Introduction to Emergency Medicine


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  • This lecture is designed for 1st or 2nd year Medical students to be introduced to the field of Emergency Medicine. We will not cover various aspects regarding the residency application process. This is covered under a companion lecture.
  • The purpose of this lecture is to introduce you to the specialty of emergency medicine. I would like you to develop an understanding of what emergency medicine is, what working as an emergency medicine physician is like, and how the emergency department is unique in both its approach to patients and the type of patients we evaluate.
    I would like also to discuss in general terms the various positive and negative aspects of emergency medicine so that you can better determine if this is the specialty for you.
    I would like to describe briefly how residency training is accomplished.
    Finally I would like to describe the Emergency Medicine Residents Association and various Emergency Medicine Interest Groups that are available to you.
  • Emergency medicine is still a relatively new field within medicine. Historically, emergency departments were staffed by physicians and nurses from various specialties. Often a triage nurse would call the appropriate physician down to care for the patient.
    In the 1960’s, a few physicians of various specialty backgrounds began to practice only down in the ED. It became obvious that there was a need for a specialty to care for these patients.
    In 1968, several physicians organized the American College of Emergency Physicians. This group undertook the daunting task of establishing recognition of emergency medicine as a specialty within various US medical establishments.
    In 1988, the American Board of EM became an independent board without influence of other specialties.
  • Residency training within emergency medicine began quietly in 1969 with a single resident from the University of Cincinnati creating his own curriculum for emergency medicine.
    From there, Emergency medicine residencies began to develop in 1974 with the University of Cincinnati. The training at these programs has been standardized by organizations such as ACEP, ABEM and SAEM.
    EMRA was founded in 1974 as a group to promote the interests of the EM resident
  • The number of residencies in emergency medicine has steadily grown over the last twenty years. It has stabilized over the last 5 years.
    The number of resident positions within EM have also grown.
  • Why would one choose emergency medicine?
    Here are the Top Ten leading causes of death in the United States.
    As you can see from the table, Heart Disease, Cancer, Stroke, Pulmonary Disease and Trauma make up the top 5 causes. The patients that we evaluate in the emergency department, typically have these types of disease processes.
  • What does an emergency medicine physician do? It depends what type of patients arrive that day. This is one of the draws of emergency medicine.
    However, it means that you must have a breadth as well as depth of knowledge of many different fields of medicine.
    Many patients may represent true emergencies.
  • Others may have an urgent presentation. These may turn out to be emergent conditions, but may also be a easily treatable disease process.
    Each of these patients may go home or end up in the hospital. Each patient is different.
  • And then there are the non emergent conditions that arrive each and every day. Some by choice and some because they have no other access to medical care. Some need extensive help that is not medical.
    These patients are often bread and butter for the EM physician. If these patients aggravate you, you may need to consider another profession.
    Although it is named Emergency Medicine, most patients do not have a true “medical emergency”. They do, however, have what they consider to be an emergency and therefore should be welcomed into your emergency department.
  • As an EM physician, there are limitless opportunities to work in the field of medicine. Although it is the best place to work, the ED is not the only venue in which an EM physician can ply his/her trade.
  • There is no better job than emergency medicine. We work as the detective to determine the cause of the patients complaints. Patients are not admitted to us with pyelonephritis. They present with an undifferentiated complaint such as back pain and fever. We have to investigate the complaint through history and physical exam, as well as labs and radiographs. We have to work through a very large differential.
    We see anybody and everybody. We have the chance to make the difference in somebody’s health almost every day. We must be prepared to take care of any emergency that arrives at the ED.
  • Within EM, we work through a team approach with other specialties to arrive at an appropriate diagnosis and treatment plan for the patient. We must stand firm on what is best for the patient even if our consultants would rather not admit them.
    We work set hours which allows us to better plan our lives. It allows us more time for our families or interests. We know where our work day ends and our private lives begin.
    The opportunities within academics are huge. You can work in any setting from a community hospital to a level 1 intercity trauma center.
    Emergency medicine will continue to grow in the future. There are many avenues that we can improve upon and develop.
