Emergency medicine

Emergency Medicine is a speciality of medicine that focuses on the diagnosis and treatment of acute illnesses and injuries that require immediate medical attention. While not usually providing long-term or continuing care, emergency medicine physicians diagnose a wide array of pathology and undertake acute interventions to stabilize the patient. These professionals practice in hospital emergency departments, in the prehospital setting via emergency medical service and other locations where initial medical treatment of illness takes place. Just as clinicians operate by immediacy rules under large emergency systems, emergency practioniers aim to diagnose emergent conditions and stabilize the patient for definitive care.

Urgent Care Centers are often staffed by physicians, physician assistants, nurses and nurse practitioners who may or may not be formally trained in emergency medicine. They 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.

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), and stop a bad nosebleed (ENT).

Definition

"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."

International Federation for Emergency Medicine 1991

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 70's, hospital "emergency rooms" 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 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 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 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.

Organizations around the world

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 organizations initiated steps, and have applied for a royal seal, to merge as the Royal 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 Canadian nation have no specific emergency medicine residency training.Fact|date=July 2008 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 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 via either route.

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

* The American College of Emergency Physicians (ACEP) is presently the largest member organization of emergency physicians, and Active membership is open to all physicians that have completed an emergency medicine residency approved by the Accreditation Council on Graduate Medical Education (ACGME) or the American Osteopathic Association (AOA), or are certified by any emergency medicine certifying body recognized by ACEP. Physicians engaged in the practice of emergency medicine prior to 2000 also qualify for membership under a grandfather clause. Originally founded in 1968, ACEP was the first Emergency Medicine society formed in the United States. Fellows use the designation FACEP. As of 2006, ACEP had about 25,000 members. [ [http://www.acep.org/aboutus.aspx?LinkIdentifier=ID&id=22546&fid=1526&Mo=No&acepTitle=About%20ACEP About ACEP] ] [ [http://www.acep.org/ACEPmembership.aspx?LinkIdentifier=ID&id=30214&fid=746&Mo=No&acepTitle=ACEP%20Membership ACEP Membership] ]

* The American Academy of Emergency Medicine (AAEM) was formed in 1993 and is a true professional organization in that, unlike ACEP, AAEM mandates board certification for fellowship status (FAAEM). AAEM is very concerned about the "corporate practice of medicine" and the negative consequences related to patient care. AAEM works cooperatively alongside the ACEP and the ACOEP when the interests of emergency medicine calls for a united front. Active membership is open to all physicians who have completed an emergency medicine residency approved by either ACGME or the AOA. Fellows use the designation FAAEM. As of 2008, the AAEM had about 6,000 members.

* The American College of Osteopathic Emergency Physicians (ACOEP) was founded seven years later in 1975.cite web
url=http://www.acoep.org/about/default.asp?main=about |title=ACOEP (American College of Osteopathic Emergency Physicians): About |accessdate=2008-05-08] Active membership is open only to osteopathic (D.O.) medical physicians who have practiced emergency medicine for the past three years and/or have completed an emergency medicine residency approved by the AOA or ACGME. Fellows use the designation FACOEP. As of 2006, ACOEP enrolled about 2,300 members

*The Association of Emergency Physicians (AEP), which was founded in 1991, offers membership to any practicing emergency physician regardless of training.cite web |url=http://www.aep.org/ |title=AEP.org |accessdate=2008-05-08] AEP acknowledges that a portion of practicing emergency physicians in the United States have not completed training in the practice of emergency medicine. AEP is a relatively small organizations though has members in 45 states.cite web |url=http://aep.org/memprofile.asp |title=AEP.org |accessdate=2008-05-08]

* The American Board of Emergency Medicine (ABEM) provides board certification to emergency physicians. Although ABEM now requires successful completion of an ACGME-approved residency in emergency medicine followed by completion of an additional year of practice before taking the exam, currently about one-third of the emergency physicians currently holding ABEM certification were "grandfathered" in to certification eligibility via the practice track by training in another specialty, practicing emergency medicine, and then passing the ABEM certification exam.

