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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 advanced 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.
There is only one organization that represents all emergency professionals
(broadly speaking: physicians, nurses and paramedics), without any
political activity or concern about income generation. The United States
Alliance of Emergency Medicine (USAEM) is a unique group, created in 2006,
after a report from the Institute of Medicine (IOM), calling for greater
collaboration amongst the various disciplines in emergency medical care.
Unlike the other professional organizations, USAEM deliberately maintains
a very low membership fee in order to capture as many professionals as
possible.
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
practicing emergency medicine was closed off from ABEM and AOBEM several
years ago. Currently (as of 7/06), only the state of Florida has
recognized "BCEM", with the state of North Carolina affirmiatively
rejecting the "BCEM" designation.
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, with the chief among
them is that the specialty training has only been available for
approximately the last 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 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 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.
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