The criteria that was used and assessed a point value is as follows:

What is Emergency Medicine?

Emergency medicine is a specialty that diagnoses and treats conditions that require immediate attention. This may include accidents of any sort, illness, trauma, sports injuries, industrial and occupational accidents, poisoning, allergic reactions and heart failure.

Wikipedia states the following :

Emergency medicine is a branch of medicine that is practiced in a hospital emergency department, in the field (in a modified form - see EMS), and other locations where initial medical treatment of illness takes place. Emergency medicine focuses on diagnosis and treatment of acute illnesses and injuries that require immediate care. While not usually providing long-term care, EM physicians and pre-hospital personnel still provide care with the aim of improving long-term patient outcome. In the United States, some people use the emergency department for outpatient care that could be provided at a doctor's office. As a result, much of emergency room care is general practice (coughs, colds, aches, pains).

A variant of an Emergency Department is an Urgent Care Center, often staffed by non-Emergency Medicine trained physicians and/or nurses, which treats patients who desire or require immediate care, but do not reach the acuity that requires care in an emergency department.

Emergency Medicine involves a large amount of general medicine but involves all fields of medicine including the surgical sub-specialties. Emergency Physicians are tasked with seeing a large number of patients, treating their illnesses and admitting them to the hospital as necessary. The field requires a broad field of knowledge and requires advance procedural skills often including surgical procedures, trauma resuscitation, advance cardiac life support and advanced airway management.

Definition

"Emergency medicine is 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

Emergency Medicine as a standalone medical specialty is relatively young. Prior to the 1960's and 70's, hospital emergency rooms were generally staffed by doctors trained in other specialties, such as internal medicine and primary care. However, during this time period, groups of physicians mostly located in the Midwestern United States (notably Cincinnati, Ohio, and Denver, Colorado) recognized the need, and the niche, for physicians specifically trained to handle acute medical emergencies.

Organizations

In the United States, the American College of Emergency Physicians (ACEP) is presently the largest member organization of emergency physicians (EPs), and is open to most physicians who practice in an Emergency Department. Originally founded in 1968, it was the first Emergency Medicine society formed in the United States. Fellows use the designation FACEP.

The American College of Osteopathic Emergency Physicians (ACOEP) was founded seven years later in 1975. Membership is open to both osteopathic (D.O.) and allopathic (M.D.) physicians who practice emergency medicine. Fellows use the designation FACOEP.

The American Academy of Emergency Medicine (AAEM) is another specialty society of Emergency Medicine. It was formed after ACEP and ACOEP and is considered a rival organization although both organizations have cooperated in the past. Members must be board certified in Emergency Medicine. Fellows use the designation FAAEM.

The American Board of Emergency Medicine (ABEM) provides board certification to allopathic (M.D.) emergency physicians who have successfully completed a residency in emergency medicine, completed an additional year of practice, passed a written exam, and then an oral exam.

The American Osteopathic Board of Emergency Medicine (AOBEM) provides board certification to osteopathic (D.O.) emergency physicians who have successfully completed a residency in emergency medicine, completed an additional two years of practice, passed a written exam, and passed an oral exam.

The American Board of Physician Specialties (ABPS) also offers Board Certification in Emergency Medicine (BCEM). This certification is offered to experienced physicians who have trained initially in other settings, and who have more than 5 years of emergency medicine experience and are certified in ACLS/ATLS courses, provide letters of recommendation and file case reports, as well as pass written and oral testing. The ABPS certification is controversial and not widely recognized as it allows non-emergency residency trained physicians to claim specialization in Emergency Medicine without going through a residency. The 'grandfathering-in' of other experienced non-residency trained physicians practicing emergency medicine was closed off from ABEM and AOBEM several years ago. Currently (as of 7/06), only the state of Florida has recognized "BCEM", with the state of North Carolina affirmiatively rejecting the "BCEM" designation.

Board certification is maintained through annual testing over required reading lists and a more extensive written exam every 10 years (for ABEM).

