Emergency Medicine/Organization of emergency medicine

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The specialty of emergency medicine

In some jurisdictions, Emergency Medicine is almost regarded as a sub-discipline to Family Medicine. Most authors would now hold that Emergency Medicine has become sufficiently specialised, in techniques and knowledge scope, to be a discipline in its own right. While there can be a General Practice component to many cases seen in the typical emergency room, most emergency rooms now have to deal with an acuity and complexity of case that general practitioners are no longer sufficiently skilled to handle such cases. For General Practitioners who expect to practise in smaller towns or in rural areas, it is particularly important to incorporate good Emergency Medicine experience into their training.

Usually practicing in a hospital setting, EM physicians have training to deal with most medical emergencies, and usually maintain certifications in CPR, at least the first two of the following:

• Advanced Cardiac Life Support (ACLS)
• Advanced Trauma Life Support (ATLS)

For those who also operate in the extramural (pre-hospital) setting:

• PreHospital Trauma Life Support (PHTLS)
• PreHospital Pediatric Emergency Care (PPEC)

For those who specialize in pediatric trauma care:

• Advanced Pediatric Trauma Life Support (APTLS)

In addition, in cases of disasters requiring special resources, many hospitals have protocols to rapidly deploy on-site and off-site staff.

The management of both emergency department (ED) and inpatient medical emergencies are guided by the basic ACLS and ATLS principles and protocols. Irrespective of the nature of the clinical emergency, maintenance of adequate blood pressure, adequate blood flow to vital organs and adequate oxygenation and ventilation are important guiding principles. (Although sometimes these principles must be deliberately broken, as in the deliberate clamping of an arterial bleeder to prevent exsanguination).

The first step in emergency medicine is triage: determining who (if there are multiple casualties) requires medical assistance first. Triage is done at multiple stages in the care process, especially in case of incidents involving many casualties.

• On-site personnel decides which victims are treated on the scene and which are to be taken to a hospital, and in which order.
• At the entrance to the ED, an ED worker (usually a nurse) determines to which treatment room each victim should be taken.
• The ED physician checks which patient he needs to attend to first.

Introduction to emergency medicine

The art of emergency medicine can best be described using the following ideas examined upon initial evaluation:

• Airway
• Breathing
• Circulation
• Disability (neurologic) or Differential Diagnosis

These point are known as the ABC(D)'s of Emergency Medicine.

Then the general steps of practicing Emergency Medicine:

• Assessment
• Diagnosis
• Treatment
• Disposition

The ABC's of emergency medicine are basic to life support. Every time one enters into an emergency one should determine whether the patient has an open airway, if they are breathing in an unobstructed manner, if they have an adequate pulse (circulation), if they have any obvious sources of bleeding, and if they have any (neurologic) disability (e.g. a broken neck that has led to neurological injury.)

Assessment using the ABC's is the cornerstone of emergency care and it should be a continuous and ongoing process. Just because initially someone's airway is patent doesn't mean it necessarily will stay that way. So the key point is to stay flexible in assessment and treatment. The mark of an ED physician is someone who can manage the airway (intubate), someone who can manage the breathing of a patient (set a ventilator) and someone who can provide cardiac or respiratory support (ACLS treatment of cardiac problems like shock, myocardial infarction or arrhythmias.)

Disposition

A central decision in emergency medicine is whether a patient requires emergent treatment, is suitable for admission, or is stable for discharge. Emergency physician training emphasizes prompt and appropriate disposition of patients to the location that best meets their health needs. In increasingly busy emergency departments, the emergency physician must choose tests judiciously, perform emergent interventions and procedures efficiently, and disposition patients appropriately. In most Western hospitals, the emergency department now serves as the "front door" of the hospital, with most inpatients having been admitted via the emergency department first. Further, the emergency department, unlike clinic or office based practices, generally has access to the full diagnostic and interventional resources of the hospital, allowing medical care to be front-loaded. Many diagnoses can now be made before the patient leaves the emergency department with the aid of resources like CT and MRI. And many definitive treatments can now be initiated in the emergency department as well, such as thrombolytics in heart attack and stroke, antibiotic treatment in severe infections, and surgical procedures like chest drains, incision and drainage of abscesses, and laceration repair.

Clinical crisis protocol

The "clinical crisis protocol" is an approach to dealing with urgent problems when a patient's life is in danger and there is limited time to act. Thus, diagnosis of the problem must be accompanied by initial empirical treatment, i.e. diagnosis and treatment must be carried out concurrently, even when it's far from clear what is going on. For example, severe bradycardia (heart rate < 40) may or may not be associated with symptoms such as syncope and can be due to many different causes, (e.g. third degree heart block, beta blocker overdose, use of an anti-cholinesterase without sufficient anticholinergic (e.g. neostigmine without glycopyrrolate or atropine), increased intracranial pressure, etc.)

An approach to rapidly assess the patient the trouble is sometimes needed:

LOOK: Color (cyanosis, erythema, pallor), respirations (rate, pattern), diaphoresis, bleeding/dressings/drains, neck (jugular venous distenstion, tracheal deviation), restlessness, discomfort

LISTEN: breath sounds (?equal), wheezes, crackles, stridor, heart sounds, patient’s complaints, observations of bystanders

FEEL: pulse (rate, intensity, pattern), grip strength (esp. after muscle relaxants given), forehead (temperature, diaphoresis)

GET: help, vital signs, old chart, crash cart, labs, chest x-ray... Again, we emphasize that initial empirical treatment is essential while we are finding out what is going on. For example, in the case of symptomatic severe bradycardia, intravenous atropine (0.6 - 1 mg) should be given (among other things).