emergency departments , then called  casualties  ( as indeed they were ) , should have a senior doctor in charge . in 1965
these newly appointed directors , mainly orthopedic surgeons , established the casualty surgeons association . in 1982
the royal colleges of physicians and surgeons of edinburgh in scotland established the first specialty exams for emergency medicine in the uk . in the same year the author went to the uk . at southampton general hospital , a major teaching hospital , the  accident and emergency  was directed by a general practitioner who looked after minor injuries .
the emergency work was done by pgy2 doctors , and it was unavoidable that incompetence contributed to 
there was one registrar on the new training scheme , which was viewed by other specialty trainees as not one that anyone who took themselves seriously in medicine would do .
in australia the first  casualty  to get a director was at geelong in victoria in 1967 . in the 1970s new directors grouped in local societies . by 1981
there were sufficient numbers to establish an australian society for emergency medicine , expanded to australasian to include new zealand .
the society determined that the way to progress training in emergency medicine was to establish an independent autonomous college , modeled on the colleges of the well - established specialties , particularly surgery .
the australasian college for emergency medicine was founded in 1984 with a fellowship of 70 directors of  casualties  and  a&e ,  who charged themselves with the task of building emergency medicine as a specialty .
the first president , tom hamilton , was a scotsman in western australia and a former surgeon .
the college conducted the first exit exams in 1986 , from which eight new specialists were added to the fellowship .
all this happened because there were doctors working in emergency departments who saw the inadequacies of having the least trained , least competent , least supervised junior doctors attending the most unstable , least differentiated patients in the hospital , while senior staff from the in - patient specialties leveled criticism at them .
this was a time when anyone more senior than pgy2 who wanted to work in a 
casualty  was regarded as incompetent for anything worthwhile , as a failure , as treading water until retirement , or as mad .
it was with the emergence of the first doctors claiming specialty status by training and examination that the battle for recognition by colleagues in other specialties could really get under way . from their efforts
would eventually come the evidence that emergency medicine deserved to be fully recognized by the several layers of medical governance and by the national body , the national specialist qualifications advisory council ( nasqac ) .
this was an effort from the ground up , and it took 10  years .
a seminal paper of the time was an editorial in the medical journal of australia in 1989 by peter cameron and joe epstein , the second president and also a former surgeon .
worse there than in australia and the uk , and in some respects worse than in kenya .
that year he also learned of the new australasian college for emergency medicine . in 1989
he became the first fellow of acem by examination in new zealand , was recognized as a specialist by christchurch hospital and set to work on several fronts .
a key tool in getting started was the paper  emergency medicine - no longer a casualty  . by default
he became the new zealand representative at college on the training body , called the board of censors , and on the management body , the council .
as the poor cousin from new zealand he was able to bring back developments by the bigger and stronger neighbor , australia .
these included training programs , a system of triage , standards for staffing of eds , standards for transport of patients , and much else . in 1993
the new zealand medical journal published a leading article  emergency medicine - a new specialty  .
he quotes ( with permission from nzmj ) :  with the development of expertise , emergency departments have undergone fundamental changes in the last 10  years . in the resuscitation room , specialists coordinate a multidisciplinary team in the management of multisystem major trauma .
safety and efficiency considerations make the emergency department ( ed ) a logical location for soft tissue repairs , urgent procedures warranting conscious sedation , joint enlocations and lumbar puncture .
efficiencies are gained by the judicious ordering of appropriate investigations , and management strategies are initiated expeditiously .
for example , in the area of toxicology there has been a major shift from inpatient to short - term ed management .
the final paragraph read :  in areas of resuscitation , differential diagnosis , initiation of appropriate investigation and management , and in the appropriate disposal of their patients , specialists are bringing emergency care up to parity with the inpatient services of longer established specialties .
their ability to act as gatekeepers , while dealing efficiently with the expanding range of illness and injury that can be managed without hospital admission , will become increasingly important in the new health environment .
it took another 2  years to persuade the medical council and the government of new zealand that em was worthy of full recognition as a specialty . by 1997
there were 70 nz doctors in the acem training program , and a decade later there were 111 specialist emergency physicians there .
it was built from the ground floor of eds and through the energies of the fellowship .
the college , the  union for this movement , established a training program demonstrably as rigorous as that of other specialties .
