Emergency Medication is a category of medicines which are used in medical emergencies.However,in this write up we will concentrate on emergency medical care related with disasters.
Emergency medicine, also known as accident and emergency medicine, is the medical specialty concerned with caring for undifferentiated, unscheduled patients with illnesses or injuries requiring immediate medical attention.
In their role as medical first- respondors and care providers, emergency physicians are responsible for initiating resuscitation and stabilization, starting investigations and interventions to diagnose and treat illnesses in the acute phase, coordinating care with specialists, and determining disposition regarding patients’ need for hospital admission, observation, or discharge. Emergency physicians generally practice in hospital emergency departments, pre-hospital settings via emergency medical services, and intensive care units, but may also work in primary care settings such as urgent care clinics.
Austwell, Texas, September 11, 2017 – Disaster survivor Terry Roundtree (center) gets a FEMA hug from Hector Marerro (center left), Disaster Survivor Assistance (DSA) Crew Lead, after Terry Roundtree receives FEMA disaster survivor registration information at her home following Hurricane Harvey. FEMA partners with other federal agencies, the state, local communities, counties, volunteer agencies active in disaster and tribal entities to provide assistance to disaster survivors. Photo by Christopher Mardorf / FEMA.
Different models for emergency medicine exist internationally. In countries following the Anglo-American model, emergency medicine was originally the domain of surgeons, general practitioners, and other generalist physicians, but in recent decades it has become recognised as a speciality in its own right with its own training programmes 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 speciality does not exist and emergency medical care is instead provided directly by anesthesiologists (for initial resuscitation), surgeons, specialists in internal medicine, or another speciality as appropriate.In developing countries, emergency medicine is still evolving and international emergency medicine programs offer hope of improving basic emergency care where resources are limited.
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.
The field of emergency medicine encompasses care involving the acute care of internal medical and surgical conditions. In many modern emergency departments, 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. They must have the skills of many specialists—the ability to resuscitate a patient (critical care medicine), 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 (cardiology), manage strokes (neurology), work-up a pregnant patient with vaginal bleeding (obstetrics and gynecology), stop a severe nosebleed (ENT), place a chest tube (cardiothoracic surgery), and to conduct and interpret x-rays and ultrasounds (radiology). Emergency physicians are thus trained in a wide array of skills, and this joint approach can obviate barrier-to-care issues resulting under less efficient service-providers. Emergency physicians also provide episodic primary care to patients during off hours and for those who do not have primary care providers.
Emergency medicine is distinct from urgent care, which refers to immediate healthcare for less emergent medical issues. However, many emergency physicians work in urgent care settings, since there is obvious overlap. 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 trained in other specialties.
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 consultants and health care 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.
Patterns vary by country and region. In the United States, the employment arrangement of emergency physician practices are either private (with a co-operative group of doctors staffing an emergency department under contract), institutional (physicians with an independent contractor relationship with the hospital), corporate (physicians with an independent contractor relationship with a third-party staffing company that services multiple emergency departments), or governmental (for example, when working within personal service military services, public health services, veterans’ benefit systems or other government agencies).
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 may be headed by general practitioners alone, sometimes with non-specialist qualifications in emergency medicine.
A brief review of some of these programs follows:
In Argentina, the SAE (Sociedad Argentina de Emergencias) is the main organization of Emergency Medicine. There are a lot of residency programs. Also it is possible to reach the certification with a two-year postgraduate university course after a few years of ED background.
Australia and New Zealand
The specialist medical college responsible for Emergency Medicine in Australia and New Zealand is the Australasian College for Emergency Medicine (ACEM). The training program is nominally seven years in duration, after which the trainee is awarded a Fellowship of ACEM, conditional upon passing all necessary assessments.
Dual fellowship programs also exist for Paediatric Medicine (in conjunction with the Royal Australasian College of Physicians) and Intensive Care Medicine (in conjunction with the College of Intensive Care Medicine). These programs nominally add one or more years to the ACEM training program.
For medical doctors not (and not wishing to be) specialists in Emergency Medicine but have a significant interest or workload in emergency departments, the ACEM provides non-specialist certificates and diplomas.
