Introduction
The Emergency Medical Team (EMT) Initiative began as a restructuring that the World Health Organization (WHO; Geneva, Switzerland) had developed in 2003. 1 The Foreign Medical Team (FMT) and Foreign Field Hospitals Guidelines delineated the basic procedures to be followed by personnel and teams, as well as the critical points to consider before deploying a field hospital. The emergency response to the Haiti earthquake in 2010 involved the deployment of as many as 390 international FMTs. Afterwards, there were reports of “ill adapted care, unnecessary procedures (ie, amputations), lack of coordination, transparency, accountability, cultural and language insensitivity, inadequate preparedness, and oversight of deployed workers….” 2 - Reference Johnson, Idzerda and Baras 7 The analysis of the health response to the 2010 Haiti earthquake by the United Nation’s Inter-Agency Standing Committee (IASC; Geneva, Switzerland; New York USA) and the WHO’s Global Health Cluster recommended the need for adopting principles, criteria, and standards for response by FMTs in emergencies and disasters in line with global efforts to improve humanitarian standards and procedures. A meeting in Havana, Cuba in December 2010 led by the WHO and the Global Health Cluster 8 engaged many key stakeholders and paved the way for FMT reform, the establishment of the EMT initiative, and the development of the current EMT Initiative Guidelines, known as the “Blue Book,” published in 2013.Reference Norton, von Schreeb and Aitken 9
The Blue Book outlined capacities, services, and minimum deployment standards for EMTs.Reference Norton, von Schreeb and Aitken 9 During the first global EMT Initiative meeting held in Panama in December 2015, 10 the use of the term “Foreign” was considered outmoded and inappropriate for ongoing use, recognizing that local national teams are the ones consistently bearing the brunt of disaster response, requiring the most recognition and support. The Initiative became formally recognized as the “Emergency Medical Teams Initiative” and national and international EMTs were abbreviated N-EMT and I-EMTs, respectively. Both types of EMTs were defined as groups of health professionals (ie, doctors, nurses, paramedics, and logisticians) that treat patients affected by an emergency or disaster in the acute phase. They come from governments (civilian and military teams), nongovernmental organizations, and international organizations. These teams work to comply with the global classification and minimum standards set by the Pan American Health Organization (PAHO; Washington, DC USA)/WHO and come trained and self-sufficient. All EMTs should be self-sufficient for shelter, food, water, sanitation, and all equipment and supplies for the initial phase of response. Additionally, emphasis was placed on regionally-based, acute phase disaster response; that is, teams within a designated WHO region should preferentially support the response that occurs in their own region. For the purposes of the EMT Initiative, the three defined WHO regions are: the Americas, Asia-Pacific, and Europe-Africa-Middle East.
The Americas represent 47 countries with over 1.5 billion people and is where more than one-third of the global natural disasters occur. The PAHO has been working with regional governments to develop and establish coordination mechanisms, learning portals, and classification of EMTs. Today, all PAHO region countries, except for Canada and the United States, have endorsed a disaster response coordination structure with PAHO and have ratified the following:
1. The 154th session of the Executive Committee in June 2014, Washington, DC USA: CE 154.re11 plan of action for the coordination of humanitarian assistance; 11 and
2. The 53rd directing council 66th session of the Regional Committee for the WHO for the Americas, October 2014, CD 53/12. 12
The PAHO established a national-international structure and successfully coordinated the recent EMT deployments and responses to the Ecuador earthquake (2016), the Costa Rican and Haitian hurricanes (2016), the Peruvian floods (2017), and the Colombian landslides (2015).
