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
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).
Australasia
In
Australia and New Zealand
, advanced training in Emergency Medicine is
overseen by the Australasian College
for Emergency Medicine (ACEM).
Canada
In
Canada
, 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
States
, 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
- Maurice Ellis Award
http://www.collemergencymed.ac.uk/temp/1026-cec_maurice_ellis_info.pdf
- BAEM-Emergency Medicine Landmarks
http://www.collemergencymed.ac.uk/CEM/History%20of%20the%20specialty/Emergency%20Medicine%20Landmarks/default.asp
- Emergency Medicine Journal http://emj.bmj.com/
- Crystal Reports -
Charting_Outcomes_2007.rpt
- ACCS web site
- The College of Emergency Medicine A trainee’s guide to
Specialty Training in Emergency Medicine CEM Training Standards
Committee July 2009
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