What is emergency medicine?

Science and Profession

The field of emergency medicine is defined as care to acutely ill and injured patients, both in the prehospital setting and in the emergency room. It is practiced as patient-demanded and continuously accessible care and is defined by the location of its practice rather than by an anatomical concern. Emergency medicine encompasses all medical specialties and physical systems. The commitment to rapid, prudent intervention under stressful and often chaotic conditions is of paramount importance to the critically ill patient. This branch of medicine is characterized by its complexity of problems, its twenty-four-hour availability to a variety of patients, and its effective and broad-based understanding of disease and injury. These features are used to orchestrate the response of multiple hands with the ultimate goal of referring the patient to ongoing care.

The hourglass is an appropriate symbol of the nature of this medical division. It not only portrays the importance of time and the need for quick intervention, but its shape—wide at either end and narrowing in the middle—also is an appropriate visualization of the pattern of emergency medical treatment. A large number of patients converge on a single area, the emergency room, where they are diagnosed, treated, and eventually released to other appropriate care, diverging on a wide range of follow-up options.

Unique to the field of emergency medicine is the importance of rapid definition and comprehension of the pathophysiology of the critically ill patient. Emergency care physicians must have a unique understanding of the practice of medicine, and the nature of disease and injury, availing themselves of a host of clinical skills needed for the treatment of the variety of physical and psychological problems that require treatment. Emergency rooms are a melting pot of problems; most are medical, many are not. All of them reflect some person’s perception of an emergency. Success in the emergency medical field often depends on the ability of personnel to use not only their medical knowledge but also their knowledge of people as well.

Most often those seeking the assistance of emergency medical providers are people suffering from pain of illness or trauma; however, any patient may seek treatment at the emergency room. Often loneliness, disability, or homelessness serves as the motivation to seek treatment. Regardless of what brought the patient, the emergency physician strives to recognize and deal with the patient’s “emergency,” remembering that not all patients are as ill as they might think and that not all are as well as they might appear. Physicians of this specialty sift through a large amount of information. It is necessary to know the patient’s pertinent medical history and the history of the present illness or complaint before appropriate and effective treatment can be prescribed. Patients rarely follow a preconceived plan. Emergency medicine works best, therefore, when its practitioners follow heuristics—that is, incomplete guides that lead to greater knowledge, a holistic approach.

Emergency medicine is primarily a hospital-based specialty; however, it also involves extensive prehospital responsibilities. Many times, patients seeking emergency care are first the responsibility of police, fire, or ambulance personnel. In these situations, the role of emergency medicine must be viewed under the wider context of the emergency medical system. This system—beginning with the first aid administered by bystanders; leading to initial treatment and transportation by trained certified emergency medical technicians, paramedics, or flight nurses; and culminating with care at an emergency room or a highly equipped trauma center—forms a uniquely structured unit. The emergency medical system is designed to provide rapid quality intervention regardless of prehospital conditions. The emergency medical physician is best viewed as a central part of a team whose knowledge and understanding of the whole allow the best possible care to patients undergoing health crises.

Emergency physicians are charged with the responsibility of providing the highest standard of care in the hospital setting. They ensure that both staff members and equipment are maintained at their utmost level of quality. Trends, breakthroughs, and advances are monitored via journals and other medical publications. Training of personnel must keep pace with medical advancement. Developing an overall program depends as much on its planning as its dissemination. The emergency physician often plays the role of teacher, actively influencing the overall quality of the program through education and skills development. Thus, the exercise of emergency medicine is truly a team effort, with all members acting in accordance with their training and level of competence in order to minimize further injury or discomfort.

In practice, emergency medicine encompasses any person or structure involved in the immediate decision making and/or actions necessary to prevent death or further disability of a patient in the midst of a health crisis. It represents a chain of human and physical resources brought together for the purpose of providing total patient care. In this respect, everyone has a part to play in the delivery of emergency care. The bottom line of emergency medicine is the welfare of the patient. Thus, it is most appropriate to view the practice of emergency medicine in the context of the entire emergency medical system.