  • At times, dealing with consultants can be difficult. This is due to the personality of that particular consultant, not the specific specialty.
    Some patients are under the influence of drugs that cause them to be violent or inappropriate. This should be looked upon as a challenge, not a problem
    Many patients arrive at the ED without any emergency. Instead they arrive because of convenience for either them or their physician. Although frustrating, it still allows you to practice medicine.
    There will be times when other specialists look back at your care and determine that it was inappropriate now that they have much more information. Always do the right thing based on what information you have available.
  • Many physicians migrate to EM due to the hours and well defined shifts. However, this must be balanced against the evenings and nights that are part of the career.
  • One can move onto various areas of sub-specialty from the specialty of Emergency Medicine. These are the four areas in which we can become board certified through fellowship training.
  • Beyond the areas of fellowships, there are several areas of expertise within the field of emergency medicine. Many other specialties may consult you about these areas to help manage patients.
    This can include the care of patients on a helicopter, or at a large gathering such as the Olympics. It might also include the management of multiple injuries at the site of a disaster such as a building collapse.
    Poisonings and environmental injuries are often managed emergently in the ED. However, the continued resuscitation within the hospital is often better known to us than the physician taking care of the patient.
  • The future of EM is limitless. We are branching out into various areas of medicine to include these.
  • Research within EM is not yet well established. However, it is limitless. You can pick almost any area of medicine and research it from the emergency department standpoint.
    As the specialty grows, there are more and more competent and qualified researchers promoting EM. The number of research projects and clinical trials will continue to grow.
  • Emergency medicine continues to need more board certified physicians to man all of the available Emergency Departments. The estimated number of EM physicians that would be needed to cover all of these departments is between 32 and 37 thousand. However, there are only 16, 149 EM board certified physicians.
    The employment opportunities in EM are innumerable. They will continue to be so until multiple more EM physicians are trained.
  • There are several organizations within emergency medicine. The American College of Emergency Physicians (ACEP) represents the broad spectrum of physicians practicing emergency medicine in the United States. ACEP remains the largest organization committed to the representation of the field.
    As well, the Society of Academic Emergency Medicine (SAEM) represents academic emergency medicine physicians. Their interests include resident and medical student education, research and the practice of EM.
    The American Academy of Emergency Medicine maintains commitment to the advancement of board certified EM physicians in the practice, business, and reimbursement arenas.
  • Emergency medicine has at least five publications that strive to disseminate information about emergency medicine. They help to discuss the various issues facing every EM physician. As well, they present the latest research as well as the latest medical treatment guidelines.
  • EM interest groups play an active role in exposing the medical students to the field of emergency medicine.
    These interests groups often promote several opportunities for medical students to learn various procedural techniques.
    Often, the EM faculty will also provide various lectures on topics germane to the medical student.
  • In order to become more familiar with the field of EM, first and second year students can do many things. Take time to do “shadow shifts” in the ED to see what actually happens. It is not the same as the “ER” television show.
    Join the EM interest group if you like the field of emergency medicine. It will help you locate others with similar interests and will allow you more time with the EM faculty.
    At this time in your medical school career, always keep your options open. Look at all areas of medicine before you lock yourself into one area. Take this time to openly investigate any area that interests you.