these pioneers engaged the medical community on every front , in hospitals , in local , state and national bodies , in interdisciplinary courses , in medical schools , in pre - hospital care , and in other arenas of acute care .
it was only when it became beyond argument that em practitioners were functioning as specialists , and were being recognized by peers and hospitals as specialists , and after multiple attempts , that em was recognized by the national authorities .
papua new guinea ( png ) provides a dramatic contrast . however , while there is much that is very different , in the business of delivering acute care there is much that is common .
png lies immediately north of australia , is its closest neighbor and from world war 1 to 1975 was administered by australia , but by many measures of infrastructure , economics and standard of living , png lies at the opposite end of the world spectrum .
there is one medical school in png , and specialty training is conducted by the postgraduate committee of the school of medicine and health sciences of the university of png .
png is now largely independent in the training of doctors for the major specialties . in 1996
the postgraduate committee recognized the need to improve the capacity to deliver care to the acutely ill and injured and established a master of medicine for emergency medicine ( m.med.em ) . without expertise , png nationals were unable to provide leadership , so the plan lay dormant . in 2000 the national department of health and the ministry of health identified emergency medicine as a priority in their 20012010 national health plan .
the australian agency for international development ( ausaid ) was asked to assist in launching the program , and in 2002 ausaid funded an emergency physician in residence and visits by others .
so this is a program built from the top down , with input from an established neighbor .
there were 17 trainees in the program , 3 from the neighboring independent state of the solomon islands .
the em trainees are establishing credibility by building local capacity to respond to acute illness and injury , particularly in rural areas , through several courses .
it has been well received by provincial hospitals because it can be delivered very simply .
there are now a number of png instructors with the capacity to run courses independently .
there are parts of the country where there are more deaths from snakebite than from malaria , and that is in malaria endemic regions .
a course has been developed , led by an australian toxinologist , david williams , and a new zealand emergency physician , simon jensen , and is now being disseminated widely . in png 80% of the population
lives in rural areas , and most health care is provided by community health workers , nurses and health extension officers .
the divine word university , a catholic church - funded institution , has established a postgraduate diploma of emergency medicine for these providers . the course was developed and delivered by sandra rennie while an australian em trainee .
the newest contribution to capacity building is an emergency life support course . the australasian society for emergency medicine developed a course for rural and remote australia and has been running it for 10  years .
the em trainees are establishing credibility by building local capacity to respond to acute illness and injury , particularly in rural areas , through several courses .
it has been well received by provincial hospitals because it can be delivered very simply .
there are now a number of png instructors with the capacity to run courses independently .
there are parts of the country where there are more deaths from snakebite than from malaria , and that is in malaria endemic regions .
a course has been developed , led by an australian toxinologist , david williams , and a new zealand emergency physician , simon jensen , and is now being disseminated widely . in png 80% of the population
lives in rural areas , and most health care is provided by community health workers , nurses and health extension officers .
the divine word university , a catholic church - funded institution , has established a postgraduate diploma of emergency medicine for these providers .
the australasian society for emergency medicine developed a course for rural and remote australia and has been running it for 10  years .
it has been well received by provincial hospitals because it can be delivered very simply .
there are now a number of png instructors with the capacity to run courses independently .
there are parts of the country where there are more deaths from snakebite than from malaria , and that is in malaria endemic regions .
a course has been developed , led by an australian toxinologist , david williams , and a new zealand emergency physician , simon jensen , and is now being disseminated widely .
in png 80% of the population lives in rural areas , and most health care is provided by community health workers , nurses and health extension officers .
the divine word university , a catholic church - funded institution , has established a postgraduate diploma of emergency medicine for these providers . the course was developed and delivered by sandra rennie while an australian em trainee .
the newest contribution to capacity building is an emergency life support course . the australasian society for emergency medicine developed a course for rural and remote australia and has been running it for 10  years .
are some pointers towards getting started : 
 champions major changes are achieved by pioneers prepared to champion a cause . for emergency medicine
this has been easier where the champion has had a recognized specialty qualification , such as in surgery . the second level to find a champion is in a hospital department , and this also has most commonly been in surgery . 

