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Emergency medicine

Emergency medicine is the medical speciality concerned with the care of illnesses or injuries requiring immediate medical attention. Emergency medicine physicians (often called "ER doctors" in the United States) specialize in providing care for unscheduled and undifferentiated patients of all ages. As first-line providers, in coordination with emergency medical services, they are primarily responsible for initiating resuscitation and stabilization and performing the initial investigations and interventions necessary to diagnose and treat illnesses or injuries in the acute phase. Emergency medical physicians generally practice in hospital emergency departments, pre-hospital settings via emergency medical services, and intensive care units. Still, they may also work in primary care settings such as urgent care clinics.

Sub-specializations of emergency medicine include; disaster medicine, medical toxicology, point-of-care ultrasonography, critical care medicine, emergency medical services, hyperbaric medicine, sports medicine, palliative care, or aerospace medicine.

Various models for emergency medicine exist internationally. In countries following the Anglo-American model, emergency medicine initially consisted of surgeons, general practitioners, and other generalist physicians. However, in recent decades it has become recognised as a speciality in its own right with its training programmes and academic posts, and the speciality 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 critical resuscitation), surgeons, specialists in internal medicine, paediatricians, cardiologists or neurologists as appropriate. Emergency medicine is still evolving in developing countries, and international emergency medicine programs offer hope of improving primary emergency care where resources are limited.

Scope
Emergency medicine is a medical speciality—a field of practice based on the knowledge and skills required to prevent, diagnose, and manage acute and urgent aspects of illness and injury affecting patients of all age groups with a full spectrum of undifferentiated physical and behavioural 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 see many patients, treating their illnesses and arranging for disposition—either admitting them to the hospital or releasing them after treatment as necessary. They also provide episodic primary care to patients during off-hours and those who do not have primary care providers. Most patients present to emergency departments with low-acuity conditions (such as minor injuries or exacerbations of chronic disease), but a small proportion will be critically ill or injured. Therefore, the emergency physician requires broad knowledge and procedural skills, often including surgical procedures, trauma resuscitation, advanced cardiac life support and advanced airway management. They must have some of the core skills from many medical specialities—the ability to resuscitate a patient (intensive care medicine), manage a difficult airway (anesthesiology), suture a complex laceration (plastic surgery), set a fractured bone or dislocated joint (orthopaedic surgery), treat a heart attack (cardiology), manage strokes (neurology), work-up a pregnant patient with vaginal bleeding (obstetrics and gynaecology), control a patient with mania (psychiatry), stop a severe nosebleed (otolaryngology), place a chest tube (cardiothoracic surgery), and conduct and interpret x-rays and ultrasounds (radiology). This generalist approach can obviate barrier-to-care issues seen in systems without specialists in emergency medicine, where patients requiring immediate attention are instead managed from the outset by speciality doctors such as surgeons or internal physicians. However, this may lead to barriers through acute and critical care specialities disconnecting from emergency care.

Emergency medicine may separate from urgent care, which refers to primary healthcare for less emergent medical issues, but there is obvious overlap, and many emergency physicians work in urgent care settings. 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 have medical skills from other specialities.

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 other specialities and healthcare 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.

Work patterns
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 or without 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 are sometimes run by general practitioners alone, sometimes with non-specialist qualifications in emergency medicine.

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 ambulances, or "flying carriages", for rapid transport of wounded soldiers to a central place where medical care was more accessible and practical. Larrey operated 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 as an independent medical speciality is relatively young. Before the 1960s and 1970s, hospital emergency departments (EDs) were generally staffed by physicians on staff at the hospital on a rotating basis, among them family physicians, general surgeons, internists, and a variety of other specialists. In many smaller emergency departments, nurses would triage patients, and physicians would be called in based on the type of injury or illness. Family physicians were often on call for the emergency department and recognized the need for dedicated emergency department coverage. Many of the pioneers of emergency medicine were family physicians and other specialists who saw a need for additional training in emergency care.

During this period, physicians began to emerge who had left their respective practices to devote their work entirely to the ED. In the UK in 1952, Maurice Ellis was appointed as the first "casualty consultant" at Leeds General Infirmary. In 1967, the Casualty Surgeons Association was co-established with Maurice Ellis as its first president. In the US, the first of such groups managed by Dr James DeWitt Mills in 1961, along with four associate physicians; Dr Chalmers A. Loughridge, Dr William Weaver, Dr John McDade, and Dr Steven Bednar, at Alexandria Hospital in Alexandria, Virginia, established 24/7 year-round emergency care, which became known as the "Alexandria Plan".

It was not until Dr. John Wiegenstein founded the American College of Emergency Physicians (ACEP) the recognition of emergency medicine training programs by the AMA and the AOA, and in 1979 a historic vote by the American Board of Medical Specialties that emergency medicine became a recognized medical speciality in the US. The first emergency medicine residency program in the world began in 1970 at the University of Cincinnati. Furthermore, the first department of emergency medicine at a US medical school occurred in 1971 at the University of Southern California. The second residency program in the United States soon followed at what was then called Hennepin County General Hospital in Minneapolis, with two residents entering the program in 1971.

In 1990 the UK's Casualty Surgeons Association changed its name to the British Association for Accident and Emergency Medicine and subsequently became the British Association for Emergency Medicine (BAEM) in 2004. In 1993, an intercollegiate Faculty of Accident and Emergency Medicine (FAEM) became a "daughter college" of six royal medical colleges in England and Scotland to arrange professional examinations and training. In 2005, the BAEM and the FAEM became a single unit to form the College of Emergency Medicine, now the Royal College of Emergency Medicine, which conducts membership and fellowship examinations and publishes guidelines and standards for the practice of emergency medicine.

Reimbursement
Many hospitals and care centres feature departments of emergency medicine, where patients can receive acute care without an appointment. While many patients get treated for life-threatening injuries, others utilize the emergency department (ED) for non-urgent reasons such as headaches or a cold. (defined as "visits for conditions for which a delay of several hours would not increase the likelihood of an adverse outcome"). As such, EDs can adjust staffing ratios and designate an area of the department for faster patient turnover to accommodate various patient needs and volumes. Policies have improved to assist better ED staff (such as emergency medical technicians, paramedics). Mid-level providers such as physician assistants and nurse practitioners direct patients towards more appropriate medical settings, such as their primary care physician, urgent care clinics or detoxification facilities. The emergency department, welfare programs, and healthcare clinics serve as a critical part of the healthcare safety net for uninsured patients who cannot afford medical treatment or adequately utilize their coverage.

In emergency departments in Australia, the government utilises an "Activity based funding and management", meaning that the amount of funding to emergency departments are allocated money based on the number of patients and the complexity of their cases or illnesses. However, rural emergency departments of Australia are funded under the principle of providing the necessary equipment and staffing levels required to provide safe and adequate care, not necessarily on the number of patients.

Compensation
Emergency physicians are compensated at a higher rate than some other specialities, ranking 10th out of 26 physician specialities in 2015, at an average salary of $306,000 annually. They are compensated in the mid-range (averaging $13,000 annually) for non-patient activities, such as speaking engagements or acting as an expert witness; they also saw a 12% increase in salary from 2014 – 2015 (which was not out of line with many other physician specialities that year). While emergency physicians work 8–12 hour shifts and do not tend to work on-call, the high level of stress and need for solid diagnostic and triage capabilities for the undifferentiated, acute patient contributes to arguments justifying higher salaries for these physicians. Emergency care must be available every hour of every day and requires a doctor to be available on-site 24/7, unlike an outpatient clinic or other hospital departments with more limited hours and may only call a physician in when needed. The necessity to have a physician on staff and all other diagnostic services available every hour of every day is thus a costly arrangement for hospitals.

Payment systems
American health payment systems are undergoing significant reform efforts, Which include compensating emergency physicians through "pay for performance" incentives and penalty measures under commercial and public health programs, including Medicare and Medicaid. This payment reform aims to improve the quality of care and control costs, despite the differing opinions on the existing evidence to show that this payment approach is effective in emergency medicine. Initially, these incentives would only target primary care providers (PCPs), but some would argue that emergency medicine is primary care, as no one refers patients to the ED. In one such program, two specific conditions listed were directly tied to patients frequently seen by emergency medical providers: acute myocardial infarction and pneumonia. (See: Hospital Quality Incentive Demonstration.)

