Emergency medicine

Emergency medicine
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List of terms related to Emergency medicine

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]

Overview

Emergency medicine is a branch of medicine that is practiced in a hospital emergency department, in the field by emergency medical service, such as paramedics, and other locations where initial medical treatment of illness takes place. Just as clinicians operate by immediacy rules under large emergency systems, emergency physicians and other allied health care workers in the emergency department base their practice on a triage system.

Emergency medicine focuses on diagnosis and treatment of acute illnesses and injuries that require immediate medical attention. While not usually providing long-term or continuous care, emergency medicine physicians and paramedics still provide care with the aim of improving long-term patient outcome.

Urgent Care Centers are often staffed by physicians, 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.

Emergency Medicine encompasses a large amount of general medicine but involves virtually all fields of medicine 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 Flying Ambulances 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 1960's 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 growingly 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 1970's, 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 States, the American College of Emergency Physicians (ACEP) is presently the largest member organization of emergency physicians (EPs), and Active membership is open to both allopathic (MD,MBBS,MBChB,etc) or osteopathic (DO) physicians. legacy physicians (physicians engaged in the practice of emergency medicine prior to 2000) and those physicians who have completed an emergency medicine residency approved by the Accreditation Council on Graduate Medical Education (ACGME), the American Osteopathic Association (AOA), or are certified by an emergency medicine certifying body recognized by ACEP. Originally founded in 1968, it was the first Emergency Medicine society formed in the United States. Fellows use the designation FACEP. Membership census: unknown (2006)

The American College of Osteopathic Emergency Physicians (ACOEP) was founded seven years later in 1975. Active membership is open to osteopathic (D.O.) 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. Membership census: 2,300 (2006)

Founded in 1991, the Association of Emergency Physicians (AEP), distinguishes itself by offering membership to any practicing emergency physician regardless of training. By so doing, the AEP acknowledges that more than half of practicing emergency physicians in the United States, much like their colleagues in other countries, completed residencies in other related specialties which included training in the practice of emergency medicine. Currently, this organization is the only one allowing non-specialty trained physicians to work within its scope of practice.

The American Academy of Emergency Medicine (AAEM) was formed in 1993 and has been the subject of some controversy due to its traditional position statements concerning board certification, resident "moonlighting", and the practice of "corporate medicine". Nevertheless, AAEM has worked cooperatively alongside the ACEP and the ACOEP when the interests of emergency medicine have called for a united front. Active membership is open to both allopathic (MD,MBBS,MBChB,etc) or osteopathic (DO) physicians who have completed an emergency medicine residency approved by ACGME or the AOA. Fellows use the designation FAAEM. Membership census: 5,000 members (2007)

The American Board of Emergency Medicine (ABEM) provides board certification to allopathic (MD,MBBS,MBChB,etc) or osteopathic (DO) 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 half 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 board certification to both allopathic and osteopathic physicians that have completed an emergency medicine or primary care residency and performed 5 years of emergency medicine practice, followed by a written and oral examination process. Many of the above mentioned legacy physicians are certified via this pathway.

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 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 Canadian nation have no specific emergency medicine residency training. 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.

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

Practice

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. Allopathic (MD,MBBS,MBChB) emergency medicine residencies 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 toxicology, sports medicine, ultrasound, and pediatric emergency medicine.

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.

Advanced Medical Priority Dispatch System

AMPDS stands for the Advanced Medical Priority Dispatch System, and is a piece of computer software used by ambulance services worldwide to prioritize calls by priorty.

The output gives a main response category - A (Immediately Life Threatening), B (Urgent Call), C (Routine Call). This may well be linked to a performance targeting system such as ORCON where calls must be responded to within a given time period. For example, in the United Kingdom, calls rated as 'A' on AMPDS are targeted with getting a responder on scene within 8 minutes.

Each call is then assigned a sub-category or code, often used as a means of gathering statistics about performance. It also helps when analysing the calls for how the call was described by the informant, compared to the injury or illness found when the crew attend. This can then be used to help improve the questioning system which gives the AMPDS classification.