Following the Global EMT Initiative Meeting in Hong Kong in October 2016, an EMT Training Working Group was established. Education and training are recognized as essential components to accomplish the goals of the EMT Initiative. 13 The purpose of the Training Working Group is to help guide education, training standards, and curriculum development for EMTs, as well as compile and develop training tools and materials to allow effective and operational EMT training. The Working Group will provide technical advice based on their own knowledge and expertise, and follow an evidenced-based approach, as well as coordinate inputs from EMT stakeholders and other partners to help generate consensus and deliver implementable outputs for training. An operational framework to ensure that individuals and teams are properly trained and prepared includes the following steps:
1. Ensure professional competence and license to practice of individuals;
2. Support adaptation of technical and nontechnical professional capacities into the low-resource and emergency context; and
3. Prepare for an effective team performance in the field.
A combination of training methodologies is recommended, including individual theory-based education, intensive simulation, and team training. The EMT Training Working Group met for the first time in Geneva in April 2016 to decide on the Group’s scope of work and to discuss training and competencies requisite for EMTs.
Some of the authors of this special report attended the meeting in Hong Kong and either are part of the WHO-EMT Training Working Group or had close collaboration with its members for the purposes of the pre-World Association of Disaster and Emergency Medicine (WADEM; Madison, Wisconsin USA) Congress EMT Training Workshop, presented here. Members of the WHO-EMT Training Working Group confirmed that information on EMT training and competencies would be useful for their purposes. A preliminary survey, designed to capture some of this information from meeting attendees and other stakeholders, was disseminated prior to the WADEM Congress in Toronto, Canada in April 2017. The survey’s main purpose was to springboard discussion during the WADEM pre-Congress workshop regarding the future needs and directions of EMT training (Appendix A; available online only).
Key Issues from the Pre-Congress Workshop on EMT Training
The pre-Congress workshop was convened because it is recognized that the WADEM Congress brings together a large and diverse group of high-level disaster and emergency medical professionals. Furthermore, the Congress location of Toronto, Canada presented a unique opportunity to bring PAHO region EMTs together to discuss EMT training. The purpose of the workshop was to examine EMT training competencies and curriculum in order to inform the WHO-EMT Training Working Group, and also to establish a working group for EMT training in the Americas.
Workshop attendees hailed from North America, Europe, Australia, South America, and Asia. The organizations represented included national, international, governmental, nongovernmental, and academic institutions. A full list can be found in Appendix B (available online only). The pre-Congress workshop began with an update of the EMT Initiative in the Americas (PAHO) and was followed by an update from the WHO Technical Working Group for EMT Training, as their inaugural meeting was held the week prior in Geneva. A summary of the EMT training survey targeted to workshop attendees was presented in addition to current EMT training initiatives from representatives in the Americas, Europe, and Asia.
Throughout the workshop, several recurrent training themes were highlighted. The ability to adapt one’s professional skills to a low-resource setting was repeatedly identified as a critical EMT training competency. This echoes the findings of Camacho, et alReference Amat Camacho, Hughes and Burkle 4 that professional competence and license to practice in one’s home country are not sufficient for deployment, and that members must also be able to adapt their own professional skills to the affected country’s environment. As such, context-specific clinical skills, such as triage in a resource-limited setting, logistics, and cultural awareness are essential and warrant a larger role in future EMT training curriculums. Amongst the workshop attendees, adaptation of training to in-field context should be a priority, but this is often not the case in existing EMT training programs.
Part of context-specific training involves being well-prepared to serve the needs of the affected population. Given that one-quarter of the world’s population is under the age of 14, workshop attendees stressed the importance of increased pediatric-specific content in EMT curriculums. 14 This is especially relevant given that children are particularly vulnerable in disaster scenarios. For example, they are at a critical period of development when toxic and traumatic exposures can have long-term, disastrous effects on their health. They may also lack the developmental ability and danger comprehension to flee hazards. In addition, children depend on others for shelter and food. 15 Another recurrent theme was the importance of training together as a multi-disciplinary EMT prior to deployment. The workshop attendees repeatedly emphasized that team training proves crucial to ensuring an effective team response when deployed. Workshop attendees agreed that communication, coordination with local authorities, and team building were some of the most important competencies.
