Emergency medicine

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Emergency department entrance at the Toronto General Hospital

Emergency medicine is a medical specialty in which a physician receives practical training to care for patients with acute illnesses or injuries which require immediate medical attention. While not usually providing long-term or continuing care, emergency medicine physicians diagnose a variety of illnesses and undertake acute interventions to stabilize the patient. Emergency medicine physicians practice in hospital emergency departments, in pre-hospital settings via emergency medical services, other locations where initial medical treatment of illness takes place, and recently the intensive-care unit. Just as clinicians operate by immediacy rules under large emergency systems, emergency practitioners aim to diagnose emergent conditions and stabilize the patient for definitive care.

Physicians specializing in emergency medicine in the US can enter fellowships to receive credentials in subspecialties. These are palliative medicine, medical toxicology, pediatric emergency medicine, sports medicine, and undersea and hyperbaric medicine.

Scope

Main articles: List of emergency medicine topics and List of medical emergencies

Emergency medicine has evolved to treat conditions that pose a threat to life, limb, or have a significant risk of morbidity. In the words of the International Federation for Emergency Medicine:

"Emergency medicine is a medical specialty—a field of practice based on the knowledge and skills required for the prevention, diagnosis and management of acute and urgent aspects of illness and injury affecting patients of all age groups with a full spectrum of undifferentiated physical and behavioral disorders. It further encompasses an understanding of the development of pre-hospital and in-hospital emergency medical systems and the skills necessary for this development."

Emergency Medicine encompasses a large amount of general medicine and surgery including the surgical sub-specialties. Emergency physicians are tasked with seeing a large number of patients, treating their illnesses and arranging for disposition—either admitting them to the hospital or releasing them after treatment as necessary. The emergency physician requires a broad field of knowledge and advanced procedural skills often including surgical procedures, trauma resuscitation, advanced cardiac life support and advanced airway management. Emergency physicians must have the skills of many specialists—the ability to resuscitate a patient (Critical Care Medicine), manage a difficult airway (Anesthesia), suture a complex laceration (Plastic Surgery), reduce (set) a fractured bone or dislocated joint (Orthopedic surgery), treat a heart attack (Cardiology), work-up a pregnant patient with vaginal bleeding (Obstetrics and Gynecology), stop a bad nosebleed (ENT), place a chest tube (Cardiothoracic Surgery), and to conduct and interpret ultrasounds (Radiology).

History

During the French Revolution, after seeing the speed with which the carriages of the French flying artillery maneuvered across the battlefields, French military surgeon Dominique Jean Larrey applied the idea of ambulances, or "flying carriages", for rapid transport of wounded soldiers to a central place where medical care was more accessible and effective. Larrey manned ambulances with trained crews of drivers, corpsmen and litter-bearers and had them bring the wounded to centralized field hospitals, effectively creating a forerunner of the modern MASH units. Dominique Jean Larrey is sometimes called the father of emergency medicine for his strategies during the French wars.

Emergency medicine (EM) as a medical specialty is relatively young. Prior to the 1960s and 70s, hospital emergency departments were generally staffed by physicians on staff at the hospital on a rotating basis, among them general surgeons, internists, psychiatrists, and dermatologists. Physicians in training (interns and residents), foreign medical graduates and sometimes nurses also staffed the Emergency Department (ED). EM was born as a specialty in order to fill the time commitment required by physicians on staff to work in the increasingly chaotic emergency departments (EDs) of the time. During this period, groups of physicians began to emerge who had left their respective practices in order to devote their work completely to the ED. The first of such groups was headed by Dr. James DeWitt Mills who, along with four associate physicians; Dr. Chalmers A. Loughridge, Dr. William Weaver, Dr. John McDade, and Dr. Steven Bednar at Alexandria Hospital, VA established 24/7 year round emergency care which became known as the "Alexandria Plan". Soon, the problem of the "ER", propagated by published reports and media coverage of the poor state of affairs for emergency medical care had culminated with the establishment of the first emergency medicine training program at Cincinnati General Hospital, with Bruce Janiak, M.D. being the first emergency medicine resident in 1970. During the 1970s, several other residency programs developed throughout the country. At this time, EM was not yet a recognized specialty and hence had no primary board certification exam. It was not until the establishment of American College of Emergency Physicians (ACEP), the recognition of emergency medicine training programs by the AMA and the AOA, and in 1979 a historical vote by the American Board of Medical Specialties that EM became a recognized medical specialty.

Development of emergency medicine as a specialty in the UK

Emergency medicine traces its development as a specialty in UK to 1952 when Mr Maurice Ellis was appointed as the first consultant in Emergency Medicine in the UK at Leeds General Infirmary. In 1967 the Casualty Surgeons Association was established with Maurice Ellis as its first President. The name of the Association was changed twice, in 1990, to the British Association for Accident and Emergency Medicine, and later on in 2004, to British Association for Emergency Medicine (BAEM). In 1993, Intercollegiate Faculty of Accident and Emergency Medicine (FAEM) was formed at the Royal College of Surgeons of England, London. In 2005, the BAEM and the FAEM were merged to form College of Emergency Medicine (CEM). The College of Emergency Medicine is the single authoritative body for emergency medicine in the UK. It conducts its fellowship and membership exams, publishes guidelines and standards for the practise of emergency medicine, and has its own journal, called the Emergency Medicine Journal (EMJ).

