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.

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."

International Federation for Emergency Medicine 1989.

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), stop a bad nosebleed (ENT), and place a chest tube (Cardiothoracic Surgery).

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 Emergency Department (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.

Development of Emergency Medicine as a Specialty in the UK

Emergency Medicine traces its development as a specialty in UK to 1952 when Mr Maurice Ellis was appointed as the first consultant in Emergency Medicine in the UK at Leeds General Infirmary. In 1967 the Casulty Surgeons Association was established with Maurice Ellis as its first President. The name of the Association was changed twice, in 1990, to the British Association for Accident and Emergency Medicine, and later on in 2004, to British Association for Emergency Medicine (BAEM). In 1993, Intercollegiate Faculty of Accident and Emergency Medicine (FAEM) was formed at the Royal College of Surgeons of England, London. In 2005, the BAEM and the FAEM were merged to form College of Emergency Medicine (CEM). The College of Emergency Medicine is the single authoritative body for Emergency Medicine in the UK. It conducts its fellowship and membership exams, publishes guidelines and standards for the practise of Emergency Medicine, and has its own journal, called Emergency Medicine Journal (EMJ).

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 certification in emergency medicine. However, more than two-thirds of the physicians currently practicing emergency medicine across Canada have no specific emergency medicine residency training or certification. 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 in emergency medicine to obtain a Certificate of Special Competence in Emergency Medicine from the College of Family Physicians of Canada (CCFP-EM). Physicians wanting to practice 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 more 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, or to Legacy emergency physicians - those who have been in practice prior to the year 2000. 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.


 * The American College of Osteopathic Emergency Physicians (ACOEP) was founded seven years later in 1975. 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 2008, ACOEP had approximately 3,100 members.


 * The American Academy of Emergency Medicine (AAEM) was formed eighteen years later in 1993. AAEM's mission is its concern with 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 approximately 5,100 members.


 * The Association of Emergency Physicians (AEP), which was founded in 1991, offers membership to any practicing emergency physician regardless of training. 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.


 * The American Board of Emergency Medicine (ABEM) provides board certification to allopathic (M.D.)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.

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. Emergency medicine residencies (M.D., D.O., M.B.B.S.,MBChB) can be three or four years in length, depending on the training institution. 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), research, 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, acute 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.

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