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American College of Emergency Physicians

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What is Emergency Medicine?

What is the definition of Emergency Medicine?
According to the American College of Emergency Physicians (ACEP), an emergency is commonly defined as any condition percieved by the prudent layperson, or someone on his or her behalf, as requiring immediate medical or surgical evaluation and treatment.The practice of emergency medicine has the primary mission of evaluating, managing and providing treatment to these patients with unexpected injury or illness.

According to the curriculum of the College of Emergency Medicine (CEM) United Kingdom, Emergency medicine is a field of practice based on the knowledge and skills required for the prevention, diagnosis and management of the 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 is a specialty in which time is critical.

Emergency medicine has evolved to include added responsibilites in the areas of :
Management of medical and administrative aspects of emergency services system.
Disaster planning and management for both natural and man made events.
Toxicology and Poison center development.
Education of both medical students and personnel as well as common people.
Preventive medicine.
Basic and Clinical research, especially in resuscitation methods and acute interventions.

(Emergency is defined by the perception of the patient or the attenders who bring the patient to the emergency department. What the emergency physician percieves may not be the same.

(Definitions and references from the United States are used more often because they are the pioneers in emergency medicine.)


Who is an emergency physician?
The American Medical Association in 1975 defined the emergency physician as a physician trained to engage in :
-The immediate intial recognition, evaluation, care and disposition of patients with acute illness and injury.
-The administration, research and teaching of all aspects of emergency medical care.
-The direction of the evaluated patient to sources of follow-up care, in or out of the hospital as may be required.
-The provision when requested of emergency, but not continuing, care to in-hospital patients.
-The management of the emergency medical system for the provision of prehospital emergency care.

What are advantages & pros of working in emergency medicine?
-Every patient has a new unexpected problem.
-Diagnosis is unknown in majority of the patients, therefore a clinical challenge.
-There will not be any patients for regular follow up like in other specialties
-Work is only during duty hours. You're free once you leave the emergency department. You don't have to worry about any patients.
-The scope of EM extends thoroughout the breadth of medicine & surgery. You can see patients who can be categorized into every known specialty.
-You get to know every consultant and doctor in the institute or hospital due to the referrals given from the emergency department.
-You are never bored in emergency medicine.
-You play a major and most significant role in prehospital care and disaster management.

What are the disadvantages & cons of working in emergency medicine?
-Emergency physicians need a level 1 hospital, where there is access to all specialties and major investigations, to function. They cannot open clinics.
-Majority of the patients are not emergencies.
-Violent abusive patients and attenders are a common scenario.
-Very sick and severely injured are a common presentation. Resuscitations and deaths are common.
-Patients usually do not stay for more than 24 hours under you.
-Patients and attenders often do not remember or acknowledge the effort you would have put in.
-Your own collegues (from other specialties) fail to understand the nature of EM work and think that you're only doing first aid & referrals.
-Pay scales cannot reach the level achieved by other specialists who have well established practice such as those in cardiology, orthopedics, etc.
Copyright 2006-2008 www.emergencymedicine.in

What is the difference between emergency medicine & critical care?

In Emergency Medicine

-Work is in an Emergency department with emergency physicians, EM residents, emergency nursing staff, emergency medical technicians (paramedics), ambulance drivers and control room personnel.
-Emergency physicians are trained and qualified in the specialty of emergency medicine after MBBS graduation
-Prehospital care/ambulance services are a part of EM
-Disaster management has a major role
-Patients are unlimited
-Uncontrolled environment
-Short term management of patients (usually less than 24hrs)
-Spectrum of patients and problems is vast
-Diagnosis is not required for initiation of treatment
-No need to worry about long term effect of drugs, long term sedation, total parenteral nutrition or ICU related disorders.
-Short term management on ventilators

Whereas in Critical care

-Work is in Intensive care units with intensivists, anesthetists, critical care nurses and other support staff like pharmacologists, microbiologists, etc.
-Intensivists are qualified in critical care medicine after completion of postgraduation in medicine, surgery or anesthesia
-There is no role in prehospital care
-Limited role in disaster management
-Patients limited by number of beds
-Controlled environment
-Long term management of patients
-Spectrum limited to the specialty of intensive care unit (Eg: Medical ICU, Surgica ICU, Neurosurgical ICU, etc)
-Diagnosis is necessary and required for continuation of treatment
-Knowledge of long term drug effects required
-Knowledge of long term sedation required
-Knowledge of ICU related disorders required
-Total parenteral nutrition knowledge required
-Long term ventilator management
-Patient can stay for weeks to months

What is similar and common between emergency medicine & critical care?
-Both deal with very sick and injured patients.
-Both require personnel (doctors, nurses, assistants, etc) who are specifically trained in these respective specialties.
-Emergency medicine personnel are not adequately trained for ICU work and ICU personnel are not skilled to function in an emergency department.
-Procedural skills are the same for both specialties.
-Resuscitations and deaths are common in both specialties

What are the subspecializations in emergency medicine?
-Pediatric emergency medicine
-Medical toxicology
-Wilderness medicine (Practice of EM in isolated & rural areas)
-Emergency medical services (EMS) [Prehospital care system & ambulances]
-EM Research
-Trauma care (Initial management & coordination)
-Observational medicine (Continued EM care of critical patients not admitted to ICU)
-Undersea & Hyperbaric medicine
-Aerospace medicine & air evacuation
-International EM (Establishing EM departments in third world countries)

(People who think emergency medicine being a specialty is absurd, will find these subspecializations more absurd! Nevertheless there are lots of consultants in these EM sub specialties already and they are growing in number)
Copyright 2006-2008 www.emergencymedicine.in

Where are all the emergency physicians in India?
They are very few emergency physicians working in India. Most of them are concentrated in institutes which support emergency medicine's growth like Christian Medical College-Vellore, Apollo Health City-Hyderabad, St. John's Medical College-Bangalore, Sri Ramachandra Medical College-Chennai, Sri Vinayaka Mission Hospital-Salem, etc.