Many types of physicians may practice in an Emergency Department; however, only those who have successfully passed the board certification process are considered "Emergency Medicine Specialists". Currently the ABEM and AOBEM require a number of years of residency training after medical school, followed by comprehensive written and oral examinations. The BCEM requires (in addition to passing written and oral examinations) completion of an ACGME approved residency in an approved specialty such as Family Medicine or Internal Medicine, 5 years of the practice of emergency medicine, 10 Peer reviewed case reports, current ATLS/ACLS certification and 3 letters of recommendation from peers.

A sudden surge of interest in the specialty in the late 1990s was due to the popularity of the American TV series "ER". Showcasing the function of a Chicago Emergency Department (loosely based on Cook County Hospital) and its many characters, the show introduced a large number of people to the specialty.

Practice

In the US, Emergency Medicine is one of the more competitive specialties to get into, and residency programs generally select physicians from the top of their medical school class. There are usually many physicians competing for each residency spot.

Allopathic (M.D.) emergency medicine residencies can be 3 or 4 years in length, combining both the internship and residency into one program or "1+3," utilizing a separate internship followed by 3 years of Emergency Medicine. Osteopathic (D.O.) residencies are four years in length, requiring a one year traditional rotating internship followed by a three-year emergency medicine residency. In addition to the didactic exposure, much of an emergency medicine residency involves rotating through other specialties with a majority of such rotations through the emergency department itself. By the end of their training, EPs are expected to handle a vast field of medical, surgical, and psychiatric emergencies. EPs are therefore both clinical generalists and well-rounded diagnosticians. EPs are considered specialists in advance cardiac life support protocols ('codes') and airway management.

The employment arrangement of emergency physician practices are either private (a democratic group of EPs staff an ED under contract), institutional (EPs with an independent contractor relationship with the hospital), or corporate (EPs with an independent contractor relationship with a third party staffing company that services multiple emergency departments).

Most emergency physicians staff hospital emergency departments in shifts, a job structure necessitated by the 24/7 nature of the emergency department.

The emergency department (ED), sometimes termed the emergency room (ER), emergency ward (EW), accident & emergency (A&E) department or casualty department is a hospital or primary care department that provides initial treatment to patients with a broad spectrum of illnesses and injuries, some of which may be life-threatening and requiring immediate attention. Emergency departments developed during the 20th century in response to an increased need for rapid assessment and management of critical illnesses. In some countries, emergency departments have become important entry points for those without other means of access to medical care.

Upon arrival in the ED, people typically undergo a brief triage, or sorting, interview to help determine the nature and severity of their illness. Individuals with serious illnesses are then seen by a physician more rapidly than those with less severe symptoms or injuries. Depending on resources, if the anticipated waiting time is particularly long, patients with minor symptoms may be directed to visit a primary care physician or outpatient clinic instead. After initial assessment and treatment, patients are either admitted to the hospital, transferred to a specialty hospital, or discharged. The staff in emergency departments often includes doctors and nurses with specialized training in emergency medicine. The emergency departments of large hospitals operate continuously and accept after-hours cases not seen by smaller hospitals.

Since a diagnosis must be made by an attending physician, the patient is initially assigned a chief complaint rather than a diagnosis. This is usually a symtom: headache, nausea, loss of consciousness. The chief complaint remains a primary fact until the attending physician makes a diagnosis.

Department layout

A typical emergency department has several different areas, each specialized for patients with particular severities or types of illness.

In the triage area, patients are seen by a triage nurse who completes a preliminary evaluation, before transferring care to another area of the ED or a different department in the hospital. Patients with life or limb-threatening conditions may bypass triage and to be seen directly by a physician.

The resuscitation area is a key area of an emergency department. It usually contains several individual resuscitation bays, usually with one specially equipped for pediatric resuscitation. Each bay is equipped with a defibrillator, airway equipment, oxygen, intravenous lines and fluids, and emergency drugs. Resuscitation areas also have ECG machines, and often limited X-ray facilities to perform chest and pelvis films. Other equipment may include non-invasive ventilation (NIV) and portable ultrasound devices.

The majors, or general medical area is for stable patients who still need treatment that requires a gurney (trolley). This area is often very busy, filled with many patients with a wide range of medical and surgical problems. Many will require further investigation and possible admission. Patients who are not in need of immediate treatment are sent to the minors area. Such patients may still have been found to have significant problems, including fractures, dislocations, and lacerations requiring suturing.