In Chile, Emergency and Emergency Medicine begins its journey with the first specialty program at the beginning of the 90s, at the University of Chile. Currently it is a primary specialty legally recognized by the Ministry of Health since 2013, and has multiple training programs for specialists, notably those of the University of Chile, Pontifical Catholic University of Chile, San Sebastian University – MUE and University of Santiago of Chile (USACH).Currently, and with the aim of strengthening the specialty at the country level, FOAMed initiatives have emerged (free open access medical education in emergency medicine) and the #ChileEM initiative that brings together the programs of the Universidad San Sebastián / MUE, Universidad Católica de Chile and Universidad de Chile, with the objective of holding joint clinical meetings between the main training programs, on a regular basis and open to all the health team working in the field of urgency. The specialists already trained are grouped in the Chilean Society of Emergency Medicine (SOCHIMU).
The two routes to emergency medicine certification can be summarized as follows:
- A 5-year residency leading to the designation of FRCP(EM) through the Royal College of Physicians and Surgeons of Canada (Emergency Medicine Board Certification – Emergency Medicine Consultant).
- A 1-year emergency medicine enhanced skills program following a 2-year family medicine residency leading to the designation of CCFP(EM) through the College of Family Physicians of Canada (Advanced Competency Certification). The CFPC also allows those having worked a minimum of 4 years at a minimum of 400 hours per year in emergency medicine to challenge the examination of special competence in emergency medicine and thus become specialized.
CCFP(EM) emergency physicians outnumber FRCP(EM) physicians by a ratio of about 3 to 1, and they tend to work primarily as clinicians with a smaller focus on academic activities such as teaching and research. FRCP(EM) Emergency Medicine Board specialists tend to congregate in academic centers and tend to have more academically oriented careers, which emphasize administration, research, critical care, disaster medicine, and teaching. They also tend to sub-specialize in toxicology, critical care, pediatrics emergency medicine, and sports medicine. Furthermore, the length of the FRCP(EM) residency allows more time for formal training in these areas.
The current post-graduate Emergency Medicine training process is highly complex in China. The first EM post-graduate training took place in 1984 at the Peking Union Medical College Hospital. Because specialty certification in EM has not been established, formal training is not required to practice Emergency Medicine in China.
About a decade ago, Emergency Medicine residency training was centralized at the municipal levels, following the guidelines issued by The Ministry of Public Health. Residency programs in all hospitals are called residency training bases, which have to be approved by local health governments. These bases are hospital-based, but the residents are selected and managed by the municipal associations of medical education. These associations are also the authoritative body of setting up their residents’ training curriculum. All medical school graduates wanting to practice medicine have to go through 5 years of residency training at designated training bases, first 3 years of general rotation followed by 2 more years of specialty-centered training.
In Germany, emergency medicine is not handled as a specialisation (Facharztrichtung), but any licensed physician can acquire an additional qualification in emergency medicine through an 80-hour course monitored by the respective “Ärztekammer” (medical association, responsible for licensing of physicians).A service as emergency physician in an ambulance service is part of the specialisation training of anaesthesiology. Emergency physicians usually work on a volunteering basis and are often anaesthesiologists, but may be specialists of any kind. Especially there is a specialisation training in pediatric intensive care.
India is an example of how family medicine can be a foundation for emergency medicine training. Many private hospitals and institutes have been providing Emergency Medicine training for doctors, nurses & paramedics since 1994, with certification programs varying from 6 months to 3 years. However, emergency medicine was only recognized as a separate specialty by the Medical Council of India in July 2009.
There are three universities (Universiti Sains Malaysia, Universiti Kebangsaan Malaysia, & Universiti Malaya) that offer master’s degrees in emergency medicine – postgraduate training programs of four years in duration with clinical rotations, examinations and a dissertation. The first cohort of locally trained emergency physicians graduated in 2002.
In Saudi Arabia, Certification of Emergency Medicine is done by taking the 4-year program Saudi Board of Emergency Medicine (SBEM), which is accredited by Saudi Council for Health Specialties (SCFHS). It requires passing the two-part exam: first part and final part (written and oral) to obtain the SBEM certificate, which is equivalent to Doctorate Degree.
Most programs are three years in duration, but some programs are four years long. There are several combined residencies offered with other programs including family medicine, internal medicine and pediatrics. The US is well known for its excellence in emergency medicine residency training programs. This has led to some controversy about specialty certification.
