Emergency Medicine: A Unique Specialty (2023)

by Anthony Rodigin

What is EM?

Emergency Medicine (EM) does not claim its own body part or a physiologic system. With Vascular Surgery or Endocrinology things are straightforward. But what do we have?

Most of our procedures are shared with other specialties. We use many of the same tools and instruments. Emergency physicians also value evidence-based practice. And like providers in other fields, we believe in disease prevention, palliation, empathy, the Hippocratic oath and the magic of human touch.

In some places, emergency medicine is confused with the mere lights and sirens of ambulances or with various types of outpost facilities providing as little as vaccinations and screenings. And even if unmistakable emergency departments (EDs) are present, it is not apparent to many ED patients that the doctors seeing them are not just any doctors from somewhere else in the hospital.

It is easy to say that emergency medicine deals with emergencies. True – we initiate life-saving interventions, commence stabilizing treatments and ultimately supervise the patient’s transition to definitive care. But who is best positioned to select out these emergencies in the first place? And in what other settings besides the ED should our skills be called upon and applied? Real essence of modern EM cannot be understood without thinking through these questions.

So once again, who are we and what is EM?

Evolution of EM

History

Both prehospital emergency care and ancestral emergency rooms predate the emergency medicine specialty itself. Out of the many wars and civilian side catastrophes came the realization that competent care was needed before and during transport to a hospital. At the same time, early emergency rooms, often small and inconveniently located in basements or on second floors, served as the natural intersection for walk-ins, ambulances and hospital wards in the early and mid-twentieth century.

The technological boom following the Second World War was in part responsible for the transition from outpatient to hospital-based medicine. More could be done and in a quicker time frame inside of a hospital, and the sickest of the sick now perhaps had a chance of survival. A natural demand for expanded and better-equipped casualty (aka accident- or emergency-) departments was created. At the same time, more patients presenting to EDs with non-traumatic complaints underscored the need to move beyond mere trauma and injury.

Still, as the earlier version of this chapter correctly stated, “Only a few decades ago, emergency departments…were staffed by physicians with a variety of training backgrounds. The vast majority of these physicians had little to no emergency medicine training at all. General surgeons, family physicians, neurologists, and even psychiatrists were among those that staffed emergency departments…throughout the world” [1].

In the 1960s and 1970s things began to change rapidly. As ambulance care and destination decisions improved, in some nations relying on physicians and in others on newly established paramedics, so did the understanding that a dedicated provider specializing in ED services was invaluable. In the United States, pioneer physicians who chose to work exclusively at EDs provided additional advantages to the lifestyles and efficiency of specialists. Freeing up the latter to concentrate on more complex specialty-driven tasks led to their higher reimbursements. Thus, both the absence of competing emergency care physicians in the prehospital domain and economic incentives created by EM for narrow specialties pushed EM development in the US somewhat ahead of other parts of the world. The vast and ubiquitous benefits of EM to the general public were to follow.

From the 1970s and on rapid growth of EM residencies took place, together with the founding and strengthening of EM national boards and EM national and international societies. Brian Zink’s famous “Anyone, Anything, Anytime” comprehensively describes the history of modern EM in the United States [2]. Another excellent resource is this documentary from the Emergency Medicine Residents’ Association (EMRA). Such a trajectory was closely matched by EM’s path in the United Kingdom, Canada, Australia and other culturally Western nations, steadily but surely spreading throughout most of the world.

With every decade that followed, the number of countries developing EM increased exponentially. Arguably, each nation’s own EM chronicles are best regarded and studied in tandem with texts like Ryan Corbett Bell’s “The Ambulance”, which ought to describe the contemporaneous evolution of not only prehospital medicine but of the overall emergency care landscape in each nation as the precise background for EM’s necessity, birth and its coming of age [3].

The Future

Emergency medicine and its place within the emergency care endeavor are not going anywhere, but the scope of EM will undoubtedly change.

