Emergency medicine
Emergency medicine is the medical specialty concerned with the care of illnesses or injuries requiring immediate medical attention. Emergency physicians specialize in providing care for unscheduled and undifferentiated patients of all ages. As frontline providers, in coordination with emergency medical services, they are responsible for initiating resuscitation, stabilization, and early interventions during the acute phase of a medical condition. Emergency physicians generally practice in hospital emergency departments, pre-hospital settings via emergency medical services, and intensive care units. Still, they may also work in primary care settings such as urgent care clinics.
Sub-specialties of emergency medicine include disaster medicine, medical toxicology, point-of-care ultrasonography, critical care medicine, emergency medical services, hyperbaric medicine, sports medicine, palliative care, or aerospace medicine.
Various models for emergency medicine exist internationally. In countries following the Anglo-American model, emergency medicine initially consisted of surgeons, general practitioners, and other physicians. However, in recent decades, it has become recognized as a specialty in its own right with its training programs and academic posts, and the specialty is now a popular choice among medical students and newly qualified medical practitioners. By contrast, in countries following the Franco-German model, the specialty does not exist, and emergency medical care is instead provided directly by anesthesiologists, surgeons, specialists in internal medicine, pediatricians, cardiologists, or neurologists as appropriate. Emergency medicine is still evolving in developing countries, and international emergency medicine programs offer hope of improving primary emergency care where resources are limited.
Scope
Emergency medicine is a medical specialty—a field of practice based on the knowledge and skills required to prevent, diagnose, and manage 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.The field of emergency medicine encompasses care involving the acute care of internal medical and surgical conditions. In many modern emergency departments, emergency physicians see many patients, treating their illnesses and arranging for disposition—either admitting them to the hospital or releasing them after treatment as necessary. They also provide episodic primary care to patients during off-hours and those who do not have primary care providers. Most patients present to emergency departments with low-acuity conditions, but a small proportion will be critically ill or injured. Therefore, the emergency physician requires broad knowledge and procedural skills, often including surgical procedures, trauma resuscitation, advanced cardiac life support and advanced airway management. They must have some of the core skills from many medical specialities—the ability to resuscitate a patient, manage a difficult airway, suture a complex laceration, set a fractured bone or dislocated joint, treat a heart attack, manage strokes, work-up a pregnant patient with vaginal bleeding, control a patient with mania, stop a severe nosebleed, place a chest tube, and conduct and interpret x-rays and ultrasounds. This generalist approach can obviate barrier-to-care issues seen in systems without specialists in emergency medicine, where patients requiring immediate attention are instead managed from the outset by specialty doctors such as surgeons or internal physicians. However, this may lead to barriers through acute and critical care specialities disconnecting from emergency care.
Emergency medicine may separate from urgent care, which refers to primary healthcare for less emergent medical issues, but there is obvious overlap, and many emergency physicians work in urgent care settings. 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 have medical skills from other specialities.
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 other specialities and healthcare resources. In these areas, family physicians with additional skills in 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, institutional, corporate, or governmental.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 are sometimes run by general practitioners alone, sometimes with non-specialist qualifications in emergency medicine.
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 practical. Larrey operated 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. Before the 1960s and 1970s, hospital emergency departments 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, physicians began to emerge who had left their respective practices to devote their work entirely 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 co-established with Maurice Ellis as its first president. In the US, the first of such groups managed by Dr James DeWitt Mills in 1961, along with four associate physicians; Dr Chalmers A. Loughridge, Dr William Weaver, Dr John McDade, and Dr Steven Bednar, at Alexandria Hospital in Alexandria, Virginia, established 24/7 year-round emergency care, which became known as the "Alexandria Plan".
It was not until Dr. John Wiegenstein founded the American College of Emergency Physicians the recognition of emergency medicine training programs by the AMA and the AOA, and in 1979 a historic 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 began in 1970 at the University of Cincinnati. Furthermore, the first department of emergency medicine at a US medical school occurred in 1971 at the University of Southern California. The second residency program in the United States soon followed at what was then called Hennepin County General Hospital in Minneapolis, with two residents entering the program in 1971.
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 in 2004. In 1993, an intercollegiate Faculty of Accident and Emergency Medicine became a "daughter college" of six royal medical colleges in England and Scotland to arrange professional examinations and training. In 2005, the BAEM and the FAEM became a single unit 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 practice of emergency medicine.
Financing and practice organization
Reimbursement
Many hospitals and care centres feature departments of emergency medicine, where patients can receive acute care without an appointment. While many patients get treated for life-threatening injuries, others utilize the emergency department for non-urgent reasons such as headaches or a cold.. As such, EDs can adjust staffing ratios and designate an area of the department for faster patient turnover to accommodate various patient needs and volumes. Policies have improved to assist better ED staff. The emergency department, welfare programs, and healthcare clinics serve as a critical part of the healthcare safety net for uninsured patients who cannot afford medical treatment or adequately utilize their coverage.In emergency departments in Australia, the government utilises an "Activity based funding and management", meaning that the amount of funding to emergency departments are allocated money based on the number of patients and the complexity of their cases or illnesses. However, rural emergency departments of Australia are funded under the principle of providing the necessary equipment and staffing levels required to provide safe and adequate care, not necessarily on the number of patients.