Emergency Medicine - Scope and Limitation

By Dr.Venugopalan.P.P, DA, DNB, MNAMS / Emergency Medicine
 

Emergency Medicine - Scope and Limitation

Emergency Medicine has recently emerged as a medical specialty with the principal mission of evaluating, managing and preventing unexpected illness and injury. It encompasses a unique body of knowledge reflected in the “Model of the clinical practice of Emergency Medicine”.

Clinical Emergency Medicine may be practiced in Emergency Department, Urgent Care Clinics and other settings. It encompasses initial evaluation, treatment and disposition of any person at any time for any symptom, event or disorder deemed by the person or someone acting on his or her behalf to require expeditious medical, surgical or psychiatric attention.

“EM 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 full spectrum of undifferentiated physical and behavioral disorders”.

Emergency is commonly defined as any condition perceived by the prudent layperson or some one on his or her behalf as requiring immediate medical or surgical evaluation and treatment. So it is a situation or condition having a high probability of disabling or immediate life threatening consequences requiring urgent intervention including first aid.

ED Physician is a specialist who has been trained to engage in the immediate initial recognition, evaluation and disposition of patient with acute illness and injury. ED Physicians do not usually provide long term or continuous care but they diagnose a wide range of diseases and perform interventions to stabilize the patient. In general EM encompasses a large amount of general medicine but involves virtually all fields of medicine and surgery including sub specialties.

ED Physicians are asked to see a large number of patients, treat their illness and arrange for disposition either admitting them to the hospital or releasing them after treatment as necessary. EP requires a broad field of knowledge and advanced procedure skills including surgical procedures, trauma resuscitation, advance cardiac life support advanced airway management etc. Good ED physicians know every single details of resuscitation and treatment methods of sick and injured relating to almost every specialty.
In practice EM demands excellent communication skills and knowledge of human psychology. The ED physician has to deal with as well as establish rapport with patient and their bystanders who are in an extremely stressful situation of unexpected emergencies. Emergency Physicians also deal with crying children,child abuse, violent patient, attendants who more often than not think that the problem is not worth admitting the patient, patient who do not trust doctors, anxious and depressed patient and over worked staff.

Other responsibilities of ED Physician includes

1.Administration, research and teaching of all aspects of Emergency care.
2.Follow up care (observation medicine)
3.Provision for emergency care to hospital patient on request.
4.EMS and pre hospital care
5.Disaster planning and management (both natural and man made events)
6.Toxicology and poisons center development
7.Education of Healthcare providers and the common public
8.Preventive care medicine
9.Basic and clinical research especially in resuscitation and acute care.

In General an ED Physician should have the opportunities to become

o ED Administrator
o EMS Directors
o EMS and Paramedic Trainers
o Disaster Planning Consultants
o First Aid trainers for non medical personals
o Best PRO
o Trained appropriately in CPR, Trauma and Pediatric Resuscitation
o Medico Legal Consultant

EM team includes EM Physician, Physician Assistant, Nurses, EMT Paramedics, and Ambulance Assistants, medico-socio worker etc.

ED APPROACH
Although there is significant cross over between EM and all other clinical specialties, EM has unique aspects, such as approach to patient care and decision-making Comprehensive history, examinations, routine lab test, specific diagnosis procedures and problem oriented medical record constitute conventional methodology, which is not appropriate in ED.

Even if only 10-20 percent of people who present to a ED truly have Emergent problems, it must be presumed that every patient who comes to ED has an emergent condition. So the first and most important question that must be answered is “WHAT IS THE LIFE THREAT?”

3 components are necessary to quickly identify life-threatening patient.

1. Chief Complaints and Brief History [SAMPLE /AMPLE History].[ S-Symptoms, A-. Allergy or Anaphylaxis M- Medications P- Past Medical/surgical history L-Last Meal, E – Events leads to current problems. ]

2. Vital Signs – Pulse, Blood Pressure, Respiration, Temperature and Fifth Vital sign SpO2/GRBS (Glucometer random blood sugar) is also done at this phase.

3. VAT -Visualize, Auscultate, and Touch the patient –Use all five senses including sixth sense- common sense. {Example – life threats like- Visualize- upper airway obstruction, Auscultate – lower airway obstruction and Touch circulatory failure [shock]- vasoconstriction in hemorrhagic and Cardiogenic shock, vasodilatation in septic, Neurogenic and anaphylactic shock.

Vital sign and Chief complaints, when used as Triage Tools, will identify majority of life threatened patients. Familiarity with normal vital signs for all age groups is essential.

The idea of performing a 'complete' examination in the ED is misleading, because most frequently a 'complete' examination is neither required nor appropriate.

