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Thu Sep 7 01:29:02 BST 2006

This is an interesting, positive but flawed view. Although Australia is
geographically similar to the US in terms of land mass and travelling
distances, the driver behind the development of emergency medicine here as
in all countries is not primarily management of acute and critical
conditions in the absence of other specialists, but rather the development
of a group of doctors who themselves specialise in the initial diagnosis and
management of all acute critical illnesses. Some of these patients need
other in-hospital specialists such as surgeons and physicians, many do not.
The skill is in recognising which is which.

Implicit to the role of an emergency physician is the training to perform
immediate and sometimes extended management of many conditions, and this is
where airway management comes in. The management of ED airways has been well
demonstrated to fit into the EM physician skill set with no loss of quality
or increased rate of sentinel events than when managed by anaesthetics. The
people who do something well and continue to do so are the people who do it
most and that is the case here. I trained in the UK where ED airway
management has been traditionally supplied by the anaesthetic specialty, not
I add, by the anaesthetic specialists. The situation has arisen countless
times where a patient with a threatened airway is recognised immediately by
an ED physician or trainee, however they then have to wait until
anaesthetics can supply someone, usually quite junior, who is "allowed" to
manage airways. Often this may take some time, and I personally remember
occasions with a patient in profound respiratory failure where the person
who arrived had himself to call and describe it to his boss before being
told he could start a rapid sequence induction and intubation. The demand
for and supply of experienced ED physician airway management is driven by
patient need, as all change should be.

Also implicit is critical and lateral thinking not limited to craft specific
specialties that tend not to be interested in anything outside their own
area. One of the reasons many people like myself changed from a surgical
career to an emergency medicine one is encapsulated in the words of one of
my superiors on a ward round one morning early in my surgical training. A
patient had an ECG taken as they had complained to the nurses of some chest
discomfort overnight. Having recently finished intern jobs, one of which was
cardiology, followed by 6 months of emergency medicine and some ICU, I was
told to call the cardiologists to look at the ECG. When I commented that I
could do it and the tracing was normal, he told me that I didn't have to
know anything about ECG's as I was going to be a surgeon, so it wasn't my
job! In one sentence he removed the need to remember about 90% of medical
school teaching and training. The need to have experienced people who
specialise in both trauma AND ECG's and many other critical presentations is
why emergency physicians exist.

All the best

Paul Middleton

Emergency Medicine

Sydney

Australia

-----Original Message-----
From: trauma-list-bounces at trauma.org [mailto:trauma-list-bounces at trauma.org]
On Behalf Of bensonblues at comcast.net
Sent: Thursday, 7 September 2006 7:06 AM
To: trauma-list at trauma.org
Subject: Emergency Medicine in the US

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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Emergency Medicine in the US