There are some challenges with implementing these quality-based incentives in emergency medicine in that patients are often not given a definitive diagnosis in the ED, making it challenging to allocate payments through coding. Additionally, adjustments based on patient risk-level and multiple co-morbidities for complex patients further complicate attribution of positive or negative health outcomes. It is not easy to assess whether much of the costs directly result from the emergent condition treated in acutely care settings. It is also difficult to quantify the savings due to preventive care during emergency treatment (i.e. workup, stabilizing treatments, coordination of care and discharge, rather than a hospital admission). Thus, ED providers tend to support a modified fee-for-service model over other payment systems.

Overutilization
Some patients without health insurance utilize EDs as their primary form of medical care. Because these patients do not utilize insurance or primary care, emergency medical providers often face overutilization and financial loss, especially since many patients cannot pay for their care (see below). ED overuse produces $38 billion in wasteful spending each year (i.e. care delivery and coordination failures, over-treatment, administrative complexity, pricing failures, and fraud), Moreover, it unnecessarily drains departmental resources, reducing the quality of care across all patients. While overuse is not limited to the uninsured, the uninsured constitute a growing proportion of non-urgent ED visits. Insurance coverage can help mitigate overutilization by improving access to alternative forms of care and lowering the need for emergency visits.

A common misconception pegs frequent ED visitors as a significant factor in wasteful spending. However, frequent ED users make up a small portion of those contributing to overutilization and are often insured.

Uncompensated care
Injury and illness are often unforeseen, and patients of lower socioeconomic status are especially susceptible to being suddenly burdened with the cost of a necessary ED visit. For example, in the event that a patient is unable to pay for medical care received, the hospital, under the Emergency Medical Treatment and Active Labor Act (EMTALA), is obligated to treat emergency conditions regardless of a patient's ability to pay and therefore faces an economic loss for this uncompensated care. Estimates suggest that over half (approximately 55%) of all quantifiable emergency care is uncompensated and inadequate reimbursement has led to the closure of many EDs. Policy changes (such as the Affordable Care Act) are expected to decrease the number of uninsured people and thereby reduce uncompensated care.

In addition to decreasing the uninsured rate, ED overutilization might reduce by improving patient access to primary care and increasing patient flow to alternative care centres for non-life-threatening injuries. Financial disincentives, patient education, and improved management for patients with chronic diseases can also reduce overutilization and help manage costs of care. Moreover, physician knowledge of prices for treatment and analyses, discussions on costs with their patients, and a changing culture away from defensive medicine can improve cost-effective use. A transition towards more value-based care in the ED is an avenue by which providers can contain costs.

EMTALA
Doctors that work in the EDs of hospitals receiving Medicare funding are subject to the provisions of EMTALA. The US Congress enacted EMTALA in 1986 to curtail "patient dumping", a practice whereby patients were refused medical care for economic or other non-medical reasons. Since its enactment, ED visits have substantially increased, with one study showing a rise in visits of 26% (which is more than double the increase in population over the same period). While more individuals are receiving care, a lack of funding and ED overcrowding may be affecting quality. To comply with the provisions of EMTALA, hospitals, through their ED physicians, must provide medical screening and stabilize the emergency medical conditions of anyone that presents themselves at a hospital ED with patient capacity. EMTALA holds both the hospital and the responsible ED physician liable for civil penalties of up to $50,000 if there is no help for those in need. . While both the Office of Inspector General, U.S. Department of Health and Human Services (OIG) and private citizens can bring an action under EMTALA, courts have uniformly held that ED physicians can only be held liable if the case is prosecuted by OIG (whereas hospitals are subject to penalties regardless of who brings the suit). Additionally, the Centres for Medicare and Medicaid Services (CMS) can discontinue provider status under Medicare for physicians that do not comply with EMTALA. Liability also extends to on-call physicians that fail to respond to an ED request to come to the hospital to provide service. While the goals of EMTALA are laudable, commentators have noted that it appears to have created a substantial unfunded burden on the resources of hospitals and emergency physicians. As a result of financial difficulty, between the period of 1991–2011, 12.6% of EDs in the US closed.

Rural
Despite the practice emerging over the past few decades, the delivery of emergency medicine has significantly increased and evolved across diverse settings related to cost, provider availability and overall usage. Before the Affordable Care Act (ACA), emergency medicine was leveraged primarily by "uninsured or underinsured patients, women, children, and minorities, all of whom frequently face barriers to accessing primary care". While this still exists today, as mentioned above, it is critical to consider the location in which care is delivered to understand the population and system challenges related to overutilization and high cost. In rural communities where provider and ambulatory facility shortages exist, a primary care physician (PCP) in the ED with general knowledge is likely to be the only source of health care for a population, as specialists and other health resources are generally unavailable due to lack of funding and desire to serve in these areas. As a result, the incidence of complex co-morbidities not managed by the appropriate provider results in worse health outcomes and eventually costlier care that extends beyond rural communities. Though typically quite separated, PCPs in rural areas must partner with larger health systems to comprehensively address the complex needs of their community, improve population health, and implement strategies such as telemedicine to improve health outcomes and reduce ED utilization for preventable illnesses. (See: Rural health.)

Urban
Alternatively, emergency medicine in urban areas consists of diverse provider groups, including physicians, physician assistants, nurse practitioners and registered nurses who coordinate with specialists in both inpatient and outpatient facilities to address patients' needs, more specifically in the ED. For all systems, regardless of funding source, EMTALA mandates EDs to conduct a medical examination for anyone that presents at the department, irrespective of paying ability. Non-profit hospitals and health systems – as required by the ACA – must provide a certain threshold of charity care "by actively ensuring that those who qualify for financial assistance get it, by charging reasonable rates to uninsured patients and by avoiding extraordinary collection practices." While there are limitations, this mandate provides support to many in need. That said, despite policy efforts and increased funding and federal reimbursement in urban areas, the triple aim (of improving patient experience, enhancing population health, and reducing the per-capita cost of care) remains a challenge without providers' and payers' collaboration to increase access to preventive care and decrease in ED usage. As a result, many experts support the notion that emergency medical services should only serve immediate risks in urban and rural areas.

Patient–provider relationships
As stated above, EMTALA includes provisions that protect patients from being turned away or transferred before adequate stabilisation. Upon making contact with a patient, EMS providers are responsible for diagnosing and stabilising a patient's condition without regard for the ability to pay. In the pre-hospital setting, providers must exercise appropriate judgement in choosing a suitable hospital for transport. Hospitals can only turn away incoming ambulances if they are on diversion and incapable of providing adequate care. However, once a patient has arrived on hospital property, care must be provided. At the hospital, a triage nurse first contacts the patient, who determines the appropriate level of care needed.

According to Mead v. Legacy Health System, a patient-physician relationship is established when "the physician takes an affirmative action with regard to the care of the patient". Initiating such a relationship forms a legal contract in which the physician must continue to provide treatment or adequately terminate the relationship. This legal responsibility can extend to physician consultations and on-call physicians even without direct patient contact. In emergency medicine, termination of the patient–provider relationship prior to stabilization or without handoff to another qualified provider is considered abandonment. In order to initiate an outside transfer, a physician must verify that the next hospital can provide a similar or higher level of care. Hospitals and physicians must also ensure that the patient's condition will not be further aggravated by the transfer process.

The setting of emergency medicine presents a challenge for delivering high quality, patient-centered care. Clear, effective communication can be particularly difficult due to noise, frequent interruptions, and high patient turnover. The Society for Academic Emergency Medicine has identified five essential tasks for patient-physician communication: establishing rapport, gathering information, giving information, providing comfort, and collaboration. The miscommunication of patient information is a crucial source of medical error; minimising shortcoming in communication remains a topic of current and future research.

Medical error
Many circumstances, including the regular transfer of patients in emergency treatment and crowded, noisy and chaotic ED environments, make emergency medicine particularly susceptible to medical error and near misses. One study identified an error rate of 18 per 100 registered patients in one particular academic ED. Another study found that where a lack of teamwork (i.e. poor communication, lack of team structure, lack of cross-monitoring) was implicated in a particular incident of ED medical error, "an average of 8.8 teamwork failures occurred per case [and] more than half of the deaths and permanent disabilities that occurred were judged avoidable." Particular cultural (i.e. "a focus on the errors of others and a 'blame-and-shame' culture") and structural (i.e. lack of standardisation and equipment incompatibilities) aspects of emergency medicine often result in a lack of disclosure of medical error and near misses to patients and other caregivers. While concerns about malpractice liability are one reason why disclosure of medical errors is not made, some have noted that disclosing the error and providing an apology can mitigate malpractice risk. Ethicists uniformly agree that the disclosure of a medical error that causes harm is a care provider's duty. The critical components of the disclosure include "honesty, explanation, empathy, apology, and the chance to lessen the chance of future errors" (represented by the mnemonic HEEAL). The nature of emergency medicine is such that error will likely always be a substantial risk of emergency care. However, maintaining public trust through open communication regarding a harmful error can help patients and physicians constructively address problems when they occur.

