R. Rehmani  ( Section of Emergency Medicine, The Aga Khan University, Karachi. )

The specialty of Emergency Medicine (EM) embodies the belief by those who have chosen it as a career that "quality emergency care is a fundamental right and should be available to all who seek it."1
EM is a relatively new specialty, which has evolved just over the last quarter of a century. The American College of Surgeons was among the first groups of physicians to recognize the need for organized emergency services. In 1970, the first EM residency was started and in 1979 the American Board of Medical Specialties recognized EM as medicine's newest specialty.2 In the United Kingdom, the equivalent specialty of accident and emergency (A&E) medicine is currently in a phase of rapid development. Following the inception of Faculty of A&E Medicine in 1993 and the introduction of Calman proposals, specialist registrar training in A&E is also developing rapidly.3
EM is the medical specialty with the principal mission of evaluating, managing, treating, and preventing unexpected illness and injury. Anyone may unexpectedly require medical care at any time. Emergency medical care must therefore be available 24 hours a day as an essential component of a health care delivery system.
The specialty of EM is practiced in a variety of hospital and non-hospital settings. Emergency physicians are first contact providers. They care for a patient population undifferentiated by age or disease process. They provide rapid treatment and stabilization of true emergencies, as well as rapid differentiation between emergent and non-emergent conditions over the spectrum of disease processes. Their care extends to out-of-hospital assessment, treatment, and transport of patients into emergency facilities by virtue of their management and supervision of emergency medical services.
EM is a specialty of depth and breadth. It addresses a spectrum of clinical and social problems in a fashion and environment quite apart from that of any other medical discipline. EM encompasses many domains, each of which contribute to the body of knowledge and skills, which identify the specialty. They include: provision of clinical emergency care, teaching, research, pre-hospital and disaster medicine, resuscitative medicine, toxicology, environmental medicine, trauma, and administration.
There is a rapidly growing interest in EM throughout the world. This interest in the specialty has many sources. There has been increasing economic development in many countries, which has led to rapid urbanization, increases in deaths from injuries, and increasing outpatient visits to the hospitals. In addition, there is a desire by physicians all over the world to provide the highest quality, or at least most technically advanced level of care.4
Why do countries such as Pakistan need the specialty of EM? In the author's opinion, EM is an extremely important component of any health care system and provides a vital service to the public. In fact, EM is the first specialty to develop directly due to demand by the public. Other specialties are defined by anatomic region, a particular type of disease or by a particular age group of patients. In contrast, EM encompasses all types of medical and surgical problems of all age groups. EM also provides a "safety net" for any national health care system to ensure patient access to needed unscheduled care. Major clinical problems (all of which are common in Pakistan) that are very well managed by EM include the following: trauma, cardio-respiratory illnesses, toxicology, environmental disorders, and mass casualties from disasters.
EM has a number of beneficial effects that increase the efficiency of any national health care system. These include the prompt evaluation of emergencies and the ability to complete diagnostic work-up for patients in a single visit.
EM also provides significant benefits to the general public. These include reassurance and confidence, convenience, and ensured access to care. EM also is important for public education in illness and injury prevention, teaching the public how to correctly utilize the health care system.
There are significant benefits in developing physician residency training programs in EM.2,5 These programs provide a core of specialists to staff the nation's emergency departments. In general, these programs also ensure the quality, depth, and uniformity of training for emergency care. EM also provides significant benefits in training physician residents from other specialties about emergency care. This training gives these other physicians' ability and confidence in managing basic emergencies. It also familiarizes them with emergency department operations and needs and can improve the working relationships they have with EM faculty and residents. This training also allows them to learn cost-effective use of lab tests and radiographic procedures and can facilitate their future appropriate referral of cases to the emergency department. There are significant benefits in requiring training of all medical students in EM. This training ensures their exposure to proper emergency management of common conditions and meets the public expectation that all doctors should know basic emergency care. This training also encourages some students to pursue EM residency training or EM research projects.2,5
EM in Pakistan is a new specialty, and in fact, is not an officially designated specialty.6 The introduction of EM as a specialty in Pakistan will face challenges because primary care takes precedence over critical care. The primary care health approach is emphasized throughout the training of medical students, residents, and by the policy of the Ministry of Health. Furthermore, scarcity of resources is a limiting factor in establishing EM as a legitimate specialty because it requires upgrading of basic infrastructures and adequate training of EM personnel. Lack of trained EM faculty and a professional society to teach and represent the interest of EM among other traditional specialties are other limiting factors, as is inadequate public education as to the importance of EM in Pakistan.
The general recommendations for EM development at the national level, may not be in this sequence, would be to form a cadre of interested physicians, set model clinical Emergency Departments, form a national professional society to coordinate activities at the national level, set training standards and training curricula, organize Residency programs, publish a national specialty journal and other educational communications, establish a specialty examination, and finally declare EM an officially recognized specialty.
Despite obstacles, there is a potential for the development of EM. It is hoped that this relatively new specialty will meet the challenges and will grow with time.

1. Definition of emergency medicine:American College of Emergency Physicians.Ann Emerg Med 1994;24:553-4.
2. Schneider SM, Hamilton GC, Moyer P, et al. Definition of emergency medicine. Acad Emerg Med 1998;5:348-51.
3. Wyatt JP, Weber JE. A transatlantic comparison of training in emergency medicine. J Accid Emerg Med 1998;15:175- 80.
4. Kirsch TD. Emergency medicine around the world. Ann Emerg Med 1998;32:237-8.
5. Kellermann AL. Clinical emergency medicine, today and tomorrow. Ann Emerg Med 1995;25:235- 8.
6. Raftery KA. Emergency medicine in Southern Pakistan. Ann Emerg Med 1996;27:79-83.