We can anticipate with a high degree of probability that, somewhat paradoxically to its origins, EM will continue to expand its reach beyond the emergency department. Very possibly, post-residency training via fellowships will become the norm rather than the exception. Further integration with prehospital services and sharing of EM workplaces with non-physician EM specialists (e.g. Advanced Practice Providers) will persist. Natural and technologically driven disasters will maintain high demand for EM’s unique combination of versatility and focused expertise. 

The future may not bring ready solutions to all of the clinging problems. Lack of access to universally accepted standards of emergency care in rural, remote and low-income areas is one. EM’s ambivalently viewed safety net function arising from any healthcare system’s gaps and incapacities in non-EM arenas like primary care and preventative medicine is another example. In addition, proper relationship of EM with other conceptual definitions and terms such as Frontline Medicine, Emergency Medical Services (EMS), Acute Critical Care and Pediatric EM will have to be philosophically teased out further on a global scale.

Finally, an area of medicine that has matured to its most commonly used name of Global Health (GH) needs to be mentioned in this context. Current involvement of EM physicians in GH projects, while not uncommon, is not something universally anticipated. Today it still rests on enthusiasm of individual participants or institutions. The future may call for things to change drastically in the long run.

The prognoses mentioned are not exhaustive, but they should all be met with optimist and eagerness. It is beyond any doubt that unprecedented opportunities await future EM trainees not only through engagement in primary clinical work and research in the ED, but also in domains ranging from local policy making to transnational epidemiology, and vice versa.

The Present

Today it can be surmised with justification and pride that the battle for EM’s existence, its independence and its own standards matching or surpassing those of more traditional medical specialties has been largely won.

Distinctive and concrete advantages of EM include flexibility in work schedules and lifestyles and the balance of individual expertise with teamwork. Further, EM offers multiple areas for gaining additional proficiency – ranging from bedside ultrasound to basic research and from business practices to international health. Last but not least, EM features an unparalleled interconnected global community of people just like you. If in doubt, you should strive to attend an EM International Congress (ICEM) or a regional EM conference in your area. See for yourself!

Of course, visible and hidden currents remain in motion, bringing in tides of new trials. Efforts toward fair employment practices, workplace safety, non-malevolent legal climate, job security and sustainability, EM’s influence on healthcare policies – these are only a few of today’s pressing themes. Still, such challenges are neither unprecedented nor unique to EM, and are not anything to be afraid of for future EM clinicians.

Above all else, one should know that EM is an exciting, versatile and dynamic specialty to consider as one’s top choice for a career in medicine.

Why EM?

Who are EM docs?

Our field is not without its stereotypes.  A common one is that all EM physicians are adrenaline junkies and type A immediate gratification personalities. When we are not intubating in the ED, we are skydiving or playing extreme sports. In truth, there are as many characters, hobbies and interests in EM as there are in the world at large. The passion in EM that we all share is to be found it its mission. We believe in equal opportunities to receive competent emergency care world-wide and in EM’s unique approach to the undifferentiated patient.

What sets EM physicians apart?

In the next two chapters, you will discover more words of wisdom and advice about why EM is a great choice for a specialty, and how EM physicians think differently from other providers. Here, we will come back to the two questions mentioned at the beginning of this chapter.

The first had to do with the selection of those patients who truly do have urgent, emergent and even life-threatening conditions. Of course, some selection is self-selection, as it happens at the patient’s own home or wherever they happened to be.  At other times, primary care, walk-in or ambulance services may be involved and may even play a great part. All countries differ in how the tiers of access to emergency services are designed and staggered. Interestingly and controversially, the ethics of what and to what extent an emergency care system is allowed to miss also varies by locale depending in part on culture, in part on the level of public education and in part on historical precedent shaping expectations.

In general, however, EM does not rely on or trust other types of medical providers to do this selection for us. Our specialty was designed specifically to work with the population at large presenting with all health concerns, worries or issues. These truly can be anything coming from anyone at any time. Thus, at least a third of our jobs is to figure out who truly is at risk no matter what the actual diagnosis. This task relies on a completely different set of skills than dealing with someone you already know is critical. Afterwards, we have to perform the next crucial step and stabilize our sick patients. Like bread and butter, it is hard to imagine our field without both of these essential components of practice intertwined together. Of course, in reality, we do much more than caring only for the very ill, which is the last third. From bedside psychology and social advocacy to primary pediatrics, second opinions and after-hours dermatology – we do it all.