Treatments
Emergency medicine is a primary or first-contact point of care for patients requiring the use of the health care system. Specialists in emergency medicine are required to possess specialist skills in acute illness diagnosis and resuscitation. Emergency physicians are responsible for providing immediate recognition, evaluation, care, and stabilisation to adult and pediatric patients in response to acute illness and injury.

Emergency medical physicians provide treatments to a range of cases requiring vast knowledge. They deal with patients from mental illnesses to physical and anything in-between. An average treatment process would likely involve, investigation then diagnosis then either treatment or the patient being admitted. In terms of procedure's they cover a wide and broad range, including treatment to GSW's (Gun Shot Wounds), Head and body traumas, stomach bugs, mental episodes, seizures and much more. They are some of the most highly trained physicians in the world and are responsible for providing immediate recognition, evaluation, care, and stabilisation to adult and paediatric patients in response to acute illness and injury. As well as being the first point of care for many patients in emergency situations.

Training
There are a variety of international models for emergency medicine training. There are two different models among those with well-developed training programs: a "specialist" model or "a multidisciplinary model". Additionally, in some countries, the emergency medicine specialist rides in the ambulance. For example, in France and Germany, the physician, often an anesthesiologist, rides in the ambulance and provides stabilising care at the scene. The patient is directed to the appropriate hospital department, so emergency care is much more multidisciplinary than the Anglo-American model.

In countries such as the US, the United Kingdom, Canada and Australia, ambulances crewed by paramedics and emergency medical technicians respond to out-of-hospital emergencies and transport patients to emergency departments, meaning there is more dependence on these healthcare providers and there is more dependence on paramedics and EMTs for on-scene care. Emergency physicians are therefore more "specialists" since all patients are taken to the emergency department. Most developing countries follow the Anglo-American model: the gold standard is three or four-year independent residency training programs in emergency medicine. Some countries develop training programs based on a primary care foundation with additional emergency medicine training. In developing countries, there is an awareness that Western models may not be applicable and may not be the best use of limited health care resources. For example, speciality training and pre-hospital care in developed countries are too expensive and impractical for use in many developing countries with limited health care resources. International emergency medicine provides a critical global perspective and hope for improvement in these areas.

A brief review of some of these programs follows:

Argentina
In Argentina, the SAE (Sociedad Argentina de Emergencias) is the leading organisation of emergency medicine. There are many 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.

The Australian College of Rural and Remote Medicine (ACRRM) is the responsible body for the training and upholding of standards for practice and provision of rural and remote medical care. Prospective rural generalists undertaking this four-year fellowship program have an opportunity to complete Advanced Specialised Training (AST) in emergency medicine.

Belgium
In Belgium there are three recognised ways to practice emergency medicine. Until 2005 there was no accredited emergency medicine program. Emergency medicine was performed by general practitioners (having followed a 240-hour course, Acute Medicine) or by specialists (surgeon, internal medicine, neurologist, anesthesiologist) with or without supra-speciality training in emergency medicine.

Since 2005 residency training exists for acute medicine (3 years) or emergency medicine (6 years). At least 50% of the training is in the emergency department; the other part is a rotation between disciplines like pediatrics, surgery, orthopedic surgery, anesthesiology and critical care medicine.

Alternative an attending physician with one of following specialities (anesthesiology, internal medicine, cardiology, gastro-enterology, pneumology, rheumatology, urology, general surgery, plastic & reconstructive surgery, orthopedic surgery, neurology, neurosurgery, pediatrics) can follow a supra-speciality program of two years to become an emergency medicine specialist.

Brazil
In Brazil, the first emergency medicine residency program was created at Hospital Pronto Socorro de Porto Alegre in 1996. In 2002, the emergency medical services were standardized nationally with the creation of SAMU (Serviço de atendimento móvel de urgência), inspired by French EMS, which also provides training to its employees. The nacional emergency medicina association (ABRAMEDE – Associação Brasileira de Medicina de Emergência) was created in 2007. In 2008 the second residency program was started at Messejana Hospital in Fortaleza. Then, in 2015, emergency medicine was formally recognized as a medical specialty by the Brazilian Medical Association. After formal recognition, multiple residency programs were created nationwide (e.g. Universidade Federal de Minas Gerais in 2016 and Universidade de São Paulo in 2017). The residency consists of a three-year program with training in all emergency department specialties (i.e. internal medicine, surgery, pediatrics, orthopedics, OB/GYN), EMS and intensive care.

Chile
In Chile, emergency medicine begins its journey in Chile with the first speciality program at the beginning of the 1990s, at the University of Chile and the University of Santiago of Chile. Currently, it is a primary speciality legally recognised by the Ministry of Health since 2013. It has multiple training programs for specialists, notably the University of Chile, Pontifical Catholic University of Chile, Clínica Alemana – Universidad del Desarrollo, San Sebastian University – MUE and University of Santiago of Chile (USACH). Currently, and intending to strengthen the speciality 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, intend to hold joint clinical meetings between the leading training programs, regularly 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).

Canada
The two routes to emergency medicine certification can be summarized as follows:

 * 1) A five-year residency leads to the designation of FRCP(EM) through the Royal College of Physicians and Surgeons of Canada (Emergency Medicine Board Certification – emergency medicine consultant).
 * 2) A one-year emergency medicine enhanced skills program following a two-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 are having worked a minimum of four 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 minor focus on academic activities such as teaching and research. FRCP(EM) Emergency Medicine Board specialists tend to congregate in academic centres and 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, pediatric emergency medicine, and sports medicine. Furthermore, the FRCP(EM) residency length allows more time for formal training in these areas.

Physician assistants are currently practising in the field of emergency medicine in Canada.

China
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 speciality 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 Ministry of Public Health guidelines. 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 who want to practice medicine have to undergo five years of residency training at designated training bases, the first three years of general rotation followed by two more years of speciality-centred training.

Germany
In Germany, emergency medicine is not handled as a specialization (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). Service as an emergency physician in an ambulance service is part of the specialization training of anaesthesiology. Emergency physicians usually work on a volunteering basis and are often anesthesiologists but maybe specialists of any kind. Especially there is a specialization training in pediatric intensive care.

India
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 and paramedics since 1994, with certification programs varying from six months to three years. However, emergency medicine was only recognized as a separate speciality by the Medical Council of India in July 2009.

Malaysia
There are three universities (Universiti Sains Malaysia, Universiti Kebangsaan Malaysia, and 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.

Saudi Arabia
In Saudi Arabia, the Certification of Emergency Medicine takes the four-year Saudi Board of Emergency Medicine (SBEM), which the Saudi Council accredits for Health Specialties (SCFHS). It requires passing the two-part exam: first and final part (written and oral) to obtain the SBEM certificate, equivalent to a doctorate.

Switzerland
Emergency medicine is still not recognised as a fully-fledged speciality in a country that has only recently grasped the importance of having an organised acute medical speciality (during the COVID-19 outbreak). Many attempts to organize the speciality have resulted in a subspecialists training pathway, but to this day, internal medicine, anesthesiology and surgery are still vocally opposed to an emergency medicine specialist title.

United States
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 paediatrics. The US is well known for its excellence in emergency medicine residency programs, leading to some controversy about speciality 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, paediatricians, general surgeons, and anesthesiologists). The BCEM is under the authority of the American Board of Physician Specialties.

Several ABMS fellowships are available for emergency medicine graduates, including pre-hospital medicine (emergency medical services), international medicine, advanced resuscitation, 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. It has led to several supplemental training programs in first-hour emergency care and a few fellowships for family physicians in emergency medicine., and 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 correlates to higher quality and more cost-effective practice, primarily 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 per cent of ED payments come from Medicare, fifteen per cent from Medicaid, five per cent from private payment and twenty-five per cent from commercially insured patients." However, choices of physician specialities are not mandated by any agency or program, so even though emergency departments see many Medicare/Medicaid patients and thus receive much funding for training from these programs, there is still concern over a shortage of speciality-trained emergency medicine providers.

United Kingdom
In the United Kingdom, the Royal College of Emergency Medicine has a role in setting professional standards and assessing trainees. Emergency medical trainees enter speciality training after five or six years of Medical school followed by two years of foundation training. Speciality 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.

Turkey
Emergency medicine residencies last four years in Turkey. These physicians have a two-year obligatory service in Turkey to be qualified to have their diploma. After this period, EM specialists can choose to work in private or governmental emergency departments.