Call categorization

AMPDS Call categorization

Problem	Category A	Category B	Category C
Abdominal Pain/Problems		Not Alert	Abdominal Pain
		Fainting or near fainting
		Females with fainting 12-50
		Males with pain above the navel > 35
		Females with pain above the navel > 45
Allergies/Envenomations	Difficulty breathing or swallowing	Special medications or injections used	Spider bite
	Severe respiratory distress	Unknown status (3rd party caller)
	Not Alert	No difficulty breathing or swallowing
	Condition worsening
	Swarming attack (bee, wasp, hornet)
	Snakebite
	Ineffective breathing
Animal bites/attacks	Unconscious or arrest	Dangerous body area	Non-dangerous body area
	Not Alert	Large Animal	Not recent injury
		Exotic animal	Superficial bites
		Attack or multiple animals
		Possible dangerous body area
		Serious Haemorrhage
		Unknown status (3rd party caller)
Assault, Sexual Assault	Unconscious or Arrest	Multiple Injuries	Not dangerous body area
	Not Alert	Possible dangerous body area	Not recent (>6 hours)
	Abnormal breathing	Serious Haemorrhage
	Dangerous Body Area	Unknown status (3rd party caller)
Back Pain		Not Alert	Non-traumatic
		Fainting or near >50	Not recent traumatic (>6hrs)
Breathing Problems	Severe Respiratory distress	Clammy
	Not Alert	Abnormal Breathing
	Ineffective Breathing	Cardiac History
Burns, Scalds, Explosion	Unconscious or Arrest	Explosion	Sunburn or minor (< hand size)
	Severe respiratory distress	Multiple victims
	Not Alert	Building fire - persons reported
		Difficulty breathing
		Burns > 18%
		Unknown status (3rd party caller)
		Burns < 18%
		Fire alarm (unknown status)
Carbon Monoxide, Hazchem	Unconscious or Arrest	Multiple victims
	Severe respiratory distress	Alert with difficulty breathing
	Not Alert	Alert without difficulty breathing
	Unknown status (3rd party caller)	Carbon monoxide detector alarm
Cardiac or Respiratory arrest, Death	Ineffective breathing	Obvious death unquestionable
	Not breathing at all	Expected Death
	Breathing Uncertain (Agonal)
	Hanging
	Strangulation
	Suffocation
	Underwater
Chest Pain	Abnormal breathing		Breathing normally <35
	Cardiac history
	Cocaine
	Breathing normally > 35
	Severe respiratory distress
	Not Alert
	Clammy
	Nausea or vomiting
Choking	Not alert	Abnormal breathing	Not choking now
	Verified/ineffective breathing
Convulsions, Fitting	Pregnancy	Diabetic
	Not breathing	Cardiac History
	Continuous or multiple fitting	Breathing regularly not verified < 35
	Irregular breathing	Not seizing now and breathing regularly
	Breathing regularly not verified > 35
Diabetic Problems	Unconscious	Not Alert	Alert
		Abnormal Behaviour
		Abnormal breathing
Drowning, Diving,SCUBA accident	Unknown status (3rd party call)	SCUBA accident
	Unconscious	Alert with abnormal breathing
	Not Alert	Alert and breathing normally (injuries or in water)
	Diving or suspected neck injury	Alert and breathing normally (No injuries)
Electrocution, Lightning	Unconscious	Alert and breathing normally
	Not disconnected from the power
	Power not off - hazard present
	Long fall > 6ft
	Not Alert
	Abnormal breathing
	Unknown status (3rd party caller)
	Not Breathing/Ineffective breathing
Eye Problems		Not Alert	Medical Eye Problem
		Severe eye injuries	Minor eye injuries
		Moderate eye injuries
Falls	Dangerous Injuries	Long fall > 6ft	Not dangerous injuries
	Not Alert	Possible dangerous body area	Not recent (>6 hours)
	Abnormal breathing	Serious Haemorrhage
		Unknown status(3rd party caller)
Headache		Not alert	Normal breathing
		Abnormal breathing
		Speech problems
		Sudden on set of pain <3hrs
		Numbness or paralysis
		Change in behaviour >3hrs
		Unknown status (3rd party caller)
Heart Problems	Chest Pains > 35	Firing of AICD	Chest Pain < 35
	Severe respiratory distress	Abnormal breathing	Heart rate > 50 and < 130
	Not Alert	Cardiac History
	Clammy	Cocaine
		Heart rate <50 or >130bpm
		Unknown status (3rd party caller)
Haemorrhage/Laceration	Haemorrhage through tubes	Possible Dangerous Haemorrhage	Minor Haemorrhage