The other question was about applying ourselves beyond the ED. EM skills are not only for the hospital. Over the last few decades, it has become obvious that EM physicians function superbly in multiple other settings, from ground and helicopter EMS (including direction and planning) to disaster relief and event medicine. EM physicians make excellent wilderness docs, public and organizational consultants, surgical assistants on GH medical missions (sometimes functioning as the only “anesthesiologist”), proceduralists, tactical support physicians, academic researchers, critical care and ICU providers and much more. All of these cojoined fields provide and will continue to provide ample opportunities for worldwide EM practice for generations of EM aficionados to come.

So, would you like to join in on the fun?

Author

Anthony RODIGIN

Anthony RODIGIN

Anthony has practiced clinical EM in the San Francisco Bay Area since 2010 and has lived in California for nearly thirty years. A fourth-generation doc, he was awed as a kid by his great-grandmother’s ambulance stories spanning decades. EM’s versatility has been a personality match from the get-go.

Since residency, choices for EM projects have been guided mainly by fun and intellectual curiosity, trying to mimic a childhood hero Sherlock Holmes. Anthony does not play a horrible violin, but rather a lousy synth keyboard. He has been passionate about education since a university TA and has comparatively studied nations’ emergency care systems for twenty years instead of sleeping. He continues to work at a busy community ED, volunteers as an EMS medical advisor for the US National Park Service, and has experience with telemedicine, urgent care, academic shifts and admin leadership. He is also a couch househusband with a spouse, two kids and a real scaredy cat.

Listen to the chapter

Cite This Article

Please replace “iEM Education Project Team” below with the author(s) surname and initials.

Cite this article as: iEM Education Project Team, "Emergency Medicine: A Unique Specialty (2023)," in International Emergency Medicine Education Project, April 7, 2023, https://iem-student.org/2023/04/07/emergency-medicine-a-unique-specialty-2023/, date accessed: September 27, 2023

References

  1. Sanderson W., Cuevas D. and Rogers R. “Emergency Medicine: A Unique Specialty”. iEmergency Medicine for Medical Students and Interns. 1st edition, Version 1, 2018.
  2. Zink, Brian J. “Anyone, Anything, Anytime: A History of Emergency Medicine”, 2nd Edition Hardcover – January 1, 2018
  3. Bell, Ryan Corbett. “The Ambulance: A History”. Reprint edition, McFarland & Company, Inc., 2009

Reviewed By

Arif Alper Cevik, MD, FEMAT, FIFEM

Arif Alper Cevik, MD, FEMAT, FIFEM

Prof Cevik is an Emergency Medicine academician at United Arab Emirates University, interested in international emergency medicine, emergency medicine education, medical education, point of care ultrasound and trauma. He is the founder and director of the International Emergency Medicine Education Project – iem-student.org, vice-chair of the International Federation for Emergency Medicine (IFEM) core curriculum and education committee and board member of the Asian Society for Emergency Medicine and Emirati Board of Emergency Medicine.

Things You Should Know Before Your First ED Shift

Things You Should Know Before Your First ED Shift

I recently posted a question to the Twitterverse:

“Imagine that an Emergency Medicine intern asked you for advice before his/her FIRST SHIFT. What would be your FIRST ADVICE?”

I also raised the same question in Turkish. In a couple of days, I received nearly 100 answers from reputable names of Emergency Medicine working worldwide. I highly benefited from these advice, and I think that our site’s valuable readers can also benefit. I tried to select the most inspiring ones and divided them into main categories. Under each advice, you can find the name of the tweet owner and the link to the original tweet. Let’s start.

Core

Enjoy being on the frontline by helping patients who are seeking your help in their most difficult time. This is a great privilege and responsibility that we should never forget.

Never forget what a privilege and responsibility it is that people don’t know you ask for your help on the WORST DAY OF THEIR LIFE.