Pakistan
The College of Physicians and Surgeons Pakistan accredited the training in emergency medicine in 2010. Emergency medicine training in Pakistan lasts for five years. The initial two years involve trainees being sent to three major areas: medicine and allied, surgery, and allied and critical care. It is divided into six months each, and the rest six months out of the first two years are spent in the emergency department. In the last three years, trainee residents spend most of their time in the emergency room as senior residents. Certificate courses include ACLS, PALS, ATLS, and research and dissertations are required to complete the training successfully. At the end of five years, candidates become eligible to sit for the FCPS part II exam. After fulfilling the requirement, they become fellows of the College of Physicians and Surgeons Pakistan in emergency medicine.

Institutions providing this training include Shifa International Hospitals Islamabad, Aga Khan University Hospital Karachi, POF Hospital Wah, Lady Reading Hospital Peshawar, Indus Hospital Karachi and Jinnah Post Graduate Medical Center Karachi, and Mayo Hospital, Lahore.

Iran
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 the supervision of the emergency medicine speciality board committee. There are now more than 200 (and increasing) board-certified Emergency Physicians in Iran.

Ethical and medicolegal issues
Ethical and medico-legal issues are embedded within the nature of emergency medicine. Issues surrounding competence, end of life care, and the right to refuse care are encountered daily within the emergency department. Of growing significance are the ethical issues and legal obligations that surround the Mental Health Act, as increasing numbers of suicide attempts and self-harm are seen in the emergency department. The Wooltorton case of 2007, in which a patient arrived at the emergency department post overdose with a note specifying her request for no interventions, highlights the dichotomy that often exists between a physician's ethical obligation to "do no harm" and the legality of a patient's right to refuse.

title: Emergency medicine


text:
Emergency medical services

Emergency medical services (EMS), also known as ambulance services or paramedic services, are emergency services that provide urgent pre-hospital treatment and stabilisation for serious illness and injuries and transport to definitive care. They may also be known as a first aid squad, FAST squad, emergency squad, ambulance squad, ambulance corps, life squad or by other initialisms such as EMAS or EMARS.

In most places, EMS can be summoned by members of the public (as well as medical facilities, other emergency services, businesses and authorities) via an emergency telephone number (such as 911 in the United States) which puts them in contact with a dispatching centre, which will then dispatch suitable resources for the call. Ambulances are the primary vehicles for delivering EMS, though squad cars, motorcycles, aircraft, boats, fire apparatus, and others may be used. EMS agencies may also operate a non-emergency patient transport service, and some have rescue squads to provide technical rescue or search and rescue services.

When EMS is dispatched, they will initiate medical care upon arrival on scene. If it is deemed necessary or a patient requests transport, the unit is then tasked with transferring the patient to the next point of care, typically an emergency department of a hospital. Historically, ambulances only transported patients to care, and this remains the case in parts of the developing world. The term "emergency medical service" was popularised when these services began to emphasise emergency treatment at the scene. In some countries, a substantial portion of EMS calls do not result in a patient being taken to hospital.

Training and qualification levels for members and employees of emergency medical services vary widely throughout the world. In some systems, members may be present who are qualified only to drive ambulances, with no medical training. In contrast, most systems have personnel who retain at least basic first aid certifications, such as basic life support (BLS). In English-speaking countries, they are known as emergency medical technicians (EMTs) and paramedics, with the latter having additional training such as advanced life support (ALS) skills. Physicians and nurses may also provide pre-hospital care to varying degrees in certain countries, a model which is popular in Europe.

Precursors
Emergency care in the field has been rendered in different forms since the beginning of recorded history. The New Testament contains the parable of the Good Samaritan, in which a man who has been beaten is cared for by a passing Samaritan. Luke 10:34 (NIV) – "He went to him and bandaged his wounds, pouring on oil and wine. Then he put the man on his own donkey, took him to an inn and took care of him." During the Middle Ages, the Knights Hospitaller were known for rendering assistance to wounded soldiers in the battlefield.

The first use of the ambulance as a specialized vehicle, in battle came about with the ambulances volantes designed by Dominique Jean Larrey (1766–1842), Napoleon Bonaparte's chief surgeon. Larrey was present at the battle of Spires, between the French and Prussians, and was distressed by the fact that wounded soldiers were not picked up by the numerous ambulances (which Napoleon required to be stationed two and half miles back from the scene of battle) until after hostilities had ceased, and set about developing a new ambulance system. Having decided against using the Norman system of horse litters, he settled on two- or four-wheeled horse-drawn wagons, which were used to transport fallen soldiers from the (active) battlefield after they had received early treatment in the field. Larrey's projects for 'flying ambulances' were first approved by the Committee of Public Safety in 1794. Larrey subsequently entered Napoleon's service during the Italian campaigns in 1796, where his ambulances were used for the first time at Udine, Padua and Milan, and he adapted his ambulances to the conditions, even developing a litter which could be carried by a camel for a campaign in Egypt.

Early civilian ambulances
A major advance was made (which in future years would come to shape policy on hospitals and ambulances) with the introduction of a transport carriage for cholera patients in London during 1832. The statement on the carriage, as printed in The Times, said "The curative process commences the instant the patient is put in to the carriage; time is saved which can be given to the care of the patient; the patient may be driven to the hospital so speedily that the hospitals may be less numerous and located at greater distances from each other". This tenet of ambulances providing instant care, allowing hospitals to be spaced further apart, displays itself in modern emergency medical planning.

The first known hospital-based ambulance service operated out of Commercial Hospital, Cincinnati, Ohio (now the Cincinnati General) by 1865. This was soon followed by other services, notably the New York service provided out of Bellevue Hospital which started in 1869 with ambulances carrying medical equipment, such as splints, a stomach pump, morphine, and brandy, reflecting contemporary medicine.

Another early ambulance service was founded by Jaromir V. Mundy, Count J. N. Wilczek, and Eduard Lamezan-Salins in Vienna after the disastrous fire at the Vienna Ringtheater in 1881. Named the "Vienna Voluntary Rescue Society," it served as a model for similar societies worldwide.

In June 1887 the St John Ambulance Brigade was established to provide first aid and ambulance services at public events in London. It was modelled on a military-style command and discipline structure.

Motorization
Also in the late 19th century, the automobile was being developed, and in addition to horse-drawn models, early 20th century ambulances were powered by steam, gasoline, and electricity, reflecting the competing automotive technologies then in existence. However, the first motorized ambulance was brought into service in the last year of the 19th century, with the Michael Reese Hospital, Chicago, taking delivery of the first automobile ambulance, donated by 500 prominent local businessmen, in February 1899. This was followed in 1900 by New York City, who extolled its virtues of greater speed, more safety for the patient, faster stopping and a smoother ride. These first two automobile ambulances were electrically powered with 2 hp motors on the rear axle.

During World War I, further advances were made in providing care before and during transport; traction splints were introduced during the war and were found to have a positive effect on the morbidity and mortality of patients with leg fractures. Two-way radios became available shortly after World War I, enabling for more efficient radio dispatch of ambulances in some areas. Prior to World War II, there were some areas where a modern ambulance carried advanced medical equipment, was staffed by a physician, and was dispatched by radio. In many locations, however, ambulances were hearses, the only available vehicle that could carry a recumbent patient, and were thus frequently run by funeral homes. These vehicles, which could serve either purpose, were known as combination cars.

Prior to World War II, hospitals provided ambulance service in many large cities. With the severe manpower shortages imposed by the war effort, it became difficult for many hospitals to maintain their ambulance operations. City governments in many cases turned ambulance services over to the police or fire department. No laws required minimal training for ambulance personnel and no training programs existed beyond basic first aid. In many fire departments, assignment to ambulance duty became an unofficial form of punishment.

Rise of modern EMS
Advances in the 1960s, especially the development of CPR and defibrillation as the standard form of care for out-of-hospital cardiac arrest, along with new pharmaceuticals, led to changes in the tasks of the ambulances. In Belfast, Northern Ireland the first experimental mobile coronary care ambulance successfully resuscitated patients using these technologies. Freedom House Ambulance Service was the first civilian emergency medical service in the United States to be staffed by paramedics, all of whom were African-American.

One well-known report in the US during that time was Accidental Death and Disability: The Neglected Disease of Modern Society, also known as The White Paper. The report concluded that ambulance services in the US varied widely in quality and were often unregulated and unsatisfactory. These studies placed pressure on governments to improve emergency care in general, including the care provided by ambulance services. The government reports resulted in the creation of standards in ambulance construction concerning the internal height of the patient care area (to allow for an attendant to continue to care for the patient during transport), and the equipment (and thus weight) that an ambulance had to carry, and several other factors.

