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emergency medicine the specialty seminar papers emergency medicine the specialty th rainer the perception of emergency medicine as a defined specialty may vary widely in different locations around the world ...

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                                                                                                              Emergency medicine—the specialty
                                           SEMINAR PAPERS
                Emergency medicine—the specialty
                TH Rainer
                The perception of emergency medicine as a defined specialty may vary widely in different locations
                around the world. While no single emergency medical system can fulfil the needs of all countries, there
                are three main models of delivery: the European model, the Anglo-American model, and the neglect
                model. This article reviews aspects of emergency medical systems around the world and compares the
                European and Anglo-American models of emergency care. The current state of emergency medicine in
                Hong Kong is also presented, including challenges facing the specialty as we enter the 21st century.
                HKMJ 2000;6:269-75
                Key words: Curriculum; Educational measurement; Emergency medical services; Emergency medicine; Models,
                organizational; Specialties, medical
                Introduction                                                          The population in a community includes a large
                                                                                  pool of healthy individuals who do not require med-
                The perception of emergency medicine as a defined                 ical care. Within a community, however, there are also
                specialty may vary widely in different locations                  individuals who have acute or chronic illnesses, which
                around the world.1 There has always been a need for               range in severity from minor to critical. While some
                ‘emergency care’ but the organisation of such care                of these people can be seen as out-patients , some
                under defined national medical banners originated                 require immediate treatment in the community, some
                                               2-6
                mainly in the 20th century.  The ideal in emergency               require immediate resuscitation at the interface
                care is to provide the most experienced appropriate               between hospital and community, and some require
                knowledge and expertise available as soon as possible             admission to medical, surgical, paediatric, intensive
                and in the most cost-effective manner, with the aim               care, or other facilities. There are also others who
                of returning patients to health. However, the practical           require only a quick consultation with a trained
                realities of delivering such care vary throughout the             individual, reassurance, or minor treatment. But in a
                world. Demands are sometimes excessively high and                 heterogeneous population with such variable needs,
                resources can be limited.7                                        who decides the level of treatment that each patient
                                                                                  receives, who should deliver the appropriate care, and
                   Experts in emergency care are expensive to train               how can emergency treatment be delivered in the most
                and sustain in service. Training not only costs money             cost-effective manner? These questions have stimulated
                but also takes time, and it may need to be adapted to             much debate about the provision of emergency care,
                different environments and demands. An inadequate                 which has reached a potential state of crisis as we
                number of such experts cannot meet the needs of                   enter the 21st century.
                society, yet too many would represent an unnecessary
                waste of training and resources. Hence, the provision                 Civilian emergency medicine involves the delivery
                of emergency care needs strategic planning, experi-               of care in the following settings: the prehospital
                ence, and organisation, as well as sufficient flexibility         environment, the interface between the community and
                to adapt to change.                                               the hospital, and the in-hospital environment. Emer-
                                                                                  gency care varies greatly in different areas of the world,
                                                                                  but in general, ambulance, physician, and paramed-
                Accident and Emergency Medicine Academic Unit, The Chinese        ical personnel largely cover the prehospital environ-
                University of Hong Kong, Prince of Wales Hospital, Shatin, Hong   ment. The interface between the community and the
                Kong                                                              hospital is administered either by an admissions area
                TH Rainer, MB, BCh, MRCP                                          that is staffed by members from all specialties, or by
                Correspondence to: Prof TH Rainer                                 specially trained emergency physicians.
                                                                                                        HKMJ Vol 6 No 3 September 2000      269
               Rainer
                  This article describes some of the different systems      the patient receives faster definitive care. There are
               of emergency care delivery at the interface between          no good trials comparing the two systems, and it is
               the hospital and community. Its focus is emergency           difficult to determine whether one is better than the
               medicine as a specialty, rather than prehospital care        other. In reality, whenever individuals are motivated
               systems or emergency medical systems.                        and well trained, and when teams work well together,
                                                                            it is likely that good outcomes will result whichever
               Models of emergency care delivery                            system is used.
