Emergency Medicine was defined by the International Federation for Emergency Medicine in 1991 as:
“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 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 specialty of Emergency Medicine has embraced the challenge of providing around the clock care to patients who present with symptoms of acute illness and injury, across the whole age spectrum. In the UK , Emergency Medicine as a specialty is constantly adapting and developing. This has been in response to external pressures, for example the multiplicity of changes in the provision of out of hours and acute care, changes in the expectations of patients, changes in medical practice, government targets such as the ‘4 hour target’, as well as discussion and internal debate around the future direction of emergency and urgent care.
The specialty is quite different now compared to the first ‘casualty surgeons’ in the 60’s and 70’s. The emphasis has developed beyond simply treating traumatic injury, to encompass critical and acute care for a much wider range of problems. Departments of Emergency Medicine may be known by several names: Casualty, Accident and Emergency, or Emergency Department (the latter may best reflect the nature of the work, and is also the name used in other countries such as the USA and Australia ).
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.
It is not possible or practical to have an experienced representative from every hospital sub-specialty standing by in the Emergency Department at all times. Emergency Medicine evolved because emergencies can occur in any age group, at any time, in one or many body systems, and emergency physicians developed expertise as specialised generalists. This enables them to make working diagnoses, start appropriate treatment, and if the problem can’t be completely fixed at the time refer on to other appropriate specialists.
Many emergency physicians sub-specialise to bring particular expertise to the practice of Emergency Medicine. For example, they may become experts in the fields of children’s emergencies, acute medical emergencies, poisoning, life-threatening emergencies needing critical care skills, and emergencies in the pre-hospital setting. Other experts spend time focusing on sports medicine.
Many departments are increasing their capacity for practising observation medicine where patients remain in a ward style environment for up to 48 hours under the care of the emergency physician. This allows time for more detailed investigation and treatment, or support for those who have a temporary condition that prevents them being safe at home after discharge.
As far as training is concerned the specialty has a well developed curriculum and specific examinations. Junior doctors in the emergency department receive high quality training and experience under direct supervision of senior doctors who are dedicated to medical education and to the development of Emergency Medicine as a specialty in its own right.
Research into Emergency Medicine has to some extent lagged behind research in other areas. This situation is now changing, and high quality research has been emerging. Emergency Medicine in the UK is making an increasingly important contribution to clinical care with centres of excellence in research developing around the country and academic training programmes being developed.
Emergency Medicine has been pioneered in the UK , along with North America and Australasia. Many European countries are now developing services based on the UK model. Australasia and North America have long championed the specialty and advanced the levels of care offered by incorporating techniques from the fields of radiology (ultrasound) and intensive care medicine (advanced airway skills), and the UK is embracing these developments.
These pages will, we hope, explain what is involved in the work of the Emergency Department and reflect the perspectives of senior doctors, trainee doctors, and the public.
The representative body for Emergency Medicine (EM) in the Republic of Ireland (RoI) is the Irish Association for Emergency Medicine. There have always been very close ties between EM in the RoI and the UK in spite of there inevitably being different administrative arrangements in the two jurisdictions. The Irish Higher Training scheme in EM, administered by the Advisory Committee on Emergency Medicine Training (ACEMT), uses the CEM curriculum for training and the FCEM as its exit examination. From 2011, the only acceptable qualification to enter specialist training will be the MCEM examination.
Emergency Departments fulfil the same functions in the RoI as they do in the UK. Public healthcare, including EM, in the RoI is provided by the Health Service Executive (HSE). Heretofore, interaction between EM and either the HSE or the Department of Health and Children has been conducted exclusively by IAEM. The welcome advent of an Irish National Board of CEM will allow the benefits of a much larger College structure to be brought to bear, in addition to the local expertise IAEM provides.
There are formal links between IAEM, ACEMT and CEM, with the President of IAEM and the chair of ACEMT both being members of the Irish National Board of CEM. Further information is available on the Irish Association for Emergency Medicine’s website.
Emergency Medicine is a medical ‘specialty’. That means that the senior doctors (consultants) who work in Emergency Departments (EDs or A&Es) have undertaken specific training to learn how to look after emergencies. The specialty of Emergency Medicine has been developing rapidly in the UK for a number of years. It started off being practised in “Casualty” departments by doctors from a number of different medical backgrounds, but now has its own training programme, examinations, and professional college to ensure that standards are high.