In 1971 a progress report was published at the annual meeting, by the then president of American Association of Trauma, Sawnie R. Gaston M.D. Dr. Gaston reported the study was a "superb white paper" that "jolted and wakened the entire structure of organized medicine." This report is created as a "prime mover" and made the "single greatest contribution of its kind to the improvement of emergency medical services". Since this time a concerted effort has been undertaken to improve emergency medical care in the pre-hospital setting. Such advancements included Dr. R Adams Cowley creating the country's first statewide EMS program, in Maryland.

The developments were paralleled in other countries. In the United Kingdom, a 1973 law merged the municipal ambulance services into larger agencies and set national standards. In France, the first official SAMU agencies were founded in the 1970s.

Organization
Depending on country, area within country, or clinical need, emergency medical services may be provided by one or more different types of organization. This variation may lead to large differences in levels of care and expected scope of practice. Some countries closely regulate the industry (and may require anyone working on an ambulance to be qualified to a set level), whereas others allow quite wide differences between types of operator.

Municipal "third service" ambulance service
Operating separately from (although alongside) the fire and police services of the area, these ambulances are funded by local, provincial or national governments. In some countries, these only tend to be found in big cities, whereas in countries such as the United Kingdom, almost all emergency ambulances are part of a national health system.

In the United States, ambulance services provided by a local government are often referred to as "third service" EMS (the fire department, police department, and EMS department forming an emergency services trio) by the members of said service, as well as other city officials and residents. The most notable examples of this model in the United States are Pittsburgh Bureau of Emergency Medical Services, Boston EMS, New Orleans Emergency Medical Services, and Cleveland EMS. Government ambulance services also have to take civil service exams just like government fire departments and police. In the United States, certain federal government agencies employ emergency medical technicians at the basic and advanced life support levels, such as the National Park Service and the Federal Bureau of Prisons.

Fire- or police-linked service
In countries such as the United States, Japan, France, South Korea and parts of India, ambulances can be operated by the local fire or police services. Fire-based EMS is the most common model in the United States, where nearly all urban fire departments provide EMS and a majority of emergency transport ambulance services in large cities are part of fire departments. Examples of this model are the New York City Fire Department (FDNY) and the Baltimore City Fire Department.

It is rare for a police department in the United States to provide EMS or ambulance services, although many police officers have basic medical training (such as Nalaxone use and CPR). One notable example is New Orleans Emergency Medical Services, which was formed as a hospital-based service, was operated by the New Orleans Police Department from 1947 to 1985, and is currently operated by the New Orleans Health Department and the New Orleans Office of Homeland Security and Emergency Preparedness, separate from the New Orleans Fire Department.

Charity/not-for-profit ambulance service
Charities or non-profit ambulance departments operate some emergency medical services. They are primarily staffed by volunteers, though many also have paid personnel. These may be linked to a volunteer fire service, and some volunteers may provide both services. Some ambulance charities specialize in providing cover at public gatherings and events (e.g. sporting events), while others provide care to the wider community.

The International Red Cross and Red Crescent Movement is the largest charity in the world that provides emergency medicine. (in some countries, it operates as a private ambulance service). Other organisations include St John Ambulance, the Order of Malta Ambulance Corps and Hatzalah, as well as small local volunteer/paid departments. In the United States, volunteer ambulances are rarer, but can still be seen in both metropolitan and rural areas (e.g. Hatzalah). Charities such as BASICS Scotland, specialise in facilitating training medical professionals to volunteer to assist the statutory ambulance services in the care of patients, through their attendance at those with serious illnesses or injuries.

A few charities provide ambulances for taking patients on trips or vacations away from hospitals, hospices or care homes where they are in long-term care. Examples include the UK's Jumbulance project.

Private/corporate ambulance service
Some ambulances are operated by commercial companies with paid employees, usually on a contract to the local or national government, Hospital Networks, Health Care Facilities and Insurance Companies.

In the U.S., private ambulance companies provide emergency medical services in large cities and rural areas by contracting with local governments. In areas where the local county or city provide their own emergency services, private companies provide discharges and transfers from hospitals and to/from other health related facilities and homes. In most areas private companies are part of the local government emergency disaster plan, and are relied upon for the overall EMS response, treatment and recovery.

In some areas, private companies may provide only the patient transport elements of ambulance care (i.e. non-urgent), but in some places, they are contracted to provide emergency care, or to form a 'second tier' response, where they only respond to emergencies when all of the full-time emergency ambulance crews are busy. This may mean that a government or other service provide the 'emergency' cover, whilst a private firm may be charged with 'minor injuries' such as cuts, bruises or even helping the mobility-impaired if they have for example fallen and simply need help to get up again, but do not need treatment. This system has the benefit of keeping emergency crews available at all times for genuine emergencies. These organisations may also provide services known as 'Stand-by' cover at industrial sites or at special events. In Latin America, private ambulance companies are often the only readily-available EMS service

Combined emergency service
These are full service emergency service agencies, which may be found in places such as airports or large colleges and universities like for example the UCLA EMS.Their key feature is that all personnel are trained not only in ambulance (EMT) care, but as a firefighter and a peace officer (police function). They may be found in smaller towns and cities, where demand or budget is too low to support separate services. This multi-functionality allows to make the most of limited resource or budget, but having a single team respond to any emergency.

Hospital-based service
Hospitals or larger hospital systems may provide their own ambulance service as a service to the community, or where ambulance care is unreliable or chargeable. Many hospital-based EMS departments operate solely with their hospital, though some operate more independently and can transport patients to whichever hospital may be needed or desired.

Internal ambulances
Many large factories and other industrial centers, such as chemical plants, oil refineries, breweries, and distilleries, have emergency medical services provided by employers as a means of protecting their interests and the welfare of their staff. These are often used as first response vehicles in the event of a fire or explosion.

Purpose
Emergency medical services exists to fulfill the basic principles of first aid, which are to Preserve Life, Prevent Further Injury, and Promote Recovery. This common theme in medicine is demonstrated by the "star of life". The Star of Life shown here, where each of the 'arms' to the star represent one of the six points, are used to represent the six stages of high quality pre-hospital care, which are:

 * 1) Early detection – members of the public, or another agency, find the incident and understand the problem
 * 2) Early reporting – the first persons on scene make a call to the emergency medical services (911) and provide details to enable a response to be mounted
 * 3) Early response – the first professional (EMS) rescuers are dispatched and arrive on scene as quickly as possible, enabling care to begin
 * 4) Good on-scene/field care – the emergency medical service provides appropriate and timely interventions to treat the patient at the scene of the incident without doing further harm.
 * 5) Care in transit -– the emergency medical service load the patient in to suitable transport and continue to provide appropriate medical care throughout the journey
 * 6) Transfer to definitive care – the patient is handed over to an appropriate care setting, such as the emergency department at a hospital, in to the care of physicians

Strategies for delivering care

Although a variety of differing philosophical approaches are used in the provision of EMS care around the world, they can generally be placed into one of two categories; one physician-led and the other led by pre-hospital allied health staff such as emergency medical technicians or paramedics. These models are commonly referred to as the Franco-German model and Anglo-American model.

Studies have been inconclusive as to whether one model delivers better results than the other. A 2010 study in the Oman Medical Journal suggested that rapid transport was a better strategy for trauma cases, while stabilization at the scene was a better strategy for cardiac arrests.

Levels of care
Many systems have tiers of response for medical emergencies. For example, a common arrangement in the United States is that fire engines or volunteers are sent to provide a rapid initial response to a medical emergency, while an ambulance is sent to provide advanced treatment and transport the patient. In France, fire service and private company ambulances provide basic care, while hospital-based ambulances with physicians on board provide advanced care. In many countries, an air ambulance provides a higher level of care than a regular ambulance.