There are three ways to become board-certified in emergency medicine:
- The American Board of Emergency Medicine (ABEM) is for those with either Doctor of Medicine (MD) or Doctor of Osteopathic Medicine (DO) degrees. The ABEM is under the authority of the American Board of Medical Specialties.
- The American Osteopathic Board of Emergency Medicine (AOBEM) certifies only emergency physicians with a DO degree. It is under the authority of the American Osteopathic Association Bureau of Osteopathic Specialists.
- The Board of Certification in Emergency Medicine (BCEM) grants board certification in emergency medicine to physicians who have not completed an emergency medicine residency, but have completed a residency in other fields (internists, family practitioners, pediatricians, general surgeons, and anesthesiologists).
A number of ABMS fellowships are available for Emergency Medicine graduates including pre-hospital medicine (emergency medical services), critical care, hospice and palliative care, research, undersea and hyperbaric medicine, sports medicine, pain medicine, ultrasound, pediatric Emergency Medicine, disaster medicine, wilderness medicine, toxicology, and critical care medicine.
In recent years, workforce data has led to a recognition of the need for additional training for primary care physicians who provide emergency care.
This has led to a number of supplemental training programs in first hour emergency care, and a few fellowships for family physicians in emergency medicine.
Funding for Training
“In 2010, there were 157 allopathic and 37 osteopathic emergency medicine residency programs, which collectively accept about 2,000 new residents each year. Studies have shown that attending emergency physician supervision of residents directly correlates to a higher quality and more cost-effective practice, especially when an emergency medicine residency exists.” Medical education is primarily funded through the Medicare program;payments are given to hospitals for each resident. “Fifty-five percent of ED payments come from Medicare, fifteen percent from Medicaid, five percent from private payment and twenty-five percent from commercially insured patients.” However, choices of physician specialties are not mandated by any agency or program, so even though emergency departments see many Medicare/Medicaid patients, and thus receive a lot of funding for training from these programs, there is still concern over a shortage of specialty-trained Emergency Medicine providers.
In the United Kingdom, the Royal College of Emergency Medicine has a role in setting the professional standards and the assessment of trainees. Emergency medical trainees enter specialty training after five or six years of Medical school followed by two years of foundation training. Specialty training takes six years to complete and success in the assessments and a set of five examinations results in the award of Fellowship of the Royal College of Emergency Medicine (FRCEM).
Historically, emergency specialists were drawn from anaesthesia, medicine, and surgery. Many established EM consultants were surgically trained; some hold the Fellowship of Royal College of Surgeons of Edinburgh in Accident and Emergency — FRCSEd(A&E). Trainees in Emergency Medicine may dual accredit in Intensive care medicine or seek sub-specialisation in Paediatric Emergency Medicine.
Emergency Medicine residency lasts for 4 years in Turkey. These physicians have a 2-year Obligatory Service in Turkey to be qualified to have their diploma. After this period, EM specialist can choose to work in private or governmental ED’s.
Emergency Medicine training in Pakistan lasts for 5 years. The initial 2 years involve trainees to be sent to three major areas which include Medicine and allied, Surgery and Allied and critical care. It is divided into six months each and the rest six months out of first two years are spent in emergency department. In last three years trainee residents spend most of their time in emergency room as senior residents. Certificate courses include ACLS, PALS, ATLS, and research and dissertations are required for successful completion of the training. At the end of 5 years, candidates become eligible for sitting for FCPS part II exam. After fulfilling the requirement they become fellow of College of Physicians and Surgeons Pakistan in Emergency Medicine.
Presently there are two institutions where you can acquire this training which are Shifa International Hospitals Islamabad and Aga Khan Hospital Karachi. there are approximately 30 residents in different years of training, while the College has conducted its first exit examination for the FCPS in Emergency Medicine during December 2015.
The first residency program in Iran started in 2002 at Iran University of Medical Sciences, and there are now three-year standard residency programs running in Tehran, Tabriz, Mashhad, Isfahan, and some other universities. All these programs work under supervision of Emergency Medicine specialty board committee. There are now more than 200 (and increasing) board-certified Emergency Physicians in Iran.