  • Introduction to Emergency Medicine

    1. 1. 11 Introduction to EmergencyIntroduction to Emergency MedicineMedicine Slides Courtesy ofSlides Courtesy of American College of EmergencyAmerican College of Emergency PhysiciansPhysicians
    2. 2. 2 Everything you want to know aboutEverything you want to know about Emergency Medicine-and dare to askEmergency Medicine-and dare to ask John Cunha, DOJohn Cunha, DO Attending PhysicianAttending Physician Holy Cross HospitalHoly Cross Hospital Ft. Lauderdale, FLFt. Lauderdale, FL
    3. 3. 3 Lecture ObjectivesLecture Objectives Convey an understanding of the field ofConvey an understanding of the field of Emergency MedicineEmergency Medicine Discuss pros and cons of specialtyDiscuss pros and cons of specialty Describe emergency medicine residencyDescribe emergency medicine residency trainingtraining Monetary considerationsMonetary considerations
    4. 4. 4 History of Emergency MedicineHistory of Emergency Medicine Emergency DepartmentsEmergency Departments  Staffed by physicians of various backgroundsStaffed by physicians of various backgrounds  No specialty trainingNo specialty training American College of Emergency PhysiciansAmerican College of Emergency Physicians  Established 1968Established 1968 ACOEPACOEP  Established in 1975Established in 1975
    5. 5. 5 Emergency Medicine ResidencyEmergency Medicine Residency First “resident” - 1969First “resident” - 1969 First residencies - 1970First residencies - 1970  University of CincinnatiUniversity of Cincinnati Emergency Medicine Residents’ Association -Emergency Medicine Residents’ Association - 19741974
    6. 6. 6 Emergency Medicine ResidencyEmergency Medicine Residency Emergency Medicine ResidenciesEmergency Medicine Residencies  1983 - 66 programs1983 - 66 programs  1990 - 84 programs1990 - 84 programs  2007-36 AOA programs, 138 AMA programs2007-36 AOA programs, 138 AMA programs  Multiple “combined programs”Multiple “combined programs”
    7. 7. 7 Specialty SelectionSpecialty Selection Top Ten Leading Causes of Death in the U.S.Top Ten Leading Causes of Death in the U.S. Heart Disease:Heart Disease: 726,974726,974 Cancer:Cancer: 539,577539,577 Stroke:Stroke: 159,791159,791 Chronic Obstructive Pulmonary Disease:Chronic Obstructive Pulmonary Disease: 109,029109,029 Accidents:Accidents: 95,64495,644 Pneumonia/Influenza:Pneumonia/Influenza: 86,44986,449 Diabetes:Diabetes: 62,63662,636 Suicide:Suicide: 30,53530,535 Nephritis, Nephrotic Syndrome, and NephrosisNephritis, Nephrotic Syndrome, and Nephrosis 25,33125,331 Chronic Liver Disease and Cirrhosis:Chronic Liver Disease and Cirrhosis: 25,17525,175
    8. 8. 8 Exciting Patient EncountersExciting Patient Encounters Motor vehicle versus pedestrian accidentMotor vehicle versus pedestrian accident Acute myocardial infarctionAcute myocardial infarction 24 yo with GSW to chest24 yo with GSW to chest 66 yo with CPR in progress66 yo with CPR in progress
    9. 9. 9 What’s Your Diagnosis ?What’s Your Diagnosis ?
    10. 10. 10 What’s Your Diagnosis ?What’s Your Diagnosis ?
    11. 11. 11 Not So Exciting Patient EncountersNot So Exciting Patient Encounters 5 yo with Asthma5 yo with Asthma 75 yo with Emphysema75 yo with Emphysema 45 yo alcoholic vomiting blood45 yo alcoholic vomiting blood 3 week old with fever of 1043 week old with fever of 104 37 week pregnant female with vaginal37 week pregnant female with vaginal bleedingbleeding
    12. 12. 12 Everyday Non-emergent Patient EncountersEveryday Non-emergent Patient Encounters 25 yo with a rash25 yo with a rash Homeless patient with no other physicianHomeless patient with no other physician Back pain for 3 monthsBack pain for 3 months Migraine headacheMigraine headache Ran out of medicinesRan out of medicines
    13. 13. 13 Employment OpportunitiesEmployment Opportunities Urban, rural, or suburban hospitalsUrban, rural, or suburban hospitals Teaching or community hospitalsTeaching or community hospitals  Trauma or not-traumaTrauma or not-trauma Traveling (Locum tenens) physiciansTraveling (Locum tenens) physicians International opportunitiesInternational opportunities Third world opportunitiesThird world opportunities Cruise shipCruise ship