	Dangerous Haemorrhage	Serious Haemorrhage	Not dangerous Haemorrhage
	Not Alert	Bleeding disorder or thinners
	Abnormal Breathing
Heat/Cold Exposure		Not Alert	Alert
		Cardiac History
		Change in skin colour
		Unknown status (3rd party caller)
Industrial or Machinery Accident	Life Status Questionable	Multiple Victims
	Caught in Machinery (Unknown Status)	Unknown situation (not caught in machinery)
Overdose, Poisoning, Ingestion	Unconscious	Violent (Police must secure)
	Severe Respiratory Distress	Not Alert
		Abnormal Breathing
		Antidepressants
		Cocaine (or derivative)
		Narcotics (heroin)
		Acid or Alkali (lye)
		Unknown status (3rd Party Caller)
		Poison control request response
Pregnancy, Childbirth, Miscarriage	Breech or Cord	Head visible/out	1st trimester or miscarriage
	Imminent Delivery (>5 months/20weeks)	2nd Trimester haemorrhage or miscarriage
	Baby Born	1st trimester serious haemorrhage
	3rd trimester haemorrhage	Labour (delivery not imminent. >5 months
	High risk of complications	Unknown status (3rd party caller)
Psychiatric, Suicide attempt		Not Alert	Non-violent and non-suicidal
		Violent (police must secure)
		Threatening Suicide
		Near hanging, strangulation or suffocation (alert)
		Unknown status
Sick Person		Not Alert	No priority symptoms
		Cardiac History	Deafness
		Unknown status (3rd party caller)	Defecation
			Earache
			Enema
			Gout
			Haemorrhoids
			Hepatitis
			Hiccups
			Hungry
			Nervous
			Boils
			Object stuck (nose, ear, vagina, rectum, penis)
			Object swallowed (not choking)
			Penis problem or pain
			Rash or skin disorder
			Sore Throat
			Toothache
			Transportation only
			Venereal disease
			Wound infected
			Bumps (non traumatic)
			Can't sleep
			Can't urinate
			Catheter problem
			Constipation
			Cramps or spasms
			Cut off ring request
Stabbing, Gunshot, Penetrating Trauma	Unconscious or Arrest	Multiple victims	Not recent (>6 hours) single peripheral wound
	Not Alert	Not Recent (>6 hours) single central wound
	Central wounds	Known single peripheral wound
	Multiple Wounds	Serious Haemorrhage
		Unknown status (3rd party caller)
Stroke, CVA		Not Alert
		Abnormal breathing
		Speech or movement problems
		Numbness or tingling
		Stroke history
		Breathing normally > 35
		Unknown status (3rd party caller)
		Breathing Normally <35
Traffic & transportation accidents	High Mechanism - Ejection	Major Incident
	Not Alert	High Mechanism
		High Mechanism
		HAZMAT
		Pinned or trapped victim
		Injuries
		Multiple victims (one unit)
		Multiple victims (additional units)
		Serious Haemorrhage
		Unknown status (3rd party caller)
		1st party caller with non-dangerous injury
Traumatic Injuries (specific)	Dangerous body area	Serious Haemorrhage	Not Dangerous Injury
	Not Alert	Possibly dangerous body area	Not recent (>6 hours)
	Abnormal breathing
Unconscious or fainting (near)	Multiple fainting episodes	Alert with abnormal breathing	Single fainting episode (age <35)
	Unconscious	Cardiac history
	Severe respiratory distress	Single or near fainting. Alert >35
	Not Alert	Females 12-50 with abdominal pain
	Ineffective breathing
Unknown problem or 3rd party report	Life status questionable	Standing, sitting, moving or talking
		Medical Alert notification
		Unknown status (3rd party caller)

See also

• CPR
• Toxicology
• Emergency medical service
• Traumatology
• Physical trauma
• Rescue squad
• Emergency medical technician
• First aid
• Paramedic
• Golden hour
• Emergency Medical Care

External links

• Association of Emergency Physicians
• American Academy of Emergency Medicine
• American Board of Emergency Medicine
• American Board of Medical Specialties
• The American Board of Physician Specialties
• American College of Emergency Physicians
• Canadian Association of Emergency Physicians
• Emergency Medicine
• European Resuscitation Council
• European Society for Emergency Medicine
• National Centre for Emergency Medicine Informatics
• On-Line Emergency Medicine Journal Club (via JournalReview.org
• Society for Academic Emergency Medicine
• Hong Kong College of Emergency Medicine