The pre-Congress workshop also discussed the importance of simulation as an effective tool to deliver training and to evaluate competency acquisition. This proves consistent with Eyck and Raymond’s findings that high-fidelity simulation is an effective teaching tool for clinical skills that improves student satisfaction, test performance, and most importantly, clinical performance.Reference Eyck and Raymond 16 Despite these benefits, however, workshop attendees revealed that simulation is currently under-utilized in EMT training curriculums and highlighted this as a critical area for improvement. One of the identified drawbacks of running regular simulation trainings was the financial cost. Collaborating with other EMTs to conduct joint simulation trainings was one solution put forth by the workshop attendees.
A recent literature review on the characteristics of EMTs demonstrates the importance of team training using simulation.Reference Oldenburger, Baumann and Banfield 17 As EMTs are working in highly stressful environments, within different contexts, and even alongside different EMTs. Therefore, team training in simulated settings that offer similar contexts to what might be expected in a real deployment is essential. It is not enough to be a competent health worker in one’s own environment; EMT members must be able to adapt their professional skills (eg, surgical skills) to resource-limited, emergency contexts while focusing on the essential health needs and priorities.
Previous professional expertise and the completion of emergency and low-resource adapted individual courses provide the basis for good practice in the field, but do not ensure the successful performance of a team deployed into a disaster. All EMT members deploying as part of a multi-disciplinary team integrated within an EMT-deploying organization need to be prepared for specific aspects of their deployment, including main protocols, communication pathways, security guidelines, teamwork dynamics, basic aspects of personal health and travel, and other subjects related to deployment working and living conditions.
Finally, at the meeting in Toronto, representatives from PAHO discussed the need to establish a working group for EMT training in the Americas, which should address the key components for an operational learning framework for EMTs, as well as the recommended agreed upon curriculum content for the three-step training approach. Input should be included from government, nongovernment, academic, and private key stakeholders.
Taken together, the proceedings from the pre-Congress workshop demonstrate that organizational, managerial, and interpersonal medical skills prove invaluable to EMT training. Specifically, adapting professional skills to low-resource settings and training as a team are essential. Indeed, the art of medicine has long been recognized as fundamental: “The practice of medicine is an art, not a trade; a calling, not a business” (Dr. William Osler).
Limitations
This group has identified several relevant limitations to the current report. The recurrent themes and recommendations of the pre-Congress workshop were not measured in an objective fashion and with standardized criteria. Rather, conclusions and recommendations from the attendees were ascertained by the authors of this paper after having collected and discussed them in small groups with the workshop attendees, and again at the end of the workshop as a whole group. As such, not all workshop attendees may have agreed with every statement in this report. The authors may also have missed reporting some valid recommendations if there was no perceived consensus among attendees. Moreover, the limitations of the survey in Appendix A includes the low response rate that may leave the survey results susceptible to nonresponse bias. For example, there may be distinct differences between those that respond to an EMT training survey, such as the fact that those with higher levels of training may feasibly be more likely to respond. Despite this limitation, the results of the survey support the discussion of experts at the pre-WADEM Congress and give a basic understanding of current training initiatives, gaps in training, and perceived priorities for EMT training initiatives. This type of information is not currently available in the literature. Lastly, it should be noted that the authors did not seek approval by an independent ethics committee prior to distribution of the survey.
Conclusion
Training for individual members of EMTs and EMT training is essential to accomplish the goals of the EMT Initiative. Today, training is essential for teams to be verified by the EMT secretariat in Geneva, and EMTs that are not verified will soon not be able to deploy. The future of the EMT Initiative will likely see the standardization of curriculum and the recognition or accreditation of selected training programs which lead to different levels of certification or recognition of competency. The outputs of this pre-Congress workshop provide an important initial contribution to the EMT Training Working Group, as this group works on mapping training, competencies, and curriculum. This special report highlights certain important themes with respect to future EMT training. Namely, pre-Congress workshop attendees revealed that effective EMT training should include instruction on adapting one’s professional skills to the low-resource setting, training as a multi-disciplinary EMT prior to deployment, and a further role for pediatric medicine. Moreover, it was felt that simulation activities could be beneficial to both training and in competency assessment.
Supplementary Material
To view supplementary material for this article, please visit https://doi.org/10.1017/S1049023X18000262