In the Emergency Department, you may be worried about 'why am I here?' one day, but you may think that you are doing the best job in the world another day. Now you have a lifetime which every day and every patient is different. Love your profession EVERY WAY, glorify knowledge and skill, and always be at peace with your job.

Education

Never be afraid to say, "I don't know." It's why you're here to be taught. If you already knew everything, then you wouldn't need residency.

Trust yourself as if you know everything, try to learn as if you know nothing.

Want to get smart? Do 2 things: 1) Read up on at least 1 patient every shift. 2) Ask lots of questions to residents, attendings and consultants.

Feel free to ask me (or another senior) about anything (/everything). When I was at that stage I wish I’d asked more. I suspect some people think asking is a sign of ignorance or weakness. Actually, it helps us to be safe & to appreciate other perspectives.

This is the Emergency Room; this is the lion’s den; first, you have to protect yourself, and you will do this with your knowledge. So don't think ‘I'll practice, I'll fill my knowledge gap in 3-5 months', sit down, and read the textbook.

First compel yourself to read at specific points, and gradually you will find your appetite for reading. You are the one primarily responsible for your education!

Never feel shy to ask or say I don't know. It's your chance to make mistakes and learn, share the knowledge you have and don't keep it to yourself.

Of course, you cannot know everything, but you can start learning.

80% of “KNOWLEDGE” is "INTEREST"

Resilience

Resilience

The Emergency Medicine career is a marathon, not just the first few years of residency. Don't waste your energy inordinately for things you can't fix. Invest in the future self.

When you dance with the bear you can't stop until the bear wants to stop.

Calm down. Every shift eventually ends.

Rest and eat, whenever you get the opportunity. The Emergency Room is like a HIIT, you need to slow down first to speed up.

If you are a parent, sleep when the child sleeps.

Empathy

Empathy

Don’t judge patients or consultants without walking a mile in their shoes.

Think of every patient as your relative. Balance your professional authority with your kindness.

Communication is important. Tell the patient and one of his/her relatives what you already did and what you plan to do, and ask if there is anything they want to ask.

Peter Rosen once said, “Nobody woke up this AM decided to ruin your day.” Happiness is YOUR choice. Be happy, stay positive.

Remember, when you see a patient in the middle of the night who requests you to apply his/her prescribed topical cream on his/her back because –apparently- he/she can’t, that person is the joy of the night.

Follow up on your patients. This will reinforce your learning. Call patients at home to see how they’re doing. They will love it, and it reminds you of why you chose this profession.

Remember to acknowledge that you most likely are a stranger to your patient. It only takes a few minutes to reassure someone that you are there to help them through their ER experience as a team. We tend to forget this in the busy ER.

Values

Values

Nobody expects you to know much (yet). But it is expected you to be 100% reliable. Never EVER EVER EVER lie. If you don’t know something or you don’t do something, be honest.

Your attitude to this advice will determine your path through our specialty. The blindingly following advice will bring as much peril as ignoring it all. Emergency Medicine requires you to consider impacts on patients, professionals & the populations - no one approach fits all.

Never EVER EVER EVER be arrogant. You will be wrong many times in your career. Learn humility NOW.

What I like most about emergency medicine is how it allows us new perspectives every day. In the pandemic, we are treating the same disease all the time, but each patient and their family brings a different story, and every time I feel more humble in the face of life, the disease, and the future. Being in a LIMC country can be so challenging, so painful to treat and suffer along with inequalities and lack of resources... But we have the opportunity to be our best, as I said yesterday to my residents: we don’t have the best hospital, but we can be our best and give the patient what they may not have in the best hospital: treatment with dignity and respect and love. For me, being able to show my patients that I care, and receiving their gratitude has been undoubtedly the only possible prevention of Burnout. So I would say: Our specialty is beautiful, the opportunity for growth is vast, but it takes humility and perseverance to complete this journey.

Never allow senior residents of other departments to treat you as if you are their junior.

Our fingers are not equal, and so are the attendings whose hands you train on are not the same nature. There is the gentle one who loves you and there are critics who believe that development comes only with criticism and a dose of pain. Your job is not to try to classify them but to do what is required of you and to benefit from everyone.

