Emergency medicine is a medical specialty involving care for undifferentiated, unscheduled patients with acute illnesses or injuries that require immediate medical attention. While not usually providing long-term or continuing care, emergency physicians undertake acute investigations and interventions to resuscitate and stabilize patients. But emergency physicians also treat a wide variety of minor illnesses, since they provide care 24 hours a day when many primary care offices are closed. Emergency physicians generally practice in hospital emergency departments, pre-hospital settings via emergency medical services, and intensive care units, but also work in a variety of settings including urgent care clinics and other primary care settings. In developing countries, emergency medicine is still evolving and international emergency medicine programs offer hope of improving basic emergency care where resources are limited.
In the United States and other developed countries, emergency medicine is now recognized as an essential public service. Although it developed more than 40 years ago, it is still one of the newest medical specialties. In developed countries, esp. in the US, emergency medicine has achieved recognition for it's contributions to public health and academic medicine. Most academic medical centers have independent departments of Emergency Medicine, and the specialty is now a popular specialty among medical students and residents.
International Emergency Medicine is now its own subspecialty, and focuses not only on the global practice of emergency medicine but also on efforts to promote the growth of emergency care throughout the world. This article highlights the development of emergency medicine in the United States, and includes some aspects of Emergency medicine in other countries.
Scope
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.
The field of emergency medicine encompasses care involving the acute care of internal medical and surgical conditions. In many modern emergency departments, 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. They 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), manage strokes (neurology), work-up a pregnant patient with vaginal bleeding (obstetrics and gynecology), stop a severe nosebleed (ENT), place a chest tube (cardiothoracic surgery), and to conduct and interpret x-rays and ultrasounds (radiology). Emergency physicians also provide episodic primary care to patients during off hours and for those who do not have primary care providers.
Emergency medicine is distinct from urgent care, which refers to immediate healthcare for less emergent medical issues. However, many emergency physicians work in urgent care settings, since there is obvious overlap. Emergency medicine also includes many aspects of acute primary care, and shares with family medicine the uniqueness of seeing all patients regardless of age, gender or organ system . The emergency physician workforce also includes many competent physicians who trained in other specialties.
Physicians specializing in emergency medicine can enter fellowships to receive credentials in subspecialties such as palliative care, critical-care medicine, medical toxicology, wilderness medicine, pediatric emergency medicine, sports medicine, disaster medicine, tactical medicine, ultrasound, pain medicine, pre-hospital emergency medicine, or undersea and hyperbaric medicine.
The practice of emergency medicine is often quite different in rural areas where there are far fewer consultants and health care resources. In these areas, family physicians with additional skills in emergency emergency medicine often staff emergency departments. Rural emergency physicians may be the only health care providers in the community, and require skills that include primary care and obstetrics.
Work patterns
Patterns vary by country and region. In the United States, the employment arrangement of emergency physician practices are either private (with a co-operative group of doctors staffing an emergency department under contract), institutional (physicians with an independent contractor relationship with the hospital), corporate (physicians with an independent contractor relationship with a third-party staffing company that services multiple emergency departments), or governmental (for example, when working within military services, public health services, veterans' benefit systems or other government agencies).
In the United Kingdom, all consultants in emergency medicine work in the National Health Service and there is little scope for private emergency practice. In other countries like Australia, New Zealand or Turkey, emergency medicine specialists are almost always salaried employees of government health departments and work in public hospitals, with pockets of employment in private or non-government aeromedical rescue or transport services, as well as some private hospitals with emergency departments; they may be supplemented or backed by non-specialist medical officers, and visiting general practitioners. Rural emergency departments may be headed by general practitioners alone, sometimes with non-specialist qualifications in emergency medicine.
Pediatric Emergency Medicine Board Review Video
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 as an independent medical specialty is relatively young. Prior to the 1960s and 1970s, hospital emergency departments (EDs) were generally staffed by physicians on staff at the hospital on a rotating basis, among them family physicians, general surgeons, internists, and a variety of other specialists. In many smaller emergency departments, nurses would triage patients and physicians would be called in based on the type of injury or illness. Family physicians were often on call for the emergency department, and recognized the need for dedicated emergency department coverage. Many of the pioneers of emergency medicine were family physicians and other specialists who saw a need for additional training in emergency care.