A pediatric area for the treatment of children has recently become standard, to dedicate separate waiting areas and facilities for children. Some departments employ a play therapist whose job is to put children at ease to reduce the anxiety caused by visiting the emergency department, as well as provide distraction therapy for simple procedures.

The obstetrics area, for women before, during and after pregnancy, is usually a separate part of an emergency department and/or a separate part of a hospital. Women are often primarily seen by obstetricians in an environment where equipment is available for specialized care.

Many hospitals have a separate area for evaluation of psychiatric problems. These are often staffed by psychiatrists and psychiatry-trained nurses and psychiatric social workers. There is typically at least one room for people who are actively a risk to themselves or others (e.g. suicidal). Emergency departments may also have a separately streamed service for minor and rapidly treatable conditions, such as minor injuries. The fast  track may be staffed by emergency nurse practitioners and/or physicians, and special consultation rooms are specifically designated for this purpose. This system allows for quicker treatment of patients who may otherwise be forced to wait for more pressing cases to resolve. This part of the department may be called by several names e.g. Urgent Care Center or Primary Care Suite depending on the local emphasis. Where this type of service is provided on a separate site from the local ED it is called a Minor Injuries Unit.

In the United States an emergency department is often referred to as an emergency room (ER). Emergency rooms are actually departments of a hospital with many rooms. The ER interacts with every other department in the hospital and often represents a significant percentage of the  hospital's work load and finances. It is common for emergency department doctors to work for a company hired by the hospital to provide emergency services.

During the 1990s, an effort was made to change to the more accurate term emergency department (ED), which is a term increasingly used by members of the specialty internationally. The effort failed and ED never caught on among the U.S. public, perhaps because of the popularity of the TV show, "ER", and the heavy marketing of the euphemism "ED" for erectile dysfunction by pharmaceutical companies. However, the term does have some circulation among emergency medicine physicians.

A smaller facility that may provide assistance in medical emergencies is known as a clinic. Larger communities often provide a drop-in clinic where people with medical problems that would not be considered serious enough to warrant an emergency department visit can be seen. These clinics often do not operate on a 24 hour basis, and visiting them is sometimes less expensive than going to the ED.

Patients arrive at emergency departments in two main ways: by emergency ambulance or independently. Ambulance paramedics or technicians notify the hospital beforehand if they are transporting a severely-ill patient. These patients are rushed to the emergency department's resuscitation area, where they are met by a team with the expertise to deal with the patients' conditions. For example, patients with major trauma are seen by a trauma team consisting of emergency physicians and nurses, a surgeon, and an anesthesiologist (anesthetist).

Patients arriving independently or by ambulance are typically triaged by a nurse with training in emergency medicine. Patients are seen in order of medical urgency, not in order of arrival. Patients are triaged to the resuscitation area, majors area, or minors area. Emergency/Accident and Emergency departments usually have one entrance with a lobby and a waiting room for patients with less-urgent conditions, and another entrance reserved for ambulances.

Critical Conditions Handled

Cardiac arrest

Cardiac arrest may occur in the ED/A&E or a patient may be transported by ambulance to the emergency department already in this state. Treatment is basic and advanced life support as taught in the Advanced Life Support and Advanced Cardiac Life Support courses. This is an immediately life-threatening condition which requires immediate action in salvageable cases.

Heart attack

Patients arriving to the emergency department with a myocardial infarction (heart attack) are likely to be triaged to the resuscitation area. They will receive oxygen and monitoring and have an early ECG; aspirin will be given if not contraindicated or not already administered by the ambulance team; morphine or diamorphine will be given for pain; sublingual (under the tongue) or buccal (between cheek and upper gum) glyceryl trinitrate (nitroglycerin) (GTN or NTG) will be given.