We want you to be the brain of a machine in which none of its cogs can work properly. Sometimes, even if you don't know how to swim, you will find yourself in the ocean surrounded by the waves, but most of the time, in the hardest moments, you will find a huge army with you. Welcome...

If you think a senior is wrong about something, give him evidence, but don’t be obstinate...

You may be untutored, but never be uninterested. Because knowledge definitely comes to those who have interest.

Appear weak when you are strong and strong when you are weak. Look weak when strong; look strong when weak. Also don't forget to look at vital signs 😉

Don’t be a d*ck.

Enjoy your junior days, qualify for your senior days.

Patient Records

Patient Records

(Carefully) Fill out the patient records. What will save you from everything are these records.

Spoken words fly away, written words remain. Record everything...

What is not written is deemed not done. First, protect yourself and then protect the patient. Choose a good role model.

Workup

No workup can replace a good physical examination.

Never order a test that you won’t check the results.

Know your tests! Know their rough sens/spec and when to trust them (and more importantly, when NOT to trust them)!! No test is 100%, and all are context-dependent!

Decision Making

Being efficient should never be at the expense of being thorough. You will eventually have to waste more time making things right.

If someone brings up a concern, go to the bedside.

Think simple, make a quick decision. Determine the senior you will take as a model.

Once you suspect about a diagnosis, be sure to rule it out.

Do not forget to consider emergencies and other diseases while focusing on frequent diseases of the period, such as COVID. The most important thing that the emergency doctor needs to do is to look at the case from a wide perspective from the very beginning.

Watch out for the last patient who came just before your shift ends.

In emergency medicine [and in life :)] the possibilities are 0% or 100% only in limited scenarios. You need to quickly learn managing probabilities, setting priorities, distinguishing acceptable and unacceptable risks. Also you need to learn reading the environment; because it usually gives many signs before the problem emerges.

Patient in the Resus is easy. Spotting the patient with a real emergency in minors is the tough one.

First rule of emergency response is to ensure your own safety!

When in doubt or worried about someone, talk to floor senior physicians EARLY.

I would say to try your best to remain open-minded and try to be aware of your biases and blindspots. This applies especially to patients with psychiatric illness and substance use disorders. If you're explaining X symptom on Y problem, always ask yourself, "Does this actually make sense?

The most frequently overlooked diagnosis in the emergency room is the second diagnosis! Do not limit your perspective to one diagnosis. Most frequently missed fracture in the emergency room? The second one! Remember that the patient may have a second fracture!

While assessing only isolated parts, don’t miss to assess the patient as a whole. Do not evaluate the patient on a single system, single organ basis. Emergency Medicine requires ‘holistic assessment’.

Discharging

No hospital bed belongs to you. If in doubt, do not discharge the patient.

Do not discharge the patient relying on what someone else is telling you without assessing by yourself!

Do not discharge the patient after midnight: You may be tired, you may overlook something, the patient and his relatives may not find a car or money to leave, or they may try to go to the town or another city but have an accident on the road, etc. Those all happened (Not my personal experience, but I have seen them), evidence based...

Before discharging the patient whose treatment is completed, make sure to think like that: ‘Is there any possibility that this patient will come back with a cardiac arrest before the shift ends?’ If you are hesitant, prolong the process.

The patient at the hospital is better than the patient at home’. Do not discharge if you are not sure.

Team Play

Emergency Medicine is teamwork. Get along well with your colleagues, your nurse, your intern, your staff and your secretary. Find yourself a role model, try to be a good example for others. And enjoy the Emergency Medicine.

You may learn a lot of thing from your nurse, act like a teammate.

That’s all for now. By the way, what would your advice be?

Cite this article as: Ibrahim Sarbay, Turkey, "Things You Should Know Before Your First ED Shift," in International Emergency Medicine Education Project, July 13, 2020, https://iem-student.org/2020/07/13/things-you-should-know-before-your-first-ed-shift/, date accessed: September 27, 2023