Examples of level of care include:
 * First aid consists of basic skills that are commonly taught to members of the public, such as cardiopulmonary resuscitation, bandaging wounds and saving someone from choking.
 * Basic Life Support (BLS) is often the lowest level of training that can be held by those who treat patients on an ambulance. Commonly, it includes administering oxygen therapy, some drugs and a few invasive treatments. BLS personnel may either operate a BLS ambulance on their own, or assist a higher qualified crewmate on an ALS ambulance. In English-speaking countries, BLS ambulance crew members are known as emergency medical technicians or emergency care assistants.
 * Intermediate Life Support (ILS), also known as Limited Advanced Life Support (LALS), is positioned between BLS and ALS but is less common than both. It is commonly a BLS provider with a moderately expanded skill set, but where it is present it usually replaces BLS.
 * Advanced Life Support (ALS) has a considerably expanded range of skills such as intravenous therapy, cricothyrotomy and interpreting an electrocardiogram. The scope of this higher tier response varies considerably by country. Paramedics commonly provide ALS, but some countries require it to be a higher level of care and instead employ physicians in this role. Additionally Advanced Life Support includes administering therapeutic doses of electrical shock to those who are in cardiac arrest or using drugs to stimulate the heart, Airway therapy, and so on and so forth. Most ambulances are equipped with advanced Life Support equipment and have paramedics on board. While some fire departments have ambulances, first aid and squads utilize ambulances for emergency medical services.
 * Critical Care Transport (CCT), also known as medical retrieval or rendez vous MICU protocol in some countries (Australia, NZ, Great Britain, and Francophone Canada) refers to the critical care transport of patients between hospitals (as opposed to pre-hospital). Such services are a key element in regionalized systems of hospital care where intensive care services are centralized to a few specialist hospitals. An example of this is the Emergency Medical Retrieval Service in Scotland. This level of care is likely to involve traditional healthcare professionals (in addition to or instead of critical care-trained paramedics), meaning nurses and/or physicians working in the pre-hospital setting and even on ambulances.

Transport-only
The most basic emergency medical services are provided as a transport operation only, simply to take patients from their location to the nearest medical treatment. This was historically the case in all countries. It remains the case in much of the developing world, where operators as diverse as taxi drivers and undertakers may transport people to hospital.

Transport-centered EMS
The Anglo-American model is also known as "load and go" or "scoop and run". In this model, ambulances are staffed by paramedics and/or emergency medical technicians. They have specialized medical training, but not to the same level as a physician. In this model it is rare to find a physician actually working routinely in ambulances, although they may be deployed to major or complex cases. The physicians who work in EMS provide oversight for the work of the ambulance crews. This may include off-line medical control, where they devise protocols or 'standing orders' (procedures for treatment). This may also include on-line medical control, in which the physician is contacted via radio or phone to provide advice and authorization for various medical interventions or for a patient's desire to refuse care.

In some cases, such as in the UK, South Africa and Australia, a paramedic may be an autonomous medical professional, and does not require the permission of a physician to administer interventions or medications from an agreed list, and can perform roles such as suturing or prescribing medication to the patient. Recently "Telemedicine" has been making an appearance in ambulances. Similar to online medical control, this practice allows paramedics to remotely transmit data such as vital signs and 12 and 15 lead ECGs to the hospital from the field. This allows the emergency department to prepare to treat patients prior to their arrival. This is allowing lower level providers (Such as EMT-B) in the United States to utilize these advanced technologies and have the doctor interpret them, thus bringing rapid identification of rhythms to areas where paramedics are stretched thin. While most insurance companies only reimburse EMS providers for transporting patients to 911 receiving facilities (e.g. Emergency Departments),the Center to Medicare and Medicaid Services is in the process of evaluating a payment model to enable reimbursement for patients evaluated and treated on-scene.

Major trauma
The essential decision in prehospital care is whether the patient should be immediately taken to the hospital, or advanced care resources are taken to the patient where they lie. The "scoop and run" approach is exemplified by the MEDEVAC aeromedical evacuation helicopter, whereas the "stay and play" is exemplified by the French and Belgian SMUR emergency mobile resuscitation unit or the German "Notarzt"-System (preclinical emergency physician).

The strategy developed for prehospital trauma care in North America is based on the Golden Hour theory, i.e., that a trauma victim's best chance for survival is in an operating room, with the goal of having the patient in surgery within an hour of the traumatic event. This appears to be true in cases of internal bleeding, especially penetrating trauma such as gunshot or stab wounds. Thus, minimal time is spent providing prehospital care (spine immobilization; "ABCs", i.e. ensure airway, breathing and circulation; external bleeding control; endotracheal intubation) and the victim is transported as fast as possible to a trauma centre.

The aim in "Scoop and Run" treatment is generally to transport the patient within ten minutes of arrival, hence the birth of the phrase, "the platinum ten minutes" (in addition to the "golden hour"), now commonly used in EMT training programs. The "Scoop and Run" is a method developed to deal with trauma, rather than strictly medical situations (e.g. cardiac or respiratory emergencies), however, this may be changing. Increasingly, research into the management of S-T segment elevation myocardial infarctions (STEMI) occurring outside of the hospital, or even inside community hospitals without their own PCI labs, suggests that time to treatment is a clinically significant factor in heart attacks, and that trauma patients may not be the only patients for whom 'load and go' is clinically appropriate. In such conditions, the gold standard is the door to balloon time. The longer the time interval, the greater the damage to the myocardium, and the poorer the long-term prognosis for the patient. Current research in Canada has suggested that door to balloon times are significantly lower when appropriate patients are identified by paramedics in the field, instead of the emergency room, and then transported directly to a waiting PCI lab. The STEMI program has reduced STEMI deaths in the Ottawa region by 50 per cent. In a related program in Toronto, EMS has begun to use a procedure of 'rescuing' STEMI patients from the Emergency Rooms of hospitals without PCI labs, and transporting them, on an emergency basis, to waiting PCI labs in other hospitals.

Physician-led EMS
Physician-led EMS is also known as the Franco-German model, "stay and play", "stay and stabilize" or "delay and treat". In a physician-led system, doctors respond directly to all major emergencies requiring more than simple first aid. The physicians will attempt to treat casualties at the scene and will only transport them to hospital if it is deemed necessary. If patients are transported to hospital, they are more likely to go straight to a ward rather than to an emergency department. Countries that use this model include Austria, France, Belgium, Luxembourg, Italy, Spain, Brazil and Chile.

In some cases in this model, such as France, there is no direct equivalent to a paramedic. Physicians and (in some cases) nurses provide all medical interventions for the patient. Other ambulance personnel are not non-medically trained and only provide driving and heavy lifting. In other applications of this model, as in Germany, a paramedic equivalent does exist, but is an assistant to the physician with a restricted scope of practice. They are only permitted to perform Advanced Life Support (ALS) procedures if authorized by the physician, or in cases of immediate life-threatening conditions. Ambulances in this model tend to be better equipped with more advanced medical devices, in essence, bringing the emergency department to the patient. High-speed transport to hospitals is considered, in most cases, to be unnecessarily unsafe, and the preference is to remain and provide definitive care to the patient until they are medically stable, and then accomplish transport. In this model, the physician and nurse may actually staff an ambulance along with a driver, or may staff a rapid response vehicle instead of an ambulance, providing medical support to multiple ambulances.

Personnel

Ambulance personnel are generally professionals and in some countries their use is controlled through training and registration. While these job titles are protected by legislation in some countries, this protection is by no means universal, and anyone might, for example, call themselves an 'EMT' or a 'paramedic', regardless of their training, or the lack of it. In some jurisdictions, both technicians and paramedics may be further defined by the environment in which they operate, including such designations as 'Wilderness', 'Tactical', and so on.

A unique aspect of EMS is that there are two hierarchies of authority, as the chain of command is separate to medical authority.

Emergency medical dispatcher
An emergency medical dispatcher is also called an EMD. An increasingly common addition to the EMS system is the use of highly trained dispatch personnel who can provide "pre-arrival" instructions to callers reporting medical emergencies. They use carefully structured questioning techniques and provide scripted instructions to allow callers or bystanders to begin definitive care for such critical problems as airway obstructions, bleeding, childbirth, and cardiac arrest. Even with a fast response time by a first responder measured in minutes, some medical emergencies evolve in seconds. Such a system provides, in essence, a "zero response time," and can have an enormous impact on positive patient outcomes.

First responder
Certified first responders may be sent to provide first aid, sometimes to an advanced level. Their duties include the provision of immediate life-saving care in the event of a medical emergency; commonly advanced first aid, oxygen administration, cardio-pulmonary resuscitation (CPR), and automated external defibrillator (AED) usage. The first responder training is considered a bare minimum for emergency service workers who may be sent out in response to an emergency call. First responders are commonly dispatched by the ambulance service to arrive quickly and stabilize the patient before the ambulance arrives, and to then assist the ambulance crew.

Some EMS agencies have set up volunteer schemes, who can be dispatched to a medical emergency before the ambulance arrives. Examples of this include Community First Responder schemes run by ambulance services the UK and similar volunteer schemes operated by the fire services in France. In some countries such as the US, there may be autonomous groups of volunteer responders such as rescue squads. Police officers and firefighters who are on duty for another emergency service may also be deployed in this role, though some firefighters are trained to a more advanced medical level.