If the ECG confirms an ST elevation myocardial infarction or there is onset of left bundle branch block this indicates complete blockage of one of the  main cardiac blood vessels. These patients require reperfusion (re-opening) of the occluded vessel. This can be achieved in two ways: thrombolysis (clot-busting medication) or percutaneous transluminal coronary angioplasty (PTCA). Both of these are effective in reducing significantly the  mortality of myocardial infarction. Many centers are now moving to the use of PTCA as it is somewhat more effective than thrombolysis if it can be administered early. This may involve transfer to a nearby facility with facilities for angioplasty.

Trauma

Major trauma, the term for patients with multiple injuries, often from a road traffic accident or a fall, is treated by a trauma team who have been trained using the principles taught in the internationally recognized Advanced Trauma Life Support (ATLS) course of the American College of Surgeons. Some other international training bodies have started to run similar courses based on the same principles.

The services that are provided in an emergency department can range from simple x-rays and the setting of broken bones to those of a full-scale trauma center. Emergency medical technicians often work as support staff in emergency departments under the supervision of nurses and doctors. A patient's chances of survival are greatly improved if emergency care begins within one hour of an accident (such as a car accident) or onset of acute illness (such as a heart attack). This critical time frame is commonly known as the "golden hour."

Some emergency departments in smaller hospitals are located near a helipad which is used by helicopters to transport a patient to a trauma center. This inter-hospital transfer is often done when a patient requires advanced medical care unavailable at the local facility. In such cases the emergency department can only stabilize the patient for transport.

Some patients arrive at an emergency department for a complaint of mental illness. In many jurisdictions (including many U.S. states), patients who appear to be mentally ill and to present a danger to themselves or others may be brought against their will to an emergency department by law enforcement officers for psychiatric examination. From the emergency department, patients thought to be mentally ill may be transferred to a psychiatric unit (in many cases involuntarily).

Asthma and COPD

Acute exacerbations of chronic respiratory diseases, mainly asthma and chronic obstructive pulmonary disease (COPD) are assessed as emergencies and treated with oxygen therapy, bronchodilators, steroids or theophylline, have an urgent chest X-ray and arterial blood gases and are referred for intensive care if necessary. Non invasive ventilation in the ED has reduced the requirement for intubation in many cases of severe exacerbations of COPD.

Special facilities, training, and equipment

An ED requires different equipment and different approaches than most other hospital divisions. Patients frequently arrive with unstable conditions, and so must be treated quickly. They may be unconscious, and information such as their medical history, allergies, and blood type may be unavailable. ED staff are trained to work quickly and effectively even with minimal information. ED staff must also interact efficiently with pre-hospital care providers such as EMTs, paramedics, and others who are occasionally based in an ED. The pre-hospital providers may use equipment unfamiliar to the average physician, but ED physicians must be expert in using (and safely removing) specialized equipment, since devices such as Military Anti-Shock Trousers ("MAST") and traction splints require special procedures. Among other reasons, given that they must be able to handle specialized equipment, physicians can now specialize in emergency medicine, and EDs employ many such specialists.

ED staff have much in common with ambulance and fire crews, combat medics, search and rescue teams, and disaster response teams. Often, joint training and practice drills are organized to improve the coordination of this complex response system. Busy EDs exchange a great deal of equipment with ambulance crews, and both must provide for replacing, returning, or reimbursing for costly items.

Cardiac arrest and major trauma are relatively common in EDs, so defibrillators, automatic ventilation and CPR machines, and bleeding control dressings are used heavily. Survival in such cases is greatly enhanced by shortening the wait for key interventions, and in recent years some of this specialized equipment has spread to pre-hospital settings. The best-known example is defibrillators, which spread first to ambulances, then in an automatic version to police cars, and most recently to public spaces such as airports and office buildings.

EDs usually have their own surgical facilities. They also require very fast laboratory work for blood-typing, measurements of drug levels in overdose, and so on, so they may have separate lab facilities, or first priority when using shared labs.

Non-emergency use

Emergency departments around the world are increasingly being used for non-emergency care because of overburdened healthcare systems. Many people, afflicted by minor injuries or illnesses late at night or at times when their doctor's surgery is closed, are forced to resort to attending the ED.  This is especially true for conditions with severe symptoms, such as a child's ear infection. People in lower socioeconomic classes are more likely to  require treatment for primary care ailments from EDs.

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