Majority of the hospitals in the Apollo Group have emergency physicians looking after the administration and working of their emergency departments & emergency rooms.

Other emergency physicians are scattered accross the country, majority of them in South India.

(Dr. Suresh S. David, Professor, Department of Accident & Emergency Medicine, Christian Medical College, Vellore initiated a website named as the National Network of Emergency Physicians India (NEPI) [www.nepi.in] which will hopefully be the central hub for all emergency physicians/enthusiasts working in India)

(www.emergencymedicine.in has taken the privilege of developing & supporting the NEPI website [www.nepi.in] till it establishes itself. The site is currently hosted on our servers)


What are the prospects of emergency medicine in India?
This is a difficult area to convince people about, since EM is a new in India. One thing clear is that EM will grow and develop further. We definitely expect it to grow as a specialty.

Emergency physicians can find work in any major hospitals where emergency departments exist. The only problem is that it will take a while till hospitals start phasing out casualty medical officers (CMOs) and duty doctors, and start placing emergency physicians in their place. This will happen as soon as the general public become aware and start demanding trained emergency medicine physicians to evaluate them in the emergency departments.

(We believe that specialty of EM will get instant recognition once our country's advocates and lawyers understand (and capitalize on) the statement "Quality emergency care is a fundamental individual right & should be available to all who seek it.")

(Read this good article from SAEM-Society of Academic Emergency Medicine, USA)
['EM as a Career Choice']


What are the new emerging opportunities in EM especially in India?
Emergency medicine by itself is an emerging opportunity in India. Apart from being consultants in EM, emergency physicians can become the best emergency department administrators, emergency medical services (EMS) directors, EMS & paramedic trainers, disaster planning consultants, EM research directors, first aid trainers for non medical personnel, etc. Opportunities are numerous even if you are not interested in clinical care.

They can even be the best public relation officers (Due to the close association & intricate knowledge EPs have of the working of every specialty and their personnel. And due to excellent skills they have in managing any problem whether related to patients or their attenders)

Every emergency physician is trained appropriately in the latest and correct methods of cardiopulmonary, trauma and pediatric resuscitation skills. This makes them the best doctors to teach first aid and CPR skills. We are not telling that other doctors are incapable. But the nature of EM work provides ample skills needed for the EP to train anybody (whether medical or non medical) appropriately in first aid, cardiopulmonary resuscitation and trauma resuscitation.

(A good emergency physician knows every single detail of the resuscitation & treatment methods of the sick & injured relating to almost every specialty. This makes the EP a great medicolegal consultant who can scan medical records and point out lacunae, as well as fix them!)

What are the pay scales of emergency physicians in India?
Pay scales vary depending on the hospital and the region. The quality of EM training, qualification and EM experience definitely matters. There are no average figures availlable. Pay packets currently vary widely between each EP depending on the nature of his / her responsibilities. A good emergency physician doing 36-42 hours a week duties in a corporate hospital's busy ED with no added responsibilities can expect no less than Rs. 6 lakh per annum in South India, excluding benefits. Definitely more so in the North.

People who are crossing over into EM after completing postgraduation in other specialties will not be as competitive in the job market as emergency physicians trained & qualified purely in EM.
Copyright 2006-2008 www.emergencymedicine.in

Should I choose emergency medicine as a career?
Do not choose EM just because someone else has advised you to do so.

Work in a well established emergency department for no less, we repeat, no less than six months (Ideally a year) before you decide to choose or criticize EM.

There is no point in working in a casualty or ER where emergency medicine is not established. Similarly there is absolutely no point in taking career advice or comments from people who have no experience of working in EM. Only qualified emergency physicians who have worked in independent emergency departments know what its like to be working in EM and they are the best individuals to get advice from.

If you want patients to be admitted under you , remember you, thank you for all the work you have done, EM should NOT be your choice.

If you love challenges of diagnosing, stabilizing and treating very sick patients in extremely short spans of time, then you will like EM.

Practice in EM demands excellent communication skills and knowledge of human psychology. An emergency physician has to deal, as well as establish rapport, with patients and their attenders who are in an extremely stressful situation of an unexpected emergency. An EP has to deal with crying children; abusive & violent patients; attenders who, more often than not, think that the problem is not worth admitting the patient (despite the patient having something like acute MI or sepsis); patients who don't trust doctors; anxious & depressed patients; overworked staff and the rest. So make sure you are ready for this.

(Advice for Emergency Medicine Applicants, David T. Overton, Michigan State University)
['Advice For Emergency Medicine Applicants']

(A Guide for Women Emergency Physicians. From American Association of Women Emergency Physicians Section, American College of Emergency Physicians)
['You Can! A Guide For Women Emergency Physicians']

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