The components of the emergency medical system include recognition of the emergency, initiation of emergency medical response, treatment at the scene, transport by members of an emergency medical team to the appropriate facility, treatment in the emergency room or trauma center, and release of the patient. These components are only as strong as the weakest link.

Diagnostic and Treatment Techniques

Recognition of an emergency is the first step in emergency care. Often this step is complicated by the patient’s own denial and ignorance of basic symptoms. “Emergency” is in part defined by the patient’s ability to identify, accept, and respond to a given situation. Regardless of the nature of the illness or injury, the sooner an emergency is defined, the sooner care can be provided. The typical heart attack victim, for example, waits an average of three hours after experiencing symptoms before seeking help. In such cases, treatment by bystanders who have been trained in first aid and cardiopulmonary resuscitation (CPR) has proven effective.

In the United States, the response of emergency medical personnel has been aided by the implementation of the 911 emergency system. Similar systems exist in other countries as well. While not all communities have this capability, its use is increasing. It has been documented that patients who receive treatment at an appropriate facility within sixty minutes of the onset of a life-threatening emergency are more likely to survive. This “golden hour” is precious time.

Operating under protocols developed and approved by the emergency medical director and emergency medical councils of a given locale, emergency medical technicians (EMTs) and paramedics are trained and authorized to deliver care to the patient in need at the scene. EMTs and paramedics are charged with the initial assessment of the patient’s condition, immediate stabilization prior to transport, delivery of care as far as their training allows, and the transport of the patient.

Unique to the field of emergency medicine is the special relationship of the paramedic with the doctor. Many people in need of emergency care are first treated outside the hospital. In these cases, emergency caregivers on the scene act as the eyes, ears, and hands of the physician. Through the EMT or paramedic, using telecommunications, an emergency doctor can speed the process of diagnosis. Signs and symptoms relayed through these trained professionals enable a doctor to make an accurate assessment of the patient’s condition and to request a variety of treatments for a patient whom they cannot see or touch. Linked by telephone or radio, the medic and doctor can capitalize on the golden hour with the initiation of quality care.

In the United States, paramedics operate under the medical license of a medical command physician and has been approved to provide medical directives to prehospital and interhospital providers. Protocols are the recognized practices that are within the training of the EMT and paramedic. They serve as standard procedures for prehospital treatment. While it is recognized that situations will arise that call for deviation from particular aspects of a given protocol, they are the standards under which the doctor and emergency personnel on the scene operate.

Treatment at the scene is followed by transport with advanced life support by members of the emergency medical system in 85 percent of all emergency cases. This requires much-needed equipment for the further treatment of patients. Deficiencies in the vehicle, equipment, or training of medical personnel can seriously endanger a patient. Thus, government agencies have been designated to grant permission for ambulance services and hospitals to engage in the practice of emergency medicine. This licensure process is designed to demand a level of competency for health care providers and ensure the public’s protection.

Since many emergency department admissions do not constitute life-threatening situations, not all facilities stand at the same level of readiness for a given emergency. Transportation to the appropriate facility, therefore, requires a matching of the patient’s need to the hospital’s capabilities. Hospitals are categorized according to their ability to render emergency intensive care, as well as to provide needed support services on a patient-demand basis. In general, they are viewed as emergency facilities and trauma centers designed to provide twenty-four-hour, comprehensive emergency intensive care, including operating rooms and intensive care nurses.

When the patient reaches the emergency facility, during the first five to fifteen minutes of care, many important decisions are made by the physician on duty. The process continues to overlap with needed diagnostic tests and consultations in an effort to provide quality care directed at the source of the illness or injury. The patient’s immediate needs are cared for by emergency department staff until the patient is moved to a site of continued care or released to his or her own care.

Questions correctly phrased and sharply directed are effective tools for the rapid diagnosis needed in emergency medicine. The key to this field is the ability to triage, stabilize, prioritize, treat, and refer.

Triage is the system used for categorizing and sorting patients according to the severity of their problems. Emergency practitioners seek to ascertain the nature of the patient’s problem and consider any life-threatening consequences of the present condition. This stage of triage allows for immediate care to the more seriously endangered person, relegating the more stable, less seriously ill or wounded patients to a waiting period. The emergency room, in other words, does not operate on a first come, first served basis.