               While no single emergency medical system can fulfil          Emergency medicine in the United States
               the needs of all countries, there are three main models
               of delivery: the European model, the Anglo-American          In a short period of time, emergency medicine has
               model, and the neglect model. The last model prevails        established itself in the United States (US) as a major
               when, for whatever reason, emergency care is not             and very attractive specialty, such that the Americans
               considered a national priority. From the point at which      lead the world with their model of emergency care.
               patients first feel that they need care to the point at      The first residency programme was introduced in 1970
               which they receive care that is appropriate to resolve       in the University of Cincinnati, Ohio, and by 1996,
                                                                                                                                  3
               their needs (definitive care), there are several im-         the number of programmes had increased to 127.
               portant practical steps. The subpopulation that requires
               medical care needs to be flagged before those needing        Undergraduate medical training
               in-hospital management can be identified. This pro-          A comparison between the educational systems of
               cedure may be initiated by a patient’s attending an out-     the US and the United Kingdom (UK), from nursery
               of-hospital doctor (a general practitioner) or calling       school to full specialty certification has recently been
                                                                                       2,3
               for paramedical staff (eg the ambulance service), or         outlined.  Despite some differences, the overall
               by self-referral to a hospital to see a physician at the     structures are remarkably similar. Medical school
               interface between community and hospital.                    training in the US lasts for 4 years and is a postgradu-
                                                                            ate process, whereas students in the UK train for 5
                  The Anglo-American model of emergency medi-               to 6 years as undergraduates.
               cine has developed a system of specially trained
                                                         3 These phys-      Postgraduate medical training and certification in
               hospital-based emergency physicians.
               icians will assess anyone who attends the hospital;          emergency medicine
               hence, they require training and experience in a broad       The US health care system provides a two-tiered
               range of assessment techniques. In addition, they will       system of medical provision: trainees within a specialty
               resuscitate critically ill individuals and deliver a broad   and attending physicians. In the US, prospective
               range of emergency services. The conflict within this        trainees in emergency medicine can apply to join a
               system lies in defining the scope of care and where          residency programme either from medical school or
               the boundaries lie in delivering the service. In theory,     while working as a doctor in another residency pro-
               the potential is unlimited. In practice, clear limits        gramme. Emergency medicine is a popular specialty
               need to be set because financial and human resources         in the US, and competition for residency programmes
               are limited.                                                 is intense. Approximately 90% of trainees enter an
                                                                            emergency medicine residency programme within 1
                  In the European model, resuscitation is delivered         year of qualifying as a doctor, and training in the
               to seriously ill patients in the field, after which the      specialty lasts for 3 or 4 years. Although American
               patient is immediately referred to definitive care           medical students are generally older than their UK
               facilities in the hospital. The sorting and categorisa-      counterparts, the period of general professional train-
               tion of critically ill patients occur in the field. There    ing before they enter the specialty programme is
               are few or no specialty-trained emergency physicians         shorter or absent. After completing residency train-
               at the hospital-admission interface. Patients who are        ing, the emergency physician looks for a post as an
               not critically ill attend a hospital or a ‘polyclinic’ and   attending physician. In most emergency departments,
               are seen directly by a medical or surgical physician, or     one attending physician supervises several residents
               a physician of another specialty. Different specialists      (trainees).3
               may discuss and decide who should be admitted to
               hospital and to which department. Anglo-American                 Most training is based within the emergency
               physicians believe that their system is more efficient,      department, although trainees spend considerable
               while Europeans believe that under their system,             out-of-service time in other specialties, such as
               270      HKMJ Vol 6 No 3 September 2000
                                                                                                 Emergency medicine—the specialty
              paediatrics and critical care, and they rotate to other   Postgraduate medical training and certification in
              hospitals to broaden their experience. There is a great   accident and emergency medicine
              emphasis on prehospital care and interhospital            A three-tier system currently exists within the UK
              transfer, such that most residents gain experience in     in the medical ladder: senior house officers (basic
              delivering ambulance- or helicopter-based (or both)       professional trainees), specialist registrars (trainees),
              emergency care. Each residency programme has a            and consultants. After completing medical school, a
              minimum intake of six residents, so that in a 3-year      doctor in the UK undertakes a 1-year apprenticeship
              training programme, at least 18 doctors are trained at    as a house officer, which comprises 6 months of experi-
              any one time.                                             ence in medicine and 6 months in surgery. After
                                                                        having received 3 to 4 years of general professional
              Emergency medicine in the United Kingdom                  training, physicians may apply to enter the specialty
                                                                        training of their choice.