    14. 14. 14 Appeal of Emergency MedicineAppeal of Emergency Medicine Make an immediate differenceMake an immediate difference Life threatening injuries and illnessesLife threatening injuries and illnesses Undifferentiated patient populationUndifferentiated patient population Challenge of “anything” coming inChallenge of “anything” coming in Emergency / invasive proceduresEmergency / invasive procedures Safety net of healthcareSafety net of healthcare
    15. 15. 15 Appeal of Emergency MedicineAppeal of Emergency Medicine Team approachTeam approach Patient advocacyPatient advocacy Open job marketOpen job market Academic opportunitiesAcademic opportunities Shift work / set hoursShift work / set hours Evolving specialtyEvolving specialty
    16. 16. 16 Downside to Emergency MedicineDownside to Emergency Medicine Interaction with difficult, intoxicated, or violentInteraction with difficult, intoxicated, or violent patientspatients Finding follow-up or care for uninsuredFinding follow-up or care for uninsured Work in a “fishbowl” without 20/20 hindsightWork in a “fishbowl” without 20/20 hindsight Working as a patient advocateWorking as a patient advocate Contract management groupsContract management groups Malpractice targetsMalpractice targets
    17. 17. 17 The Lifestyle:The Lifestyle: Two Sides of A CoinTwo Sides of A Coin Well defined shiftsWell defined shifts Usually not on callUsually not on call Part time employment possiblePart time employment possible Evenings and nightsEvenings and nights WeekendsWeekends HolidaysHolidays
    18. 18. 18 Subspecialties in EmergencySubspecialties in Emergency MedicineMedicine Pediatric Emergency MedicinePediatric Emergency Medicine ToxicologyToxicology Emergency Medical ServicesEmergency Medical Services Sports MedicineSports Medicine
    19. 19. 19 Areas of ExpertiseAreas of Expertise ToxicologyToxicology Emergency medical servicesEmergency medical services Mass gatheringsMass gatherings Disaster managementDisaster management Wilderness medicineWilderness medicine
    20. 20. 20 Upcoming Areas ofUpcoming Areas of Emergency MedicineEmergency Medicine Observation unitsObservation units ED ultrasoundED ultrasound International emergency medicineInternational emergency medicine
    21. 21. 21 Research OpportunitiesResearch Opportunities Broad range of subjectsBroad range of subjects Limited amount of work published in ourLimited amount of work published in our relatively new fieldrelatively new field Limited number of research mentorsLimited number of research mentors Limited number of clinical trialsLimited number of clinical trials
    22. 22. 22 Number of EM PhysiciansNumber of EM Physicians 4,945 Emergency Departments4,945 Emergency Departments Need 32,000 - 37,000 ED physicians to staffNeed 32,000 - 37,000 ED physicians to staff In 2000, 20,164 ACEP membersIn 2000, 20,164 ACEP members In 2000, 16,149 EM Board certified physiciansIn 2000, 16,149 EM Board certified physicians
    23. 23. 23 Emergency Medicine OrganizationsEmergency Medicine Organizations American College of Emergency PhysiciansAmerican College of Emergency Physicians American College of Osteopathic EmergencyAmerican College of Osteopathic Emergency MedicineMedicine Society for Academic Emergency MedicineSociety for Academic Emergency Medicine American Academy of Emergency MedicineAmerican Academy of Emergency Medicine Emergency Medicine Residents’ AssociationEmergency Medicine Residents’ Association
    24. 24. 24 Where to find more informationWhere to find more information
    25. 25. 25 Emergency Medicine JournalsEmergency Medicine Journals Annals of Emergency MedicineAnnals of Emergency Medicine Academic Emergency MedicineAcademic Emergency Medicine Journal of Emergency MedicineJournal of Emergency Medicine American Journal of Emergency MedicineAmerican Journal of Emergency Medicine Pediatric Emergency CarePediatric Emergency Care Several other Monthly JournalsSeveral other Monthly Journals
    26. 26. 26 EM Interest GroupsEM Interest Groups Student run organizationStudent run organization ““Shadow Shifts”Shadow Shifts” Journal clubJournal club Suture clinicSuture clinic Radiology labRadiology lab EKG clinicEKG clinic Lectures on EM topicsLectures on EM topics
