Dear Editor,

Every country has its own unique program for development of emergency medicine (EM) and Pakistan is not an exception. The authors completed 5 years EM residency training in a private tertiary hospital of Pakistan which was the first of its type. Among so many challenges, the present researchers derived some lessons from a host of diverse circumstances. During residency, we found Western trained emergency physicians conducting workshops and seminars in Pakistan for capacity building. We appreciated their efforts; however, it highlighted certain thoughts to our purpose. First, the treatment protocols taught in university were tried and tested in their specific settings and one could argue on their generalizability. Secondly, the local EM graduates felt necessity to come to teaching, mentorship, and leadership roles through gaining advanced experiences.  In addition to reinventing the wheel entirely, developing countries such as Pakistan with their existing emergency medicine training programs extracted what might have been useful for them in their own relevant context.

The Primary Trauma Care course was one of the examples of locally developed courses introduced by a team of surgeons and emergency physicians. There are a number of local instructors to run courses independently. Heat wave management, resuscitation, trauma, snakebite management, and infectious diseases management were the most commonly offered courses by these physicians. These courses have been led by local emergency physicians and are now being disseminated widely in Pakistan. The newest contribution to capacity building which was a postgraduate diploma course in emergency medicine for EM providers was established in one of the local private hospitals. Many courses and workshops were further developed in respect to particular circumstances and conditions of Pakistan.

Complex issues arise when a new training program is introduced. This happened to EM residency programs too; however, most physicians worked to do their best. With EM as a novel specialty, the College of Physicians and Surgeons established the first specialty exams for emergency medicine in Pakistan. At our private tertiary hospital, the EM residency was about 5 years as well as it was recognized by the College of Physicians and Surgeons of Pakistan. Various subjects were covered as core curriculum including the provision of emergency care, teaching and research, pre-hospital medicine, disaster medicine, resuscitation and trauma, toxicology, environmental science, and hospital administration. Trainees were required to work with a team, have a breadth of knowledge, have effective communication skills, be flexible in terms of working hours, and function well under extreme pressure.

It was with the emergence of first doctors claiming specialty status by training and examination. Also it was a recognition by colleagues in other specialties and Western trained EM physicians. From their efforts, an evidence demonstrated that emergency medicine deserved to be fully recognized by the several layers of medical governance as well as by the national body in Pakistan. Recent history showed the recognition of Emergency Medicine as an entity has greatly benefitted healthcare dynamics.

It was only when it became beyond argument that local EM physicians were functioning as specialists, and were being recognized by peers and hospitals as specialists; however after multiple attempts EM was recognized by national authorities. Building emergency medicine involved many uncertainties and we would be getting started as champions, unions, admin support, bottom up development, top down development, and endurance/energy while taking advantage of local events, local interest, and local appropriateness. The truth is that the way EM is practiced in one country cannot be transferred directly to another country in a cookie cutter fashion. Our population had their own intrinsic challenges such as poverty and lack of education. Patients returned to emergency centers in much later stages due to lack of awareness or resources. Primary health care systems were barely functional; hence, we were dealing with lots of critical patients returning to emergency centers in advanced stages of their diseases.

There were initiatives needed to link EM to local primary care and public health initiatives. Dependence on Western trained EM physicians would be a constraint in development of emergency medicine in the Pakistan. It was important to incorporate junior doctors to be trained as instructors for acute care courses, such as ATLS, ACLS, and APLS. While looking for sustainability, training program, job prospects, and career development seemed necessary.

It requires continued commitment, patience, persistence, and faith to develop the 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. Local champions must find local ways of doing things. 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, since the greatest journeys are made at a time. Keeping in mind - it has already been demonstrated in several countries - the emergency medicine journey is worthy, and the journey for Emergency Medicine in Pakistan has just begun.