Besides first responders who are deployed to an emergency, there are others who may be stationed at public events. The International Red Cross and Red Crescent Movement and St John Ambulance both provide first aiders in these roles.

Ambulance driver
Some agencies separate the 'driver' and 'attendant' functions, employing ambulance driving staff with no medical qualification (or just a first aid and CPR certificates), whose job is to drive ambulances. While this approach persists in some countries, such as India, it is generally becoming increasingly rare. Ambulance drivers may be trained in radio communications, ambulance operations and emergency response driving skills.

Non-emergency attendant
Many countries employ ambulance staff who only carry out non-emergency patient transport duties (which can include stretcher or wheelchair cases). Dependent on the provider (and resources available), they may be trained in first aid or extended skills such as use of an AED, oxygen therapy, pain relief and other live-saving or palliative skills. In some services, they may also provide emergency cover when other units are not available, or when accompanied by a fully qualified technician or paramedic. The role is known as an Ambulance Care Assistant in the United Kingdom.

Emergency care assistant
Emergency care assistants are of a frontline under both emergency and non-emergency conditions to incidents. Their role is to assist the clinician that they are working with, either a Technician or Paramedic, in their duties, whether that be drawing up drugs, setting up fluids (but not attaching), doing basic observations or performing 12 lead ECG assessments.

Emergency medical technician
Emergency medical technicians are usually able to perform a wide range of emergency care skills, such as automated defibrillation, care of spinal injuries and oxygen therapy. In few jurisdictions, some EMTs are able to perform duties as IV and IO cannulation, administration of a limited number of drugs (including but not limited to Epinephrine, Narcan, Oxygen, Aspirin, Nitroglycerin - dependent on country, state, and medical direction), more advanced airway procedures, CPAP, and limited cardiac monitoring. Most advanced procedures and skills are not within the national scope of practice for an EMT. As such most states require additional training and certifications to perform above the national curriculum standards. In the United States, an EMT certification requires intense courses and training in field skills. A certification expires after two years and holds a requirement of taking 48 CEUs (continuing education credits). 24 of these credits must be in refresher courses while the other 24 can be taken in a variety ways such as emergency driving training, pediatric, geriatric, or bariatric care, specific traumas, etc. Is usually made up of 3 levels in the US. EMT-B, EMT-I (EMT-A in some states) and EMT-Paramedic. The National Registry of EMT New Educational Standards for EMS renamed the provider levels as follows: Emergency Medical Responder (EMR), Emergency Medical Technician (EMT-B), Advanced EMT (AEMT), and Paramedic (EMT-P).

Paramedic
A paramedic has a high level of pre-hospital medical training and usually involves key skills not performed by technicians, often including cannulation (and with it the ability to use a range of drugs to relieve pain, correct cardiac problems, and perform endotracheal intubation), cardiac monitoring, 12-lead ECG interpretation, ultrasound, intubation, pericardiocentesis, cardioversion, thoracostomy, and other skills such as performing a surgical cricothyrotomy. The most important function of the paramedic is to identify and treat any life-threatening conditions and then to assess the patient carefully for other complaints or findings that may require emergency treatment. In many countries, this is a protected title, and use of it without the relevant qualification may result in criminal prosecution. In the United States, paramedics represent the highest licensure level of prehospital emergency care. In addition, several certifications exist for Paramedics such as Wilderness ALS Care, Flight Paramedic Certification (FP-C), and Critical Care Emergency Medical Transport Program certification.

Critical care paramedic
A critical care paramedic, also known as an advanced practice paramedic or specialist paramedic, is a paramedic with additional training to deal with critically ill patients. Critical care paramedics often work on air ambulances, which are more likely to be dispatched to emergencies requiring advanced care skills. They may also work on land ambulances. The training, permitted skills, and certification requirements vary from one jurisdiction to the next. It also varies to whether they are trained externally by a university or professional body  or 'in house' by their EMS agency.

These providers have a vast array of and medications to handle complex medical and trauma patients. Examples of medication are dobutamine, dopamine, propofol, blood and blood products to name just a few. Some examples of skills include, but not limited to, life support systems normally restricted to the ICU or critical care hospital setting such as mechanical ventilators, Intra-aortic balloon pump (IABP) and external pacemaker monitoring. Depending on the service medical direction, these providers are trained on placement and use of UVCs (Umbilical Venous Catheter), UACs (Umbilical Arterial Catheter), surgical airways, central lines, arterial lines and chest tubes.

Emergency care practitioner
In the United Kingdom and South Africa, some serving paramedics receive additional university education to become practitioners in their own right, which gives them absolute responsibility for their clinical judgement, including the ability to autonomously prescribe medications. An emergency care practitioner or paramedic practitioner is a position that is designed to bridge the link between ambulance care and the care of a general practitioner. ECPs are university graduates in Emergency Medical Care or qualified paramedics who have undergone further training, and are authorized to perform specialized techniques. Additionally some may prescribe medicines for longer-term care, such as antibiotics and in the United Kingdom they can prescribe a broad range of medicines. With respect to a Primary Health Care setting, they are also educated in a range of Diagnostic techniques.

Registered nurses
The use of registered nurses (RNs) in the pre-hospital setting is common in many countries in absence of paramedics. In some regions of the world nurses are the primary healthcare worker that provides emergency medical services. In European countries such as France or Italy, also use nurses as a means of providing ALS services. These nurses may work under the direct supervision of a physician, or, in rarer cases, independently. In some places in Europe, notably Norway, paramedics do exist, but the role of the 'ambulance nurse' continues to be developed, as it is felt that nurses may bring unique skills to some situations encountered by ambulance crews.

In North America, and to a lesser extent elsewhere in the English-speaking world, some jurisdictions use specially trained nurses for medical transport work. These are mostly air-medical personnel or critical care transport providers, often working in conjunction with a technician, paramedic or physician on emergency interfacility transports. In the United States, the most common uses of ambulance-based registered nurses is in the Critical Care/Mobile Intensive Care transport, and in Aeromedical EMS. Such nurses are normally required by their employers (in the US) to seek additional certifications beyond the primary nursing licensure. Four individual states have an Intensive Care or Prehospital Nurse licensure. Many states allow registered nurses to also become registered paramedics according to their role in the emergency medical services team. In Estonia 60% of ambulance teams are led by nurse. Ambulance nurses can do almost all emergency procedures and administer medicines pre-hospital such as physicians in Estonia. In the Netherlands, all ambulances are staffed by a registered nurse with additional training in emergency nursing, anaesthesia or critical care, and a driver-EMT. In Sweden, since 2005, all emergency ambulances should be staffed by at least one registered nurse since only nurses are allowed to administer drugs. And all Advanced Life Support Ambulances are staffed at least by a registered nurse in Spain. In France, since 1986, fire department-based rescue ambulances have had the option of providing resuscitation service (reanimation) using specially trained nurses, operating on protocols, while SAMU-SMUR units are staffed by physicians and nurses

Physician
In countries with a physician-led EMS model, such as France, Italy, the German-speaking countries (Germany, Switzerland, Austria), and Spain, physicians respond to all cases that require more than basic first aid. In some versions of this model (such as France, Italy, and Spain), there is no direct equivalent to a paramedic, as ALS is performed by physicians. In the German-speaking countries, paramedics are assistants to ambulance physicians (called Notarzt). In these countries, if a physician is present, paramedics require permission from the physician to administer treatments such as defibrillation and drugs. If there is no physician on scene and a life-threatening condition is present, they may administer treatments that follow the physician's instructions.

In countries where EMS is led by paramedics, the ambulance service may still employ physicians. They may serve on specialist response vehicles, such as the air ambulances in the UK. They may also provide advice and devise protocols for treatment, with a medical director acting as the most senior medical adviser to the ambulance service. In the United States, EMS became an officially recognized subspecialty by the American Board of Emergency Medicine in 2010, and the first examinations were held in 2013. Many states now recommend EMS board certifiction for newly hired medical directors of EMS agencies.

Air ambulances

Air ambulances (also known as medevac) often complement a land ambulance service. In some remote areas, they may even form the primary ambulance service. Like many innovations in EMS, medical aircraft were first used in the military. One of the first recorded aircraft rescues of a casualty was in 1917 in Turkey, when a soldier in the Camel Corps who had been shot in the ankle was flown to hospital in a de Havilland DH9. In 1928, the first civilian air medical service was founded in Australia to provide healthcare to people living in remote parts of the Outback. This service became the Royal Flying Doctor Service. The use of helicopters was pioneered in the Korean War, when time to reach a medical facility was reduced from 8 hours to 3 hours in World War II, and again to 2 hours by the Vietnam War.