    27. 27. 27 What to do to get in to EmergencyWhat to do to get in to Emergency Medicine for First and Second YearMedicine for First and Second Year StudentsStudents Observe in EDObserve in ED Summer research projects with EM staffSummer research projects with EM staff EM interest group affiliationEM interest group affiliation Be open to any medical specialtyBe open to any medical specialty
    28. 28. 28 Emergency MedicineEmergency Medicine Third Year StudentsThird Year Students See patients in ED on various rotationsSee patients in ED on various rotations Obtain EM physician as mentorObtain EM physician as mentor Start selecting fourth year rotationsStart selecting fourth year rotations Try to rotate where you want to beTry to rotate where you want to be  Even for your “other rotations”Even for your “other rotations” Do a Radiology rotation in one of your earliestDo a Radiology rotation in one of your earliest electiveselectives
    29. 29. 29 Emergency MedicineEmergency Medicine Fourth Year StudentsFourth Year Students Mandatory/Elective EM rotationMandatory/Elective EM rotation Rotate where you want to beRotate where you want to be  Make sure they know why you are thereMake sure they know why you are there Consider extramural rotationsConsider extramural rotations  Community experienceCommunity experience  Opportunity at a residency programOpportunity at a residency program SAEM maintains list of extramural EM rotationsSAEM maintains list of extramural EM rotations Letters of recommendationLetters of recommendation
    30. 30. 30 Combined EM Residency ProgramsCombined EM Residency Programs Emergency Medicine / PediatricsEmergency Medicine / Pediatrics Emergency Medicine / Internal MedicineEmergency Medicine / Internal Medicine Emergency Medicine / Internal Medicine /Emergency Medicine / Internal Medicine / Critical CareCritical Care
    31. 31. 31 MONEY $$$$$MONEY $$$$$ Emergency medicine is very variableEmergency medicine is very variable  Just about the middle of the physician pay scaleJust about the middle of the physician pay scale ““Academic” situations are less lucrativeAcademic” situations are less lucrative ““Private groups” are most lucrativePrivate groups” are most lucrative $150,000-400000 is the norm$150,000-400000 is the norm  Also varies on how much you workAlso varies on how much you work ““Contract groups” can be very trickyContract groups” can be very tricky
    32. 32. 32 How you get compensatedHow you get compensated Straight Hourly Rate---$90-150/hourStraight Hourly Rate---$90-150/hour  Rural (slow) ED=less moneyRural (slow) ED=less money RVU—relative value units (fee for service)RVU—relative value units (fee for service)  You see a patient you get paidYou see a patient you get paid  Points based on Medicare tables for how valuablePoints based on Medicare tables for how valuable an intervention you have madean intervention you have made Combination Hourly and RVUCombination Hourly and RVU  becoming the most common in private groupsbecoming the most common in private groups Unique “employee” set –up vs. being self-employedUnique “employee” set –up vs. being self-employed
    33. 33. 33 Choosing A SpecialtyChoosing A Specialty Fit your personalityFit your personality Decide between general or specialized fieldDecide between general or specialized field Look at all areas of interestLook at all areas of interest Ignore gossip and commentary from outside theIgnore gossip and commentary from outside the specialty you are investigatingspecialty you are investigating Commit to specialty you chooseCommit to specialty you choose
    34. 34. 34 American College ofAmerican College of Emergency PhysiciansEmergency Physicians Member Services DepartmentMember Services Department PO Box 619911PO Box 619911 Dallas, TXDallas, TX 75261-991175261-9911 1-800-798-1822 Touch 51-800-798-1822 Touch 5
    35. 35. 35 Emergency MedicineEmergency Medicine Residents’ AssociationResidents’ Association 1125 Executive Circle1125 Executive Circle Irving, TX 75038-2522Irving, TX 75038-2522 1-972-550-09201-972-550-0920
    36. 36. 36 ACOEPACOEP 142 East Ontario Street142 East Ontario Street Suite 1250Suite 1250 Chicago, Illinois 60611Chicago, Illinois 60611 phone 312.587.3709phone 312.587.3709 800.521.3709800.521.3709 fax 312.587.9951fax 312.587.9951