Because patient healthcare provision in the UK has been changing there are still a number of different terms used by different people. Casualty departments are now known as “Accident and Emergency” Departments, or as “Emergency Departments.” Specialists in Emergency Medicine may be known as “Consultants in Accident and Emergency Medicine,” or as “Emergency Physicians.” It doesn’t matter so much what they are called, they all do the same thing. Doctors, nurses and other professionals working in Emergency Departments are dedicated to the care of acutely ill and injured patients of all ages, and with all the different problems that can present as emergencies.
Not all acute problems need to be dealt with in Emergency Departments, and there are now a number of different ways in which patients can access help. You can find your nearest service at nhs.uk/service-search.
NHS 111 is a 24-hour telephone advice service which can give advice about health problems, and how to access NHS services.
It is possible to access GP services out of hours. If you don’t know what arrangements are in place for your area, NHS 111 should be able to help, or GPs should leave details on their answer phone services / practice information.
NHS Urgent Care Centres, Walk-In Centres and Minor Injuries Units are designed to deal with minor illnesses and injuries. They are usually staffed by nurse practitioners (specially trained nurses), and sometimes by other practitioners, with a lot of experience and expertise in treating minor illness and injuries. Some of these units have doctors working alongside the nurses or nearby, and some units have X-ray facilities. Many have links with local Emergency Departments.
If your injury or illness is not serious you can get help from a Minor Injuries Unit (MIU) rather than an emergency department. By doing so you allow ED (A&E) staff to concentrate on people with serious and life-threatening conditions and save yourself a potentially long wait.
Minor injuries units may not be equipped to deal with very young children, or with more serious conditions such as:
These are the sort of conditions that may be best treated in the Emergency Department or by your own GP.
Emergency Departments are departments based at the ‘front door’ of a hospital that specialise in the care of acutely ill and injured patients. Most departments deal with patients of all ages and with all conditions, although there are some departments that see only children, or only adults, or only patients with eye problems.
Various healthcare practitioners may work in Emergency Departments, including nurses, physiotherapists, psychiatric nurses, and doctors. The care in Emergency Departments is supervised by specialists in Emergency Medicine (Emergency Physicians), whose job is to ensure that the patients passing through these departments receive care of the highest possible standard.
Most Emergency Departments are open 24 hours a day, 7 days a week. All will have resuscitation facilities for the critically ill, cubicles to see other sorts of patients, and access to investigations (such as blood tests and X-rays) to help make diagnoses.
If you have to visit an Emergency Department you can expect to be asked for your personal details, name, address etc and to be registered onto the computer system. You may be seen by a nurse briefly before seeing the doctor or nurse practitioner. This process is sometimes called ‘triage’, or sometimes called ‘assessment’. The idea is to find out who can best deal with your problem and in which part of the department, whether any treatment or investigations can be started, and whether you need to be seen very urgently. Sometimes you can be treated on the spot, or directed to a more appropriate service. Most Emergency Departments will allocate each patient a ‘triage category’, which indicates in which order patients should be seen, not necessarily how serious the problem is. This process also allows you to be given pain killers as soon as possible.
When you are seen by a doctor or nurse practitioner they will assess your condition, and decide on what the best treatment for your condition is including whether you need to be seen by a specialist or by your own GP after discharge. Sometimes patients can be treated and discharged, and some will need to be admitted to hospital. Many Emergency Departments have their own wards to which patients can be admitted for short periods of observation or treatment. You may also be referred to other hospital specialists for advice or treatment. This doesn’t mean that the Emergency Department doctors don’t know what they are doing, but that other specialists may be able to provide exactly the right care for your particular problem as well as providing follow up care to ensure your condition responds to the treatment.
Just because Emergency Departments have to see lots of patients doesn’t mean you should ever feel that things have not been properly dealt with, or that you don’t understand what is going on. If you visit an Emergency Department and feel like this, talk to the staff and ask them to explain things for you.
Until recently in England, the government specified that 98% of patients should be seen, treated and either admitted or discharged within 4 hours of arriving in the Emergency Department. In general we believe this has been a good thing and it has enabled us to improve care in many ways in our Emergency Departments. From April 2011, this ‘4 hour standard’ has been replaced by a range of quality indicators designed to further improve patient care. The Royal College of Emergency Medicine meets regularly with the Department of Health (DOH) and has always been clear that quality of care for patients must be the priority.