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Wed Sep 6 22:05:44 BST 2006

Dr. Scot:

The emergency medicine specialist in the US (and I suspect Australia, and other countries with large "outbacks") has grown out of need. The Netherlands, as an entire country, is smaller than some of the smallest states in the US, and transport times (I suspect) are not an issue. In the US, we have large suburban and rural areas where transportation of trauma victims and other critically ill patients could be detrimental to outcome. Most of the initial trauma in the US is managed at small or medium-sized hospitals (250 beds or less). These are generally not teaching hospitals, and there may be only one anesthesiologist on staff.

Although emergency medicine training in the US occurs in large urban centers, it is because that is where the volume of experience is. These doctors are being trained to work at small to medium-sized hospitals and must be able to manage the airway expertly (no backup), manage critically ill patients, and manage trauma victims just short of laparotomy, stabilize if possible, and transfer when necessary.

Thus, in the US, the necessity of training EM physicians in airway management has slowly resulted in the anesthesiologist taking a back seat at institutions with EM training programs. The anesthesiologists don't seem to mind, and I will qoute one: "there is more liability than income in the emergency room." Further, this has not resulted in any significant quality issues, and I have my suspicions as to why. Emergency medicine training and certification is competitive and highly sought after in the States (second only to ophthalmology the last time I checked). This results in some of the brightest and most talented young doctors entering into the field. 23% of graduates from WSU Medical School desired EM training last year, and less than half got it.

I suspect that in small, well-populated Westernized countries where there is a generous physician/population ratio, there is no need for the EM specialist. Unless, of course, the nearest trauma center is well beyond the time limit placed by the patient's condition. Even the US military has figured it out: In "Bahgdad ER", the airway is managed by an EM physician.

DB

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