Emergency medicine

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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. [1] 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.[2]

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)

References

  1. http://www.aamc.org/programs/cim/chartingoutcomes.pdf
  2. Department of Health - AMPDS Call Categorisation Vers 11 (April 2005)

See also

External links

de:Notfallmedizin ko:응급의학과 id:Kedaruratan medis ia:Medicina de emergentia he:רפואת חרום hu:Oxiológia nl:Spoedeisende geneeskunde simple:Emergency medicine



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