              Until 1962, the hospital departmental site that was
              dedicated to receiving and stabilising acutely sick and       The entry requirement for training in emergency
              injured patients was termed the ‘casualty’, and the       medicine is the possession of one of the following
              patient was called ‘a casualty.’ A secondary role of      higher diplomas: Member of the Royal College of
              these departments was to assess and treat patients        Physicians (MRCP), Fellow of the Royal College
              who desired a medical opinion and who believed            of Surgeons (FRCS), Fellow of the Royal College
              that their case might be urgent. Abuse of this system     of Anaesthetists (FRCA), or Fellow of the Royal
              led to the term ‘casual attender’ and such patients       College of Surgeons in Accident and Emergency
              have progressively drained the resources of the health    (FRCS[A&E]), which are all equivalent to passing
              service, distracted its doctors from their primary        the current intermediate examination in Hong Kong.
              objective, and diluted their experience of managing       Higher specialist training lasts 5 years and produces
              critically ill patients.                                  specialists with a European certificate on completion
                                                                        of specialist training, who may apply for a consultant
                 In an effort to re-educate patients toward the es-     post. Each training post has a national number, which
              sential nature of the service, the 1962 Platt report8     is passed onto a new candidate when the previous
              recommended dropping the term casualty and re-            candidate vacates the post. These training posts are
              naming the unit as an accident and emergency (A&E)        subject to manpower controls, which are decided at a
              department. In 1967, the Casualty Surgeons Associ-        political level.
              ation was established and by 1972, 30 A&E consult-
              ants were appointed in a pilot scheme, which was          The emergency medical system
              so successful that their number had approached 100        Accident and emergency departments vary widely in
              by 1978—the year in which formal senior registrar         the UK, with respect to levels of attendance, variety of
              training was commenced. In 1983, the Royal College        medical case-load, staffing levels, and training. In
              of Surgeons of Edinburgh introduced a specialist          general, all A&E departments are extremely busy,
              fellowship examination in A&E medicine and surgery        highly stressed, and overloaded. Activities involve
              and in 1990, the first Professor of A&E Medicine          patient management, teaching and training of junior
              was appointed.                                            staff, departmental and resource management, review
                                                                        clinics, and occasionally research. Some departments
              Undergraduate medical training                            have observation wards. The academic environment,
              There are 27 medical schools in the UK; their annual      similar to the clinical service, is severely strained
              student intake is approximately 6000 and the average      and most academics experience a conflict between
              age of entry is 18 years. Traditionally, medical schools  university and health service expectations.
              operated a 5-year course with two preclinical and
              three clinical years, but basic science and clinical      Emergency medicine in mainland Europe
              programmes have recently become more integrated,
              practical, and problem-oriented. The most commonly        The provision of emergency medicine varies greatly
              awarded medical degree is the Bachelor of Medicine,       in mainland Europe, and there is no unifying policy
                                                                                                 9-13
              Bachelor of Surgery, which is equivalent to the           regarding the specialty.     The UK differs substan-
              Doctor of Medicine degree in the US. In the UK, the       tially from its European neighbours in this respect.
              Doctor of Medicine degree is a postgraduate one           Although European medical journals, societies, and
              and is roughly equal to a Doctor of Philosophy in         conferences exist, there remains confusion because
              international terms.                                      of the different definitions and practice models.
                                                                                           HKMJ Vol 6 No 3 September 2000      271
               Rainer
               Emergency medicine in Germany                                Emergency medicine in eastern Europe
               Common to all emergency systems, emergency                   The concept of emergency medicine in eastern Europe
               care occurs in both the prehospital and hospital             is similar to that of Germany, although it is not so well
                                                                                                     13
               environments, but emergency medicine is defined              developed or efficient.  Emergency departments are
               differently and more loosely in Germany than in the          little more than triage areas from which patients are
                                         9
               Anglo-American model.  Emergency medicine per se             designated to a particular specialty. A generalist with
               is not recognised, but there is a well-developed pre-        special training in the management of acute critical
               hospital system, which includes paramedical ambulance        care and emergency problems does not exist. Although
               personnel, and ambulances and cars that are staffed          not categorised as part of an emergency department,
               by physicians. The first physician-staffed ambulance         the ‘department of resuscitation’ is the nearest equiva-
               service was launched in 1957, with the aim of taking a       lent and consists usually of a resuscitation room run
               doctor to the patient in the community rather than           by emergency staff trained in anaesthesia.