“Do an 'adequate' examination!” & “Decide - The patient is stable or unstable”.
Once a life threat has identified- Do not go on. Stop immediately. Intervene to reverse the life threat. The focus should be on ABC [Airway, Breathing, and [Circulation] & establish “IV- Oxygen –Monitor”.
Stabilize the patient as fast as possible.

DIFFERENTIAL DIAGNOSIS [DD].
Once a life threat is stabilized or an immediate life threat is ruled out, the next step is to formulate a Differential Diagnosis. The DD must begin with the most serious condition possible to explain the patient's presentation and proceed from there. Not the most common diagnosis. It is unreasonable to expect that every patient evaluated in ED should or must have a diagnosis made in ED. Even in specialties sometimes it will take days, weeks, or months for the final diagnosis to be made. If there is no diagnosis, it is advisable to be intellectually honest and admit to the patient and document in medical record the inability to reach a diagnosis.
“The role of ED physician is to rule out serious or life threatening cause of a patients presentation. Not to arrive at the definitive diagnosis”
TIME BOUND & FOCUSED INVESTIGATIONS
EP should order specific investigations to aid the emergency management of the patient in ED. Example-
o 12 lead ECG should be taken and read within 10 minutes of ED arrival for all patients with chest pain and suspected ACS.
o FAST [Focused Abdominal Sonography in Trauma]-within 3 minutes along with ABCD surveys all trauma cases.
o Blood tests and C&S immediately in sepsis and septic shock
o CT head should be taken and read within one hour in all stroke cases
o Toxicological survey –send relevant sample (may be blood, urine,
Gastrointestinal Aspirate etc according to protocol)
o No role for taking X-Ray Chest to rule out and Manage Tension pneumothorax.
CHRONIC PATIENTS AND ED APPROACHES
When a patient with chronic or persistent or recurrent problem presents to ED, the EDP should try to elicit “What is different now?” eg A patient with recurrent migraine head ache, on this presentation EDP should rule out the possibility of Acute subarachnoid bleed .Such a patient may not volunteer that this head ache is different from the pattern of chronic migraines unless asked.
HOSPITAL ADMISSION -DECISIONS
Try to answer the following question
1.Is there a medical need that can be fulfilled only by hospitalization?
2.Does the patient need oxygen therapy or cardiac monitoring?
3.Does the patient need intravenous therapy?
4.Whether the patient can be safely observed in outpatient setting?
The ability of the patient to pay for services is also sometimes inappropriately used in Ed disposal.
ED DISPOSAL
1.Admission to hospital Wards, I C U, OT etc
2.Observation
3.Referral to specialists
4.ED discharge –with advice or against medical advice.
Every patient seen at ED should be disposed for follow up care. The ED discharge should be with specific follow up instruction, which include specific mention of most serious potential complication of the patient condition. Example- A patient who is being discharged home with diagnosis of probable herniated L 4-5 inter vertebral disk should be instructed to return immediately if any bowel or bladder dysfunction develops.
Before discharging the patient from ED the following 2 Questions should be answered
1.Why did the patient come to the ED?
2.Have I made the patient feel better?
EPs are bound to relieve the Physical, Physiological and Psychological pain before ED disposal.
MEDICAL AND MEDICO LEGAL RECORDS
One should be able to ascertain from reading the chart that the more serious diagnosis were indeed considered. It also must contain appropriate follow up instructions.
Writing proper Medico legal Case records, Intimating Police, Issuing wound
certificates are the primary job of EPs
SIMILARITIES BETWEEN EMERGENCY MEDICINE
AND CRITICAL CARE
o Both deal with very sick and injured patients
o Both require personnel (doctors, nurse, assistants, etc) who are specifically trained in these respective specialties.
o Emergency Medicine personnel are not adequately trained for ICU work and ICU personnel are not skilled to function in an emergency department
o Procedural skills are the same for both specialties.
o Resuscitations and deaths are common in both specialties.
Emergency department
DIFFERENCES BETWEEN EMERGENCY MEDICINE AND
CRITICAL CARE EMERGENCY MEDICINE
EMERGENCY MEDICINE
o Emergency room
o Emergency Physicians -trained and qualified in the specialty of emergency medicine after MBBS graduation
o Pre hospital care is a part of EM
o Disaster management (major role)
o Patients are unlimited
o Short-term management
o Spectrum of patients and
Problem is vast
o Diagnosis is not required
for initiation of treatment
CRITICAL CARE
o Intensive care units
o Intensivists (qualified in critical care medicine after completion of post graduation in medicine, surgery or anesthesia)
o Not much role in prehospital care
o Limited role in disaster management
o Patients limited by number of beds
o Long-term management
o Spectrum limited to the specialty of Intensive care Unit
(Eg. MICU, SICU)
o Diagnosis necessary and required for continuation of treatment
Job opportunities in EM
Presently EM is the most wanted specialty both inside and outside India with a lot of job opportunities and research scope with very good pay scale.