Organizations around the world

Australia and New Zealand

In Australia and New Zealand, advanced training in Emergency Medicine is overseen by the Australasian College for Emergency Medicine (ACEM).

India

In India, many private hospitals and institutes have been providing emergency medicine training for doctors, nurses & paramedics since 1994. The certification programs varied from 6 months to 3 years. Emergency medicine was recognized as a separate specialty by Medical Council of India (MCI) only from July 2009. After this many medical colleges are about to start postgraduate training i.e. MD in Emergency Medicine. It will be at least a few years until the specialty gets streamlined in India..

Canada

In Canada, there are two routes to certification in emergency medicine. The vast majority of full-time practicing ER physicians in Canada are certified via one of these routes. Most busy urban, sub-urban and larger rural hospitals are staffed primarily by full time, certified career emergency physicians. Smaller rural and community hospitals may still be staffed by family physicians who work in the emergency department on a part-time rotating basis. Basic experience in emergency medicine is a core component of family medicine training in Canada. The general trend in Canadian emergency departments over the last decade has been the gradual replacement of part-time, non-certified physicians (mostly family physicians) by full-time certified emergency physicians. This trend was first noted in larger academic centers but has gradually evolved to include most busy emergency departments.

The two routes to ER certification can be summarized as follows:

Route 1: A five year residency leading to the designation of FRCP(EM) through the Royal College of Physicians and Surgeons of Canada. Route 2: A 3 year residency leading to the designation of CCFP(EM) through the College of Family Physicians of Canada.

CCFP(EM) ER physicians outnumber FRCP(EM) physicians by about 3 to 1, and tend to work primarily as clinicians with a smaller focus on academic activities such as teaching and research. FRCP(EM) ER physicians tend to congregate in academic centers and tend to have more academically oriented careers, which emphasize administration, research and teaching. Furthermore the length of the FRCP(EM) residency allows more time for formal training in these areas.

As a consequence of the above, most Canadian medical students who wish to pursue an academic emergency medicine career, and/or work primarily in a major academic center, choose the FRCP route of certification. Conversely, those who wish to function primarily as clinical ER physicians choose the CCFP route of certification.

Although many in the Emergency Medicine community in Canada feel that a unified training process would be beneficial to the current 2 stream schism, this has yet to happen for a variety of complex reasons.

United Kingdom and Ireland

In the United Kingdom and Ireland, the College of Emergency Medicine sets the examinations that trainees in Emergency Medicine take in order to become consultants (fully-trained emergency physicians).

United States

In the United States, there are many member organizations for emergency clinicians:

• The American College of Emergency Physicians (ACEP) is the oldest and largest professional organization. Originally founded in 1968, it now has over 25,000 members, although many are not board certified.
• The American College of Osteopathic Emergency Physicians (ACOEP) was founded in 1975 and is open only to D.O. emergency physicians.
• The Association of Emergency Physicians (AEP) offers membership to any practicing emergency physician regardless of training.
• The American Academy of Emergency Medicine (AAEM) restricts its membership to board certified specialists in emergency medicine, and as of 2009 has over 6000 members. It promotes the independence of emergency physicians and seeks to limit the interference of corporations and other outside groups in the doctor-patient relationship.
• The Emergency Department Practice Management Association (EDPMA) is a trade association that offers membership to physician groups and staffing companies, billing companies, and emergency department supporting organizations.

In the United States and Canada, there are three traditional ways to become board certified in emergency medicine:

• The American Board of Emergency Medicine (ABEM) is primarily for MD's, and is under the authority of the American Board of Medical Specialties.
• The American Osteopathic Board of Emergency Medicine (AOBEM) certifies only emergency physicians with a D.O. degree. It is under the authority of the American Osteopathic Association.
• The Royal College of Physicians and Surgeons of Canada.

There is now an alternative route for those physicians who are either unable or unwilling to take the ABEM, AOBEM, or RCPSC exams, which is the Board of Certification in Emergency Medicine (BCEM). The BCEM is the newest certifying body in emergency medicine, and since 1988 the only organization in the United States that will grant board certification in emergency medicine to a physician who has not completed an emergency medicine residency (but did complete another residency, such as one of the primary care residencies). Many of the Legacy physicians that practice Emergency Medicine in the United States are certified by the BCEM. It is under the authority of the American Board of Physician Specialists/American Association of Physician Specialists.

Education

Canada

In Canada there are a few different ways to become certified as an emergency physician. For all methods one has to first complete a medical degree. The next most common step is to complete two years of family medicine residency offered by the College of Family Physicians Canada (CFPC) followed by a further one year residency in emergency medicine. There is also a 5 year residency offer by the Royal College of Physicians and Surgeons of Canada that may be completed instead of the above. The CFPC also allows those who have worked a minimum of 4 years at a minimum of 400 hours per year in emergency medicine to challenge the examination of special competence in emergency medicine and thus become specialized.

