Since becoming recognised as a specialty in 2015, emergency medicine is now exploding in Brazil with over 20 programs now available throughout the country.

Soon after Dr Nicole Pinheiro began her residency she realised how incredible the global EM community was, being open to sharing knowledge and experience and assisting each other whenever possible. Nicole recognised the enormous benefit networking played in advancing EM globally and in her own country and early on in her residency began actively networking, meeting emergency medicine physicians from around the world, investigating programs and before graduating took an elective in Stony Brook University Hospital.

Nicole graduated in April this year and currently works in Fortaleza at three hospitals treating critical patients as well as playing an active role in education and teaching residents. Nicole is one of the first Brazilian instructors of The Difficult Airway Course and travels throughout the country teaching the course and speaking at conferences.

Nicole is passionate about building a career in emergency medicine education and international medicine and in advancing the specialty of emergency medicine in Brazil.

What are the main emergency medicine challenges you face in Brazil?

As a new speciality one of our main challenges is ensuring people know we exist, what the speciality of emergency medicine provides and the difference we bring to the table. We have a FOAMed community growing in Brazil and we’re trying to use that and social media to spread our message. Another challenge we face is resource distribution and inequality in healthcare. We theoretically have universal healthcare coverage, but in reality what we have is a lot of public hospitals with a high number of critical patients who lack medications, supplies, ventilations and other critical resources. On the other side we have big private hospitals in the city with lots of resources but not many critical patients. We have a lot of work to do to ensure quality care is available for everyone. A third challenge is ensuring the hospitals have a sustainable work environment and employment conditions to attract emergency medicine physicians and ensure the support is there for a lifelong career in EM.

What has been your greatest emergency medicine achievement?

Since the recognition of emergency medicine in 2015 one of the greatest achievements has been the ability to bring people together, to communicate and collaborate with physicians across the country. Since 2015 we have built a fantastic network of residents and physicians. Building that network is building the foundation of what the speciality can become. Everything goes back to that network. It’s how you encourage the speciality to grow and to know that we can make a difference, not only for that patient in front of us but to the system as a whole. If you don’t work to build the system you will burn out and not see a lot of change. Being a part of The Difficult Airway Course is a great example of this as I teach it with colleagues from other parts of Brazil that I wouldn’t know if it wasn’t through networking.

What are you hoping to achieve over the next few years?

What is interesting is that most countries you speak to no matter what stage they’re at, in the beginning of EM the challenges are very similar. One way to speed up the development of EM is collaboration with other countries – countries with highly developed EM, but also countries at similar stages with similar resources who can often provide more relevant ideas and solutions to your current challenges. As the only country in South America that speaks Portuguese we often look to countries like the USA or Australia that have had EM for decades. But over the next few years I’d like to see Brazil get better at collaborating and working with our neighbouring Latin American countries. Improving healthcare quality and patient care, and improving working conditions for physicians would be a dream come true.

Why did you become an emergency medicine physician?

When I graduated I didn’t know what to do and I didn’t know emergency medicine existed. I liked everything – internal medicine, surgery, gynaecology, obstetrics, paediatrics. Every time I thought about narrowing to one of those specialties, I was sorry because I wouldn’t be using those other specialities that I studied all those years. To try and decide what to do I went to work in a tiny town in the north east in one of the poorest regions in the country. It was terrifying starting a job in an emergency department where I felt I didn’t have any of the skills or experience needed. I couldn’t intubate, I had no experience working in trauma. I was told “Don’t worry, it’s a tiny city, nothing is going to happen, you’re just going to sleep most of the time”. This couldn’t have been further from the truth! After realising this I started doing every life support course I possibly could and eventually started enjoying it rather than being afraid. I realised that you need such a broad range of knowledge, and maybe this is what I had been looking for. In one of the life support courses someone told me there was a emergency medicine program. I googled the course and realised that it had everything I had been looking for, that being an emergency medicine physician is what I wanted to be. I felt that finally I’m home, finally I know what I want to dedicate my life to.

What is the best thing about being an emergency medicine physician?

In the beginning we do it because we want to save lives. Its great to see the impact you have on someone else’s life. The boat is going south, how can you turn it around and change a person’s life. We begin because that’s what we want. As I studied more I began to find joy in the little things – it’s not necessarily the critical patient – it’s not all the crazy stuff – but it’s that patient where something seems a bit suspicious and because you made a call to investigate further and you didn’t let them go home you avoided them having a cardiac arrest and heart failure for the rest of their life. In the end, it’s the impact you can have on that patient in front of you. You don’t get to choose because they don’t fit into your speciality. Every patient is your problem. No matter who appears in front of you, a good person, a thief, black, white, poor, wealthy, they all deserve to be treated equally and to receive the best care possible.

What is the best way IFEM can assist the advancement of global emergency medicine?

Assisting with networking. We need to build better connections with other countries. We have different realities within Brazil. Some places are strong in critical care, some in trauma, others in paediatrics. Networking and helping us build through inequalities throughout the country. Training would also be valuable in areas that we currently struggle with – ophthalmology, orthopaedics. Providing opportunities to exchange knowledge through physicians visiting other countries, or physicians visiting Brazil. Connecting similar countries to share similar experiences and solutions that are relevant will strengthen EM globally.