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Emergencies are as old as humanity. Specialised emergency care is relatively new. Emergency medicine in well resourced parts of the world has become increasingly complex, coordinated, and slick. Expectations of good practice from the public and from inpatient hospital colleagues are high. Experienced and specialised nursing and medical staff run excellent services with high patient turnover. Professional organisations representing emergency medicine make recommendations to government about staffing, training requirements, and back up services.

But what of the universal picture? In most resource poor areas of the world it is very different. There are no prehospital general practice services and no regular ambulance services. Health centres provide primary care. These are staffed by one “clinical officer” (a paramedic trained in diagnosis and treatment) and one or two nurses who have available a few basic drugs. Self referred and health centre referred patients attend district or central hospitals. In these hospitals trauma cases are seen in a side room (called “casualty”) of the outpatients department. A clinical officer (CO) or medical assistant (MA) attends. Nominal supervision is given by the district medical officer, or in central hospitals by the orthopaedic or general surgical department. All other (medical) emergencies line up to see a CO or MA in outpatients. The queues are long and the staff are few. Laboratory investigations are minimal (perhaps a peripheral blood film for malaria parasites, a haemoglobin concentration, urine and stool microscopy). The World Health Organisation reports that the …