Secondary to triage is stabilization. This term refers to any immediate treatment or intervening steps taken to alleviate conditions that would result in greater pain or defect and/or lead to irreversible or fatal consequences. Primary stabilization steps include ensuring an unobstructed airway and providing adequate ventilation and cardiovascular function.

Once patients have been stabilized, all illnesses must be looked at on the scale of their hierarchical importance. Life-threatening diseases or injuries are treated before more moderate or minor conditions. This system of prioritization can be illustrated from patient to patient: A heart attack victim, for example, is treated prior to the patient with an ankle sprain. It can also be applied for multiple conditions within the same patient. The heart attack victim with a sprained ankle receives treatment first for the life-threatening cardiovascular incident.

Treatment of the critically ill patient often poses a series of further questions. What is the primary disorder? Is there more than one active pathologic process present? How does the patient appear? Is the patient’s presentation consistent with the initial diagnosis? Is a hospital stay warranted? What consultations are needed to diagnose and treat this patient?

The emergency physician’s approach is to consider the most serious disease consistent with the patient’s presentation and chief complaint. By rule of thumb, thinking the worst and hoping for the best is often the psychological stance of the emergency care provider. Only when more severe conditions have been ruled out are more minor processes considered. Often too, this broad view of patient assessment allows for multiple diagnoses. Through continued probing, alternate and additional conditions are often uncovered. It is not unlikely that the patient who seeks treatment for a head injury after a fall is diagnosed with a more serious condition that caused the fall. Focusing only on the immediate condition would endanger the patient. Success in this medical field therefore demands broad-based medical knowledge and diagnostic tools.

Emergency medicine is not practiced in a vacuum. Its very nature necessitates its interfacing with a variety of medical specialties. The emergency room is often only the first step in patient recovery. Initial diagnosis and stabilization must be coupled with plans for ongoing treatment and evaluation. Consultations and referrals play important roles in the overall care of a patient.

Perspective and Prospects

Historians are unable to document specific systems for emergency patients before the 1790s. The need to provide care to the battlefield wounded is seen as the first implementation of emergency response. Early wartime treatment did not, however, include prehospital treatment. American nurse Clara Barton is credited with providing the first professional-level prehospital emergency care for the wounded as part of the American Red Cross, founded in 1881. Ambulance services began in major cities of the United States at the beginning of the twentieth century, but it was not until 1960 that the National Academy of Sciences’ National Research Council actually studied the problem of emergency care.

Emergency medicine as a specialty is relatively new. Not until 1975, when the House of Delegates of the American Medical Association defined the emergency physician, did the US medical community even recognize this branch of medicine. In 1981, the American College of Emergency Physicians added further recognition through the development of the definition of emergency medicine. Since then, growth and changes have enabled this field to develop as a major specialty, evolving to accept greater responsibility in both education and practice. The development of emergency medicine and the increasing number of health care providers in this field have since then been dramatic.

Emergency medicine developed at a time when both the general public and the medical community recognized the need for quality accessible care in the emergency situation. It has grown to include a gamut of services provided by a community. In addition to responding to the acutely ill or injured, emergency medicine has grown to accept responsibilities of education, administration, and advocacy.

Included in the role of today’s emergency medical providers is the administration of the entire emergency medical system within a community. This system includes the development of public education programs such as CPR instruction, poison control education, and the introduction of the 911 system. Emergency management systems and coordinators are now part of every state and local government. Disaster planning for both natural and human-made accidents also comes under the heading of emergency medicine.

Research, too, plays an important role in emergency medicine. The desire to identify, understand, and disseminate scientific rationale for basic resuscitative interventions, as well as the need to improve preventive medical techniques, are often driving forces in scientific research.

Finally, emergency medicine plays a key role in many of society’s problems. Homelessness, drug use and abuse, acquired immunodeficiency syndrome (AIDS), and rising health costs have all contributed to the increase in the number of patients seen in the emergency room. In response, those administering emergency medical care have tried to communicate such problems to the general public and legislative bodies, as well as educate them regarding preventive measures. Being on the front line of medicine brings a special obligation to improve laws and services to ensure public safety and well-being.

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