United States

Emergency medicine is a moderately competitive specialty for medical graduates to enter, ranking 7 of 16 specialties in terms of percentage of U.S. graduates whose applications are successful. However, over 90% of applicants from U.S. medical schools to U.S. Emergency Medicine residencies are successful. Emergency medicine residencies can be three or four years in length, depending on the training institution. In addition to the didactic exposure, much of an emergency medicine residency involves rotating through other specialties. By the end of their training, emergency physicians are expected to handle a vast field of medical, surgical, and psychiatric emergencies, and are considered specialists in the stabilization and treatment of emergent condition.

A number of fellowships are available for emergency medicine graduates including prehospital medicine (emergency medical services), research, hyperbaric medicine, sports medicine, ultrasound, pediatric emergency medicine, and Critical Care Medicine.

United Kingdom

Emergency medical trainees enter specialty training after five years of medical school and two years of foundation training.

During the two year core training programme (Acute Care Common Stem), doctors complete training in anaesthesia, acute medicine, intensive care, and emergency medicine. In the third year the trainee learns about emergency medicine (paediatric focus) and musculo-skeletal emergency medicine. They must also pass the Membership of the College of Emergency Medicine (MCEM) examination. Trainees will then go onto Higher Training, lasting a further 3 years. Before the end of higher training, the final examination—the Fellowship of the College of Emergency Medicine (FCEM) must be passed. Upon completion of training the doctor will be eligible for entry on the GMC Specialist Register and allowed to apply for a post as a Consultant in Emergency Medicine.

Emergency Medicine training in the UK is emerging. Historically emergency specialists were drawn from anaesthesia, medicine and surgery. Many established EM consultants were surgically trained; some hold the Fellowship of Royal College of Surgeons of Edinburgh in Accident and Emergency—FRCSEd(A&E). Some of these consultants will be referred to as 'Mister' whilst others choose either not to change from 'Doctor' or to change back to 'Doctor' after passing the FCEM exam. Others used the MRCP or the FRCA as their primary examination (now replaced by MCEM). Trainees in emergency medicine may dual accredit in Intensive Care Medicine or seek sub-specialisation in Paediatric emergency medicine.

Work

The employment arrangement of emergency physician practices are either private (a democratic group of EPs staff an ED under contract), institutional (EPs with an independent contractor relationship with the hospital), corporate (EPs with an independent contractor relationship with a third party staffing company that services multiple emergency departments) or governmental (employed by the US armed forces, the US public health service, the Veteran's Administration or other government agency).

Most emergency physicians staff hospital emergency departments in shifts, a job structure necessitated by the 24/7 nature of the emergency department. In the United States, emergency medicine practitioners are expected to be competent in treating, diagnosing and managing a wide array of illnesses and conditions, both chronic and acute. Contrary to popular belief, emergency physicians do not treat a disproportionate number of, nor do they provide primary care to, the uninsured. In Massachusetts, when health insurance became mandatory, emergency department usage actually rose. Overall, more than half of emergency physicians report high levels of career satisfaction. Although career satisfaction has remained high among emergency physicians, concern about burnout is substantial.

In the United Kingdom all Consultants in Emergency Medicine work in the NHS. There is little scope for private emergency practice.

According to the American College of Emergency Physicians, the US will likely face a shortage of physicians in the near future, leading to increased employment opportunities.

Epidemiology

A U.S. government report found there were 119 million emergency department visits in 2006, an increase of 36% from 1996. During this same ten year period of increased usage, the number of emergency departments decreased, from 4,019 to 3,833 and the rate of emergency department visits per 100 people in the U.S. rose from 34.2 to 40.5.

See also

• Medical emergency, conditions that require immediate or very prompt medical attention
• First aid, Initial Medical Care designed to stabilize immediate life threats and prevent further harm.
• Emergency medical services (EMS), which provides skills above and beyond that considered First Aid, and transport to a hospital
• Rescue squad, a specialized part of the EMS system charged with gaining access to, and removing patients from special situations.
• Emergency medical technician, a Basic-Level healthcare worker who specializes in emergency and prehospital care
• Paramedic, an Advanced-level healthcare worker who specializes in emergency and prehospital care
• CPR
• Golden hour, about the importance of rapid care in medical emergencies
• Toxicology, the study of toxins and their treatment
• Traumatology, the study of physical trauma and its treatment
• Physical trauma, damage to the body such as due to a car wreck or falling down
• International emergency medicine

External links

• International Federation for Emergency Medicine
• Association of Emergency Physicians
• Canadian Association of Emergency Physicians
• American Academy of Emergency Medicine
• American Board of Emergency Medicine
• American College of Emergency Physicians
• College of Emergency Medicine (United Kingdom)
• European Society for Emergency Medicine
• Society for Academic Emergency Medicine
• Hong Kong College of Emergency Medicine

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