union a body politic , a group with one purpose , needs an organization to represent it
. these can be useful at the institutional , city and state levels as well as at a national level . 

administrator support administrator support it can take a major effort to gain the support of administrators . pursue it relentlessly , at all levels , from hospital to government . 

bottom - up development bottom - up development in australia / nz the ground swell came from the floor of eds .
the pioneers had to change the minds of hospital staff , administrators , then medical councils , health departments and governments . 

top - down development this is possible where there are examples to take advantage of .
endurance and energy progress is made by a group prepared to cope with poor recognition .
there needs to be engagement with all facets of the delivery of acute care , expanding from the ed to hospital committees , undergraduate and postgraduate training and courses , pre - hospital care and retrieval , disaster preparedness and so on . 

use benchmarking this is the process of making gains by making comparison with others doing better and campaigning to do at least as well , if not still better .
it is the reason the international federation for emergency medicine , the international emergency medicine special interest group of acem   and other international organizations exist . 

take advantage of local events take advantage of local events there are situations that can be capitalized upon .
mass casualty incidents , disasters , an emergency suffered by a vip or politician and bad outcomes in eds can all focus attention on the need to build capacity to respond to acute illness and injury . 

take advantage of local interest take advantage of local interest sometimes a particular local focus , such as disaster preparedness or a regional trauma system , can be the way in to promote em in its entirety .
in png active volcanoes are an impetus . in india an expanding road system with spiraling road trauma demands attention , not only at the roadside but also on reception in hospitals . 

the png training program is very different from the australasian and even more different from the us programs .
the way em is done in one country can not be transferred directly to another .
each country must develop its own way of providing care to the acutely ill and injured , and thereby have ownership of it . 

link em to local primary care and public health initiatives link em to local primary care and public health initiatives prevention is included in the ifem definition of emergency medicine .
while emergency physicians are advocates for public health measures , these will not eliminate the need for a capacity to respond to acute illness and injury . 

educate everyone there is a need to keep on saying what em is , to everyone .
medical colleagues , administrators , government agencies and the general public need to be told time and again .
recurring responses in developing environments include disinterest , scorn , contempt , antagonism and obstruction , from colleagues , administrators and leaders .
this can only be overcome by taking every opportunity to educate , a campaign that needs to be on multiple fronts . 

dependence on established colleges constrained the development of emergency medicine in the uk , while an independent college in australia / nz promoted it . 

become instructors an effective way to influence colleagues and junior doctors is to be instructors for acute care courses , such as atls , acls , apls and others .
one can advise that doing courses is not sufficient and does not equate to specialist training . 

look for sustainability look for sustainability this needs to be built for the training program , for job prospects and for career development .
realism is required in recognizing the limitations of local resources . at the same time , it is certain that the supply of trained emergency physicians will increase the demand for them . 
 prioritize the direction of effort . prioritize the direction of effort .
resources are always limited , so the most effective use must be made of them .
for example , effort put into training more trainers will have a greater long - term impact than effort put into providing service . 

some can be overcome alone , some need help to overcome , some need others to overcome for you , some can be circumnavigated , some can be waited out , while others - a few - are insurmountable and one simply has to go back to base camp and take an entirely different route .
our aim should be to ensure that most people worldwide have access to basic acute care .
it requires commitment and faith to develop a capacity to do this , but something can be created from nothing when the cause is right , which it is , and the pioneers have the will .
there can be long periods of apparent stagnation or impasse . then there can be sudden movements
; revolutions can happen , and one has to be ready to take advantage of them .
but mainly progress is made by a series of small increments , a multitude of small steps , so one has to be prepared for a long campaign .
keep in mind - it has already been demonstrated in several countries - the emergency medicine journey is worthy .
 aimsa rapidly increasing number of countries are developing their capacities to respond to acute illness and injury and organizing emergency medicine training programs . 
 this article offers some insight into the way emergency medicine has undergone development in the australasian region.methodsthe perspective is built from experience in australia , new zealand and papua new guinea.conclusionthe challenges are many , but with persistence can be surmounted . 
 lessons derived from these diverse environments are presented . 
Introduction
Beginnings
Australia
New Zealand
Papua New Guinea
Capacity building
Primary trauma care
Snakebite management
Diploma of emergency medicine
Emergency life support
Lessons
Conclusion