* The American Osteopathic Board of Emergency Medicine (AOBEM) provides board certification to osteopathic (D.O.) emergency physicians who have successfully completed an AOA-approved residency in emergency medicine, completed two years of practice, passed a written exam, and passed an oral exam. Like ABEM, the AOBEM at one time offered certification eligibility via a practice track, allowing training in another specialty, practicing emergency medicine, and then passing the AOBEM certification exam.

* The Board of Certification in Emergency Medicine (BCEM) provides certification to physicians who have completed a primary care residency and performed five years of emergency medicine practice, followed by a written and oral examination process. This "Board" is not acknowledged as a legitimate pathway by AAEM or ACEP and the state Board of Medicine (except Florida). It is considered a back door route that essentially encourages on-the-job specialty training.

* Currently, most emergency departments in the US insist on residency-trained, ABEM or AOBEM boarded emergency physicians.

Education

In the US, 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 US medical schools to US Emergency Medicine residencies are successful. [ [http://www.aamc.org/programs/cim/chartingoutcomes.pdf Crystal Reports - Charting_Outcomes_2007.rpt ] ] Emergency medicine residencies (MD,MBBS,MBChB) can be three or four years in length, depending on the training institution, while all osteopathic (DO) residencies are four years in length, the first being a one-year traditional rotating internship. 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), toxicology, sports medicine, ultrasound, and pediatric emergency medicine.

In the United Kingdom, emergency medical trainees enter training after five years of medical school and two-years of the Foundation Programme. During the three year core training programme (Acute Care Common Stem), doctors will complete training in anaesthesia, actue medicine, intensive care and emergency medicine and also sit the Membership of the College of Emergency Medicine (MCEM) examination. Trainees will then go onto Higher Training, lasting a further 4 years. Before the end of higher training, the final examination of MCEM must be taken. Upon completion of training the doctor will become a Consultant in Emergency Medicine and will be eligible for entry on the GMC Specialist Register. Emergency Medicine training in the UK is emerging. Traditionally emergency medics have been drawn from anaesthesia, medicine and surgery. The majority of A&E consultants are surgically trained and hold the Fellowship of Royal College of Surgeons of Edinburgh in Accident and Emergency - FRCSEd(A&E). Many of these consultants will be referred to as 'Mister'. Medical consultants will be holders of the MRCP and anaesthetic trained consultants will hold the FRCA and some may hold both FRCA and MRCP. A&E Consultants may dual accredit in Intensive Care 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.

Patients being served by the emergency medicine unit often proceed to intensive care medicine, which often is closely related to emergency medicine.

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

References

See also

* Medical emergency, conditions that require immediate or very prompt medical attention
* First aid, a style of initial medical care
* Emergency medical services (EMS), which provides first aid and transport to a hospital
* Rescue squad, a specialized part of the EMS
* Emergency medical technician, a healthcare worker who specializes in emergency care
* Paramedic, a healthcare worker who specializes in emergency 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

External links

* [http://www.aep.org/ Association of Emergency Physicians]
* [http://www.aaem.org/ American Academy of Emergency Medicine]
* [http://www.abem.org/ American Board of Emergency Medicine]
* [http://www.abms.org/ American Board of Medical Specialties]
* [http://www.abpsga.org/ The American Board of Physician Specialties]
* [http://www.acep.org/ American College of Emergency Physicians]
* [http://www.emra.org/ Emergency Medicine Residents’ Association]
* [http://www.caep.ca/ Canadian Association of Emergency Physicians]
* [http://www.collemergencymed.ac.uk/CEM/default.asp College of Emergency Medicine] (United Kingdom)
* [http://www.emedmag.com/ Emergency Medicine]
* [http://www.erc.edu/ European Resuscitation Council]
* [http://www.eusem.org/ European Society for Emergency Medicine]
* [http://www.ncemi.org/ National Centre for Emergency Medicine Informatics]
* [http://www.saem.org/ Society for Academic Emergency Medicine]
* [http://www.hkcem.com/ Hong Kong College of Emergency Medicine]