Emergency medicine

Emergency medicine is a branch of medicine that is practiced in a hospital emergency department, in the field (in a modified form; see EMS), and other locations where initial medical treatment of illness takes place.

Emergency medicine focuses on diagnosis and treatment of acute illnesses and injuries that require immediate care. While not usually providing long-term care, EM physicians and pre-hospital personnel still provide care with the aim of improving long-term patient outcome. In the United States, some people use the emergency department for outpatient care that could be provided at a doctor's office. As a result, much of emergency room care is general practice (coughs, colds, aches, pains).

A variant of an Emergency Department is an Urgent Care Center, often staffed by non-Emergency Medicine trained physicians and/or nurses, which treats patients who desire or require immediate care, but do not reach the acuity that requires care in an emergency department.

Emergency Medicine involves a large amount of general medicine but involves all fields of medicine including the surgical sub-specialties. Emergency Physicians are tasked with seeing a large number of patients, treating their illnesses and admitting them to the hospital as necessary. The field requires a broad field of knowledge and requires advance procedural skills often including surgical procedures, trauma resuscitation, advance cardiac life support and advance airway management.

Definition

"Emergency medicine is 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 behavioural 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."

International Federation for Emergency Medicine 1991

History

Emergency Medicine as a standalone medical specialty is relatively young. Prior to the 1960's and 70's, hospital emergency rooms were generally staffed by doctors trained in other specialties, such as internal medicine and primary care. However, during this time period, groups of physicians mostly located in the midwestern United States (notably Cincinnati, Ohio, and Denver, Colorado) recognized the need, and the niche, for physicians specifically trained to handle acute medical emergencies.

Organizations around the world

In the United States, the American College of Emergency Physicians(ACEP) is presently the largest member organization of emergency physicians (EPs), and is open to most physicians who practice in an Emergency Department. Originally founded in 1968, it was the first Emergency Medicine society formed in the United States. Fellows use the designation FACEP.

The American Academy of Emergency Medicine(AAEM)is another specialty society of Emergency Medicine. It was formed after ACEP and is considered a rival organization although both organizations have cooperated in the past. Members must be board certified in Emergency Medicine. Fellows use the designation FAAEM.

The American Board of Emergency Medicine (ABEM) provides board certification to emergency physicians who have successfully completed a residency in emergency medicine, completed an additional year of practice, passed a written exam, and then an oral exam. There is a roughly equivalent board process for osteopathic physicians ("DO's"). Osteopathic Emergency Physicians are certified through the American Osteopathic Board of Emergency Medicine (AOBEM).

The American Board of Physician Specialties (ABPS) also offers Board Certification in Emergency Medicine (BCEM). This certification is offered to experienced physicians who have trained initially in other settings, and who have more than 5 years of emrgency medicine experience and are certified in ACLS/ATLS courses, provide letters of recommendation and file case reports, as well as pass written and oral testing. The ABPS certification is controversial and not widely recognized as it allows non-emergency residency trained physicians to claim specialization in Emergency Medicine without going through a residency. The 'grandfathering-in' of other experienced non-residency trained physicians practising emergency medicine was closed off from ABEM and AOBEM several years ago.

Board certification is maintained through annual testing over required reading lists and a more extensive written exam every 10 years (for ABEM).

Many types of physicians may practice in an Emerency Department; however, only those who have successfully passed the board certification process are considered "Emergency Medicine Specialists." Currently the ABEM and AOBEM require a number of years of residency training after medical school, followed by comprehensive written and oral examinations. The BCEM requires (in addition to passing written and oral examinations) completion of an ACGME approved residency in an approved specialty such as Family Medicine or Internal Medicine, 5 years of the practice of emergency medicine, 10 Peer reviewed case reports, current ATLS/ACLS certification and 3 letters of recommendation from Peers.

Not all hospitals require that Emergency Medicine specialists staff an emergency department. This is due to many reasons, the chief among them is that the specialty training has only been available for the last approximately 25 years. There were (and still are) significantly fewer board certified Emergency Physicians than the need. Some physicians have extensive experience in Emergency Medicine, but are not eligible to sit for the boards as they have not completed a residency program. These physicians are still a valuable asset to Emergency Medicine and help staff many Emergency Departments throughout the country. Emergency Medicine is in a period of transition, and this is gradually changing, as more physicians are completing specialty training in this area. More progressive hospitals have seen the need for the specialized care provided by physicians with emergency medicine training and now require that their physicians be board certified in Emergency Medicine. Patients can find out which hospitals require that specialists staff their emergency department by contacting the hospital directly and asking if they are staffed by "Emergency Physicians board certified in Emergency Medicine." Alternatively (in the United States), online sites such as "www.911Emergency.org" (see links below) provide a list of hospital Emergency Departments staffed by those certified by ABEM.

Patients should be wary of anyone who represents themselves to be "Board Certified" in Emergency Medicine, but the board is not ABEM or AOBEM. The problem of Sham board certification is not unique to Emergency Medicine, and patients should be careful to check that any physician be "board certified," by one of the medical specialty boards of the American Board of Medical Specialties or the American Board of Physician Specialties. As mentioned the ABPS certification is controversial.

A sudden surge of interest in the specialty in the late 1990s was due to the popularity of the American TV series, ER. Showcasing the function of a Chicago Emergency Department(loosely based on Cook County Hospital) and its many characters, the show introduced a large number of people to the specialty.

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). The British Association for Emergency Medicine is the member organization in the UK. In 2005, the two organisations initiated steps to merge as the College of Emergency Medicine.

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

In Canada, there are two routes to practice emergency medicine. More than two thirds of physicians currently practicing emergency medicine across the nation have no specific emergency medicine residency training. Emergency physicians who tend to work in more community-based settings complete a residency specialising in Family Medicine and then proceed to obtain an additional year of training of special competence on Emergency Medicine from the College of Family Physicians of Canada (CCFP-EM). Physicians practicing 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 a great deal of 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 by either route.

See medical emergency for specific lists of medical emergencies and how best to respond.

Practice

In the US, Emergency Medicine is one of the more competitive specialties to get into, and residency programs generally select physicians from the top of their medical school class. There are usually many physicians competing for each residency spot.

Residencies are often 3 year programs although 4 years and so called 1+3 programs exist mostly in academic centers. A large amount of time of residency training involves rotations through other specialties and a majority of rotation through the emergency department. By the end of their training, Emergency Physicians(EP) are expected to handle a vast field of medical as well as surgical and psychiatric emergencies. EPs are often considered good all round diagnosticians and general physicians but are often derided as 'triage-nurses' and 'jack-of-all trades and masters of none' by some of the other medical specialties. EPs are especially good at advance cardiac life support ('codes') and airway management.

Most Emergency Practices are either private(a group of EPs staff an ED under contract) or institutional (EPs are paid by the hospital). Some large private groups have become large staffing corporations servicing dozens of EDs, which has led to some controversy regarding emergency physician independence and corporate profits.

Most Emergency Physicians work in Emergency Department by shift work since a most EDs stay open 24/7.

External links