               bringing the patient to the doctor in the hospital. Emer-
               gency medicine is thus not a hospital-based specialty that   Emergency medicine in Africa
               has its own core knowledge and defined interests, but
               rather a concept of delivery of care in the community.       Few data have been published about emergency
                                                                            medical services in Africa, but almost without excep-
                  After a call is received at a central control bureau,     tion, there are is no established emergency model. In
               an assessment is made of the severity of the patient’s       South Africa, a new integrated health system is being
               condition and a physician-staffed ambulance or               developed, but there is currently great disparity between
               standard ambulance (or both) is dispatched to treat the      regions of the country.14
               patient. Thus, a critically ill patient may be assessed
               and treated by a physician in the community and                  In Namibia, the general medical officer is the
                                                                                                                        15
               delivered to the definitive care specialty on arrival at     backbone of the state-run health service.  There is no
               the hospital. A standard ambulance service also              emergency telephone (eg 999) system, no emergency
               delivers patients to hospital, where they are evaluated      ambulance service, no emergency physicians, and no
               in an admission area by the appropriate specialty.           specialised training beyond internship. Emergency
               Specialties may cross-refer before the patient is            departments are staffed by untrained casualty officers,
               ultimately discharged or admitted. There are no out-         who view their posts as temporary until better positions
               come studies to show that this system is more or             become available. Namibia probably reflects most of
               less cost-effective when compared with the Anglo-            the rest of Africa, in which the neglect model applies.
               American model, but from the few data available,
               clinical outcomes appear to be at least as good.             Emergency medicine in Hong Kong
                  Most emergency physicians are employed by                 The history of the development of prehospital emer-
               hospitals rather than by ambulance services, and they        gency care and emergency medicine in Hong Kong
                                                                                                           4,5,16
               have trained as specialists in anaesthesiology, surgery,     has recently been reviewed.         The medical services
               or internal medicine; some may have previously been          generally followed the British system until the trans-
               private physicians. Emergency physicians may spend           fer of sovereignty to China in 1997. The first casualty
               most of their working time within the hospital, although     unit was established at the Queen Mary Hospital in
               they have a small commitment to the prehospital              1947 and the first full-time consultant was appointed
               service; some work full-time in prehospital care. In         in 1981. ‘Casualty’ was renamed ‘accident and emer-
               the US, emergency medical systems are functionally           gency’ in 1983, and the first local candidate passed
               controlled and organised by physicians. It appears           the FRCS(A&E) examination in Edinburgh in 1984.
               that the general position of the German Medical
               Society is that it is dangerous to extend physicians’            The Hong Kong Society for Emergency Medicine
               responsibilities to ambulance personnel without              and Surgery was formed in 1985, and the first Profes-
               rigorous training and continued medical control over         sor of A&E Medicine was appointed at The Chinese
                           9 While the emergency medical system is          University of Hong Kong in 1995. In 1997, the specialty
               the service.
               governed mainly by non-physicians (eg fire chiefs            matured with the inauguration of the Hong Kong
               or administrators of paramedical services such as            College of Emergency Medicine (HKCEM). With the
               the German Red Cross), the transfer of physicians’           development of the Anglo-American model of emer-
               responsibility to ambulance personnel is considered          gency medicine Hong Kong is leading Asia into the
               inappropriate and dangerous.                                 21st century .
               272      HKMJ Vol 6 No 3 September 2000
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...Emergency medicine the specialty seminar papers th rainer perception of as a defined may vary widely in different locations around world while no single medical system can fulfil needs all countries there are three main models delivery european model anglo american and neglect this article reviews aspects systems compares care current state hong kong is also presented including challenges facing we enter st century hkmj key words curriculum educational measurement services organizational specialties introduction population community includes large pool healthy individuals who do not require med ical within however have acute or chronic illnesses which has always been need for range severity from minor to critical some but organisation such these people be seen out patients under national banners originated immediate treatment mainly ideal resuscitation at interface provide most experienced appropriate between hospital knowledge expertise available soon possible admission surgical paedi...

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