Background and the Emergency Healthcare System
Brazil is a country of amazing complexity and beauty. With an area of 8,547,403.5 km2, it is the world's fifth largest country geographically and is the fifth most populous country, estimated at close to 170 million people today. It is neighbor to all of the countries in South America except Ecuador and Chile and has an extensive eastern sea border along the Atlantic Ocean. The country can be divided into five main regions - north, northeast, southeast, south and west central - each with its individual climatic, economic and cultural characteristics. Brazil's major cities are São Paulo, Rio de Janeiro, Brasília, Belo Horizonte, Recife, Curitiba and Porto Alegre. Modern and extensive highways cover the entire country. Racially, Brazilians have three main backgrounds: Natives, Europeans (mostly Portuguese and later immigrants from other European countries) and Africans (brought during the Trans-Atlantic Slave Trade). Due to its recently developed and expanded industrial sector, Brazil is now rated as the world's tenth largest economy at market exchange rates and the ninth largest in purchasing power. In 2003, the government identified the primary burdens of disease as infant mortality, maternal mortality, chronic disease (particularly cardiovascular disease and cancer) and injury due to road traffic accidents, violence and suicide. Brazil has a national healthcare plan called "SUS" (Sistema Único de Saúde) which provides care to the majority of the country's citizens. There are also private insurance carriers available to the more socioeconomically privileged population.
The Emergency Healthcare System
Emergency medicine (EM) is not a new field in Brazil. In 2002, the Ministry of Health outlined a document, the "Portaria 2048," which called upon the entire healthcare system to improve emergency care in order to address the increasing number of victims of road traffic accidents and violence, as well as the overcrowding of emergency departments (EDs) resulting from an overwhelmed primary care infrastructure. The document delineates standards of care for staffing, equipment, medications and services appropriate for both pre-hospital and in-hospital. It further explicitly describes the areas of knowledge that an emergency provider should master in order to adequately provide care. However, these recommendations have no enforcement mechanism and, as a result, emergency services in Brazil still lack a consistent standard of care.
Pre-hospital emergency medical services use a combination of basic ambulances staffed by technicians and advanced units with physicians on-board. No universal phone number exists for emergency calls, and the dispatch center physician determines whether the call merits an emergency transport or not. Pre-hospital physicians have variable training in emergency care, with training backgrounds ranging from internal medicine to obstetrics to surgery.
Similar to the early years of EM in the United States, emergency department physicians in Brazil come from different specialty backgrounds, many of them having taken the job as a form of supplementary income or as a result of unsuccessful private clinical practice. Since 50% of medical school graduates in Brazil do not get residency positions, these new physicians with minimal clinical training look for work in emergency departments. In larger tertiary hospitals, the ED is divided into the main specialty areas – internal medicine, surgery, psychiatry, pediatrics – and staffed by the corresponding physicians. Still, significant delays in care can occur when patients are inappropriately triaged or when communication between the areas is inadequate. In the non-tertiary care centers, which make up the majority of hospitals in the country, emergency department physicians are largely under-trained, underpaid and overstressed by their working conditions. This has compromised patient care and created an incredible need for improvement in the emergency care system.
American Academy of Emergency Medicine. 2008;15(6):9,11 © 2008 American Academy of Emergency Medicine
Cite this: Emergency Medicine in Brazil - Medscape - Nov 01, 2008.