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Emergency medicine is a medical specialty in which a physician receives practical training to provide 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.

Urgent care centers are staffed by physicians, physician assistants, and nurses including nurse practitioners. Such practitioners may or may not be formally trained in emergency medicine. The centers offer primary care treatment to patients who desire or require immediate care, but who do not reach the acuity that requires care in an emergency department or admission to a hospital.

Physicians specializing in emergency medicine 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

Emergency medicine has evolved to treat conditions that pose a threat to life, limb, or have a significant risk of morbidity. In the word 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 but involves virtually all fields of 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 ideally have the skills of many specialists—the ability to 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 (internist), work-up a pregnant patient with vaginal bleeding (Obstetrics and Gynecology), stop a bad nosebleed (ENT), and place a chest tube (Cardiothoracic Surgery).

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

United Kingdom and Ireland

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

Australasia

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

Canada

In Canadamarker, there are two routes to certification in emergency medicine. However, more than two-thirds of the physicians currently practicing emergency medicine across Canada have no specific emergency medicine residency training or certification. Emergency physicians who tend to work in more community-based settings complete a residency specializing in Family Medicine and then proceed to obtain an additional year of training in emergency medicine to obtain a Certificate of Special Competence in Emergency Medicine from the College of Family Physicians of Canada (CCFP-EM). Physicians wanting to practice in major urban/tertiary care hospitals will often pursue a 5 year specialist residency in Emergency Medicine, certified by the Royal College of Physicians and Surgeons of Canada. These members typically spend more time in academic and leadership roles within emergency medicine, EMS, research, and other avenues. There is no significant difference in remuneration or clinical practice type between physicians certified via either route.

United States

In the United Statesmarker, there are many member organizations for emergency physicians:











There are three ways to become board certified:





Education

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 (M.D., D.O., M.B.B.S.,MBChB) 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 with a majority of such rotations through the emergency department itself. 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. Emergency physicians are therefore both clinical generalists and well-rounded diagnosticians.

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

Working

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.By its very nature, emergency medicine is considered one of the most grueling and intensive fields to train and practice in.100-hour work weeks for residents are not uncommon. As emergency medicine practitioners often act as primary care providers for those who are uninsured, they are expected to be competent in treating, diagnosing, and managing a wide array of illnesses and conditions, both chronic and acute.Emergency department physicians experience a high rate of patient death, more than any other group except oncologists. As a result, burn-out and depression are not uncommon.

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.

Usage

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


References

  1. Maurice Ellis Award http://www.collemergencymed.ac.uk/temp/1026-cec_maurice_ellis_info.pdf
  2. BAEM-Emergency Medicine Landmarks http://www.collemergencymed.ac.uk/CEM/History%20of%20the%20specialty/Emergency%20Medicine%20Landmarks/default.asp
  3. Emergency Medicine Journal http://emj.bmj.com/
  4. Crystal Reports - Charting_Outcomes_2007.rpt
  5. ACCS web site
  6. The College of Emergency Medicine A trainee’s guide to Specialty Training in Emergency Medicine CEM Training Standards Committee July 2009


External links




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