Aircraft can travel faster and operate in a wider coverage area than a land ambulance. They have a particular advantage for major trauma injuries, especially when they occur in rural or isolated areas. The well-established theory of the golden hour suggests that major trauma patients should be transported as quickly as possible to a specialist trauma center. Therefore, medical first responders in a helicopter can provide both a higher level of care at the scene, faster transport to a specialist hospital and critical care during the journey. A disadvantage is that it can be dangerous and potentially not possible for them to fly at night or in bad weather.

Tactical (hazardous area)
Some EMS agencies have set up specialist teams to help those injured in a major incident or a dangerous situation. These include tactical police operations, active shooters, bombings, hazmat situations, building collapses, fires and natural disasters. In the US, these are often known as Tactical EMS teams and are often deployed alongside police SWAT teams. The equivalent in UK ambulance services is a Hazardous Area Response Team (HART).

Wilderness
Wilderness EMS-like systems (WEMS) have been developed to provide medical responses in remote areas, which may have significantly different needs to an urban area. Examples include the National Ski Patrol or the regional-responding Appalachian Search and Rescue Conference (USA based). Like traditional EMS providers, all wilderness emergency medical (WEM) providers must still operate under on-line or off-line medical oversight. To assist physicians in the skills necessary to provide this oversight, the Wilderness Medical Society and the National Association of EMS Physicians jointly supported the development in 2011 of a unique "Wilderness EMS Medical Director" certification course, which was cited by the Journal of EMS as one of the Top 10 EMS Innovations of 2011. Skills taught in WEMT courses exceeding the EMT-Basic scope of practice include catheterization, antibiotic administration, use of intermediate Blind Insertion Airway Devices (i.e. King Laryngeal Tube), Nasogastric Intubation, and simple suturing; however, the scope of practice for the WEMT still falls under BLS level care. A multitude of organizations provide WEM training, including private schools, non-profit organizations such as the Appalachian Center for Wilderness Medicine and the Wilderness EMS Institute, military branches, community colleges and universities,  EMS-college-hospital collaborations, and others.

Organization in different countries

 * Emergency medical services in Austria
 * Emergency medical services in Australia
 * Emergency medical services in Belgium
 * Emergency medical services in Brazil
 * Emergency medical services in Canada
 * Emergency medical services in Finland
 * Emergency medical services in France
 * Emergency medical services in Germany
 * Emergency medical services in Hong Kong
 * Emergency medical services in Iceland
 * Emergency medical services in Iran
 * Emergency medical services in Ireland
 * Emergency medical services in Israel
 * Emergency medical services in Italy
 * Emergency medical services in the Netherlands
 * Emergency medical services in New Zealand
 * Emergency medical services in Norway
 * Emergency medical services in Pakistan
 * Emergency medical services in Poland
 * Emergency medical services in Portugal
 * Emergency medical services in Romania
 * Emergency medical services in Russia
 * Emergency medical services in Spain
 * Emergency medical services in South Africa
 * Emergency medical services in Sri Lanka
 * Emergency medical services in Ukraine
 * Emergency medical services in the United Kingdom
 * Emergency medical services in the United States
 * Emergency medical services in Indonesia
 * Emergency medical services in Turkey

license: Creative Commons - Attribution Share-Alike - https://creativecommons.org/licenses/by-sa/4.0/

title: Emergency medical services


text:
Clinical neurophysiology

Clinical neurophysiology is a medical specialty that studies the central and peripheral nervous systems through the recording of bioelectrical activity, whether spontaneous or stimulated. It encompasses both research regarding the pathophysiology along with clinical methods used to diagnose diseases involving both central and peripheral nervous systems. Examinations in the clinical neurophysiology field are not limited to tests conducted in a laboratory. It is thought of as an extension of a neurologic consultation. Tests that are conducted are concerned with measuring the electrical functions of the brain, spinal cord, and nerves in the limbs and muscles. It can give the precise definition of site, the type and degree of the lesion, along with revealing the abnormalities that are in question. Due to these abilities, clinical neurophysiology is used to mainly help diagnose diseases rather than treat them.

In some countries it is a part of neurology or psychiatry, for example the United States and Germany. In other countries it is an autonomous specialty, such as Spain, Portugal, Italy, the United Kingdom, Finland, Sweden and Norway.

Hospitals that have neurologists and neurosurgeons tend to house clinical neurophysiology departments. Usually these tend to be larger hospitals that are able to employ more specialized staff units. In hospitals that possess clinical neurophysiology facilities, the major diagnostic modalities employed include:
 * Electromyography and nerve conduction studies: These diagnostic tests of the peripheral nervous system are especially useful in evaluating diseases of the muscles, nerves, and nerve roots. The basis of these tests is recording electrical activity of the muscles and the passage of electric signal along the nerves in the limbs. The disorders of nerve and muscle can either be acute (which means they rather come quickly), or have a slow developing nature. An online tool that allows the interactive exploration of these neurophysiological methods and of symptoms to which they are related can be found here.
 * Electroencephalography: Diagnostic test of thalamocortical rhythms (brain waves), useful in evaluating seizures and various abnormalities of the central nervous system. This is done by hooking up electrodes on the surface of the scalp to record currents from the cerebral cortex.
 * Evoked potentials: Diagnostic test evaluating specific tracts of the central and peripheral nervous system. May include visual, auditory, or somatosensory evoked potentials. These record the electrical responses of the brain and spinal cord to the stimulation of the senses.
 * Polysomnography: A type of sleep study employed to diagnose disorders associated with abnormal sleep behavior
 * Intraoperative monitoring, Intraoperative neurophysiologic monitoring:

In the United States
The pathway to becoming a clinical neurophysiologist in the U.S. includes completing an undergraduate degree, medical school, and postgraduate medical education, usually in neurology. Following the completion of an accredited residency program, clinicians may choose to enter a fellowship in Clinical Neurophysiology. Programs may expose their fellows to the broad spectrum of electrodiagnostic neurophysiologic studies, or may focus on a single area such as EEG or electrodiagnostic medicine. Clinical neurophysiology fellowships are generally 1–2 years in duration and may lead to board certification in one or more subspecialty areas.

In the United Kingdom
There are two healthcare professionals who typically perform neurophysiological investigations in the UK. These are medical staff trained in clinical neurophysiology, and clinical physiologists who undertake four years of practical training whilst undertaking an honours degree. Physiologists perform the majority of EEGs, evoked potentials and a portion of the nerve conduction studies. They are then clinically reported either by the physiology staff or the medical staff. Their professional organisations are the British Society for Clinical Neurophysiology and the Association of Neurophysiological Scientists

Relationship to electrodiagnostic medicine
Electrodiagnostic medicine is a subset of clinical neurophysiology. Electrodiagnostic medicine focuses only on the peripheral nervous system and not the central nervous system. Whereas a clinical neurophysiologist is trained to perform all the following studies EEG, intraoperative monitoring, nerve conduction studies, EMG and evoked potentials, and electrodiagnostic physician focuses mainly on nerve conduction studies, needle EMG, and evoked potentials. The American Board of Psychiatry and Neurology provides certification examination in clinical neurophysiology. The American Board of Electrodiagnostic Medicine provides certification in EDX medicines. The American Board of Clinical Neurophysiology certifies in electroencephalography (EEG), Evoked Potentials (EP), Polysomnography (PSG), Epilepsy Monitoring, and Neurologic Intraoperative Monitoring (NIOM). In the US physicians typically specialize in EEG or EDX medicine but not both.

Neurophysiologists in hospitals
Hospitals that have neurologists and neurosurgeons tend to house clinical neurophysiology departments. Usually these tend to be larger hospitals that are able to employ more specialized staff units. Clinical neurophysiologists are responsible for analyzing and writing reports on tests that take place within the department. They must also interpret the results that they receive and convey this information to the doctor that referred the patient to the particular neurophysiologist. Many tests involve carrying out an EMG to read the evoked potential recordings. Nerve conduction recordings are extremely common as well.

Organizations

 * International Federation of Clinical Neurophysiology
 * American Academy of Clinical Neurophysiology
 * British Society for Clinical Neurophysiology
 * Norwegian Society for Clinical Neurophysiology
 * Dutch Society for Clinical Neurophysiology
 * Italian Society for Clinical Neurophysiology
 * Mexican Society for Clinical Neurophysiology
 * Sociedad Española de Neurofisiología Clínica
 * American Academy of Neurology
 * Czech Society for Clinical Neurophysiology

title: Clinical neurophysiology