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. In the UK in 1952, Maurice Ellis was appointed as the first "casualty consultant" at Leeds General Infirmary. In 1967, the Casualty Surgeons Association was established with Maurice Ellis as its first President. In the US, the first of such groups was headed by Dr. James DeWitt Mills in 1961 who, along with four associate physicians; Dr. Chalmers A. Loughridge, Dr. William Weaver, Dr. John McDade, and Dr. Steven Bednar at Alexandria Hospital, Virginia, established 24/7 year-round emergency care, which became known as the "Alexandria Plan".
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 emergency medicine became a recognized medical specialty in the US. The first emergency medicine residency program in the world was begun in 1970 at the University of Cincinnati and the first Department of Emergency Medicine at a US medical school was founded in 1971 at the University of Southern California.
In 1990 the UK's Casualty Surgeons Association changed its name to the British Association for Accident and Emergency Medicine, and subsequently became the British Association for Emergency Medicine (BAEM) in 2004. In 1993, an intercollegiate Faculty of Accident and Emergency Medicine (FAEM) was formed as a "daughter college" of six medical royal colleges in England and Scotland to arrange professional examinations and training. In 2005, the BAEM and the FAEM were merged to form the College of Emergency Medicine, now the Royal College of Emergency Medicine, which conducts membership and fellowship examinations and publishes guidelines and standards for the practise of emergency medicine.
Training
There are a variety of international models for emergency medicine training. Among those with well developed training programs there are two different models: a "specialtist" model or "a multidisciplinary model". Additionally, in some countries the emergency medicine specialist rides in the ambulance. For example, in France and Germany the physician, often an anesthesiologist, rides in the ambulance and provides stabilizing care at the scene. The patient is then triaged to the appropriate department of a hospital, so emergency care is much more multidisciplinary than in the Anglo-American model.
In countries such as the US, the United Kingdom, Canada and Australia, ambulances transport patients to emergency departments and there is more dependence on paramedics and EMTs for on-scene care. Emergency physicians are therefore more " specialists", since all patients are taken to the emergency department. Most developing countries follow the Anglo-American model: 3 or 4 year, independent residency training programs in emergency medicine are the gold standard. Some countries develop training programs based on a primary care foundation with additional emergency medicine training. In developing countries, there is an awareness that Western models may not be applicable and may not be the best use of limited health care resources. For example, specialty training and pre-hospital care like that in developed countries is too expensive and impractical for use in many developing countries with limited health care resources. International emergency medicine provides an important global perspective and hope for improvement in these areas.
A brief review of some of these programs follows:
Argentina
In Argentina, the SAE (Sociedad Argentina de Emergencias) is the main organization of Emergency Medicine.There are a lot of residency programs. Also is possible to reach the certification with a two-year postgraduate university course after a few years of ED background.
Australia and New Zealand
The specialist medical college responsible for Emergency Medicine in Australia and New Zealand is the Australasian College for Emergency Medicine (ACEM). The training program is nominally seven years in duration, after which the trainee is awarded a Fellowship of ACEM, conditional upon passing all necessary assessments.
Dual fellowship programs also exist for Paediatric Medicine (in conjunction with the Royal Australasian College of Physicians) and Intensive Care Medicine (in conjunction with the College of Intensive Care Medicine). These programs nominally add one or more years to the ACEM training program.
For medical doctors not (and not wishing to be) specialists in Emergency Medicine but have a significant interest or workload in emergency departments, the ACEM provides non-specialist certificates and diplomas.
Canada
The two routes to emergency medicine certification can be summarized as follows:
- A 5-year residency leading to the designation of FRCP(EM) through the Royal College of Physicians and Surgeons of Canada (Emergency Medicine Board Certification - Emergency Medicine Consultant).
- A 1-year emergency medicine enhanced skills program following a 2-year family medicine residency leading to the designation of CCFP(EM) through the College of Family Physicians of Canada (Advanced Competency Certification). The CFPC also allows those having 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.
CCFP(EM) emergency physicians outnumber FRCP(EM) physicians by a ratio of about 3 to 1, and they tend to work primarily as clinicians with a smaller focus on academic activities such as teaching and research. FRCP(EM) Emergency Medicine Board specialists tend to congregate in academic centers and tend to have more academically oriented careers, which emphasize administration, research, critical care, disaster medicine, and teaching. They also tend to sub-specialize in toxicology, critical care, pediatrics emergency medicine, and sports medicine. Furthermore, the length of the FRCP(EM) residency allows more time for formal training in these areas.
