Emergency Medicine: A New Paradigm

Dr. Sumidra Laishram

What is Emergency Medicine?

In 1991, International Federation of Emergency Medicine defined Emergency Medicine (EM) as “a medical specialty—a field of practice based on the knowledge and skills required for the prevention, diagnosis and management of acute and urgent aspects of illness and injury affecting patients of all age groups with a full spectrum of undifferentiated physical and behavioral disorders. It further encompasses an understanding of the development of pre-hospital and in-hospital emergency medical systems and the skills necessary for this development.”

History: EM as a medical speciality is relatively young. Before the 1970’s, hospital Emergency Departments(ED) were generally managed by physicians on staff at the hospital on a rotating basis ,among them general surgeons, internists, psychiatrists, and dermatologists. Physicians in training (interns and residents) and sometimes nurses also staffed the ED.

EM was born as a specialty in order to fill the time commitment required by physicians on staff to work in the increasingly chaotic emergency departments (EDs) of the time. In the 1970s, groups of physicians began to leave their respective practices in order to devote their work completely to the ED. Alexandria Hospital, VA was among the first to establish 24/7 year round emergency care headed by Dr. James DeWitt Mills and his four associate physicians; Dr. Chalmers A. Loughridge, Dr. William Weaver, Dr. John McDade, and Dr. Steven Bednar .This emergency care service came to be known as the "Alexandria Plan".

The first emergency medicine residency program in the world was begun in 1970 at the University of Cincinnati and the first Department of Emergency Medicine at a U.S. medical school was founded in 1971 at the University of Southern California. After the establishment of American College of Emergency Physicians (ACEP), the recognition of emergency medicine training programs by the American Medical Association AMA) and the American Osteopathic Association(AOA), and a historical vote by the American Board of Medical Specialties in 1979, EM became a recognized medical specialty.

Scope of Emergency Medicine:

Emergency Medicine encompasses a large amount of general medicine but involves the technical and cognitive aspects of virtually all fields of medicine and surgery including the surgical sub-specialties Emergency physicians are tasked with seeing a large number of patients, treating their illnesses and arranging for disposition—either admitting them to the hospital or releasing them after treatment as necessary. The emergency physician requires a broad field of knowledge and advanced procedural skills often including surgical procedures, trauma resuscitation, advanced cardiac life support and advanced airway management. Emergency physicians must have the skills of many specialists—the ability to resuscitate a patient (critical care medicine), manage a difficult airway (anaesthesia), suture a complex laceration (plastic surgery), reduce (set) a fractured bone or dislocated joint (orthopaedic), treat a heart attack (cardiology), work-up a pregnant patient with vaginal bleeding (Obstetrics and Gynaecology), stop a bad nosebleed (ENT), place a chest tube (cardiothoracic surgery), and to conduct and interpret x-rays and ultrasounds (radiology).

The emphasis has developed beyond simply treating traumatic injury, to encompass critical and acute care for a much wider range of problems. Patients with acute illness or injury can present at any time, with a wide range of problems. Patients often have “undifferentiated” presentations (i.e. they don’t come in with a known diagnosis), with little initial information available apart from that obtained by talking to the patient; the history, examination and bedside investigations. There is a great challenge in providing rapid and appropriate treatment in the first hours, but effective early diagnosis and treatment has been shown to make big differences for short and longer term outcome in many conditions.

Indian Scenario in EM:

Since 1994, many private hospitals and institutes in India have been providing emergency medicine training for doctors, nurses & paramedics. The certification programs varied from 6 months to 3 years.

From July 2009, EM has been recognised by Medical Council of India (MCI) as a separate medical speciality. At present, there are six post-graduate seats in EM in India with plans for increasing in the near future. EM was a division of the department of Medicine in All India Institute of Medical Sciences (AIIMS). However, since September 2011, Emergency Medicine has been established as full fledged department in AIIMS with hopes of starting post-graduate courses very soon.

In Manipur, Emergency Medicine is still a very new concept among the public and even within the medical fraternity. Shija Hospitals and Research Institute (SHRI), one of the pioneering institute in health care of the state has taken up the challenge of providing EM care to the people of the state suffering from acute illness and injuries. The department of Emergency Medicine is in the process of being upgraded and expanded to provide optimal care and service.

The author is former Senior Resident, Department of Emergency Medicine (AIIMS, New Delhi) and currently working as Consultant Emergency Medicine, Shija Hospitals and Research Institute, Langol.