China
The current post-graduate Emergency Medicine training process is highly complex in China. The first EM post-graduate training took place in 1984 at the Peking Union Medical College Hospital. Because specialty certification in EM has not been established, formal training is not required to practice Emergency Medicine in China.
About a decade ago, Emergency Medicine residency training was centralized at the municipal levels, following the guidelines issued by The Ministry of Public Health. Residency programs in all hospitals are called residency training bases, which have to be approved by local health governments. These bases are hospital-based, but the residents are selected and managed by the municipal associations of medical education. These associations are also the authoritative body of setting up their residents' training curriculum. All medical school graduates wanting to practice medicine have to go through 5 years of residency training at designated training bases, first 3 years of general rotation followed by 2 more years of specialty-centered training.
India
India is an example of how family medicine can be a foundation for emergency medicine training. Many private hospitals and institutes have been providing Emergency Medicine training for doctors, nurses & paramedics since 1994, with certification programs varying from 6 months to 3 years. However, emergency medicine was only recognized as a separate specialty by the Medical Council of India in July 2009.
Malaysia
There are three universities (Universiti Sains Malaysia, Universiti Kebangsaan Malaysia, & Universiti Malaya) that offer master's degrees in emergency medicine - postgraduate training programs of four years in duration with clinical rotations, examinations and a dissertation. The first cohort of locally trained emergency physicians graduated in 2002.
Saudi Arabia
In Saudi Arabia, Certification of Emergency Medicine is done by taking the 4-year program Saudi Board of Emergency Medicine (SBEM), which is accredited by Saudi Council for Health Specialties (SCFHS). It requires passing the two-part exam: first part and final part (written and oral) to obtain the SBEM certificate, which is equivalent to Doctorate Degree. http://saudiemergencymedicine.com/welcome/index.php
United States
Most programs are three years in duration, but some academic programs are now offering four-year programs. There are several combined residencies offered with other programs including family medicine, internal medicine and pediatrics. The US is well known for it's excellence in emergency medicine residency training programs. This has led to some controversy about specialty certification. There are three ways to become board-certified in emergency medicine:
- The American Board of Emergency Medicine (ABEM) is for those with either Doctor of Medicine (MD) or Doctor of Osteopathic Medicine (DO) degrees. The ABEM 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 DO degree. It is under the authority of the American Osteopathic Association Bureau of Osteopathic Specialists.
- The Board of Certification in Emergency Medicine (BCEM) grants board certification in emergency medicine to physicians who have not completed an emergency medicine residency, but have completed a residency in other fields (internists, family practitioners, pediatricians, general surgeons, and anesthesiologists).
A number of ABMS fellowships are available for Emergency Medicine graduates including pre-hospital medicine (emergency medical services), critical care, hospice and palliative care, research, undersea and hyperbaric medicine, sports medicine, pain medicine, ultrasound, pediatric Emergency Medicine, disaster medicine, wilderness medicine, toxicology, and critical care medicine.
In recent years, workforce data has led to a recognition of the need for additional training for primary care physicians who provide emergency care. This has led to a number of supplemental training programs in first hour emergency care, and a few fellowships for family physicians in emergency medicine.
United Kingdom
Emergency medical trainees enter specialty training after five years of medical school and two years of foundation training.
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). Trainees in Emergency Medicine may dual accredit in Intensive-Care Medicine or seek sub-specialisation in Paediatric Emergency Medicine.
Turkey
Emergency Medicine residency lasts for 4 years in Turkey. These physicians have a 2-year Obligatory Service in Turkey to be qualified to have their diploma. After this period, EM specialist can choose to work in private or governmental ED's.
Pakistan
Emergency Medicine training in Pakistan lasts for 5 years. The initial 2 years involve trainees to be sent to various sub-specialties including both medicine and surgery. In last three years trainee residents spend most of their time in emergency room as senior residents. Certificate courses include ACLS, PALS, ATLS, and research and dissertations are required for successful completion of the training. At the end of 5 years, candidates become eligible for sitting for FCPS part II exam. After completion of requirements and passing the exam, the physician is called Emergency Medicine specialist.
Iran
The first residency program in Iran started in 2002 at Iran University of Medical Sciences, and there are now three-year standard residency programs running in Tehran, Tabriz, Mashhad, Isfahan, and some other universities. All these programs work under supervision of Emergency Medicine specialty board committee. There are now more than 200 (and increasing) board-certified Emergency Physicians in Iran.
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