(This thread was posted by Dr. Shahab Ansari via Submissions)
Hi frenz,
How is Emergency medicine diferent from Accident and Emergency Medicine{A&E} which is referred to as in the west.
As far as i know A&E residents and trainees in the west are supposed to gain experience in allied surgical branches as a part of their training program...where in they can choose to learn and perform emergency surgical procedures of a sub-specialty after having completed the basic training.
I personally feel if this is the case we ER trainees in india shud also have this oppurtunity to work in surgical specialities so that people having orientation in surgical branches can also think of joining the party which wud ultimately get EM more popular and sought after.
Lets say for example we shud be allowed to carry on procedures like Burr Holes,closed reductions etc as a part of emergency resuscitation in a patient of neurosurgical/orthopedic trauma respectively.
Hope i try to make my point here.
Dr.Shahab Ansari
Senior resident in EM.
Edited by webmaster on 06-02-2008 21:55
One could say 'What's in a name?'. Emergency medicine has been christened with various names over the past 2-3 decades. What started as 'Casualty' is now widely known as A&E/ER/ED.
I guess the term A&E is more popular in UK. However, you probably would have noticed that even they are moving away from this. The college which was hitherto known as the 'Faculty of A&E Medicine' under RCS, England, is now an independent body. It has also got a new name in the form of 'College of Emergency Medicine'. They have however applied for the 'Royal' charter (of course to be called as the 'Royal College of Emergency Medicine'!!!)
I fully agree with you that a resident in EM should have all round experience to be confident with any of Acute medical, Paediatric, Surgical or Trauma related emergencies. I feel that it should not be a case of an EM doctor trying his hand at fancy procedures and treatments because he or she can. The aim has to be more of quick resuscitation and timely intervention. When I say timely intervention, I certainly mean 'time to meaningful intervention'. At the end of the day, it is the patient that matters. He/she has the right to get the right treatment, at the right time, by the right person, in a right atmosphere. Also, remember the old adage 'do no further harm'!!!
Edited by maroju on 08-02-2008 16:17
Hi Maroju,
Thanks for the reply...i agree that any patient shud get the kind of attention he deserves but disagree to the fact that we arent the right people to help him in case of unavailability of a subspecialist !! Doesnt this reflect our inablility as ER doctors to be not able to perform few basic surgical procedures.
let me mention the same example ...if a patient requires a craniotomy,are we there only to prepare him for surgery and just wait for the neurosurgeon to arrive? so that he walks in and take charge and feel that the WORLD SHOULD WAIT !!...i guess NO.
We shud be trained as a back up care for that very same paient who deserves the right to treatment in case the neuro isnt available or "LATE".
The point here is,we arent denying the importance of other specailities but then they shud realise that we can help ourselves in case of emergencies at any given time and situation and i believe that wud make us emergency physicians/surgeons in toto.
Wud like to knw ur opinion on this one as well...
I certainly am not saying that you should not do 'basic surgical' procedures. I honestly hope that you are already performing a few as part of your daily practice of EM. I feel that you should be able to do those basic procedures not only when the specialists are unavailable but whenever you feel there is need for one. Now what you describe as 'basic procedure' is for you or your hospital or SEMI to decide.
As you had mentioned before, it has to be part of your training in EM (EM doesn't mean that there is no surgery involved!!!) and eventually there has to be some form of competency based assessment at work.
I feel that you should be well versed with emergency (medical and surgical) procedures like (A: RSI, needle/surgical cricothyroidotomy, mini tracheostomy etc B: needle / tube thoracostomy, Emergency 'clam-shell' thoracotomy, pericardiocentesis C: splinting fractured limbs, pelvic braces, performing FAST scans, DPL, securing central access (fem/IJV/Subclavian), IO access, Venous cutdown, arterial lines (for inv monitoring) D: Assessing the head injured patient, maintaing adquate cerebral perfusion and minimising cerebral hypoxia, management of cerebral oedema etc. Other procedures like Manipulation of fractures, reduction of dislocations, pain management, SPCs etc are our bread and butter. There are a whole myriad of other medical problems which we should be competent in dealing with.
Though I have seen a lot of Burr holes and 'bolts' being put into heads to evacuate EDH or monitor ICP, I haven't ever done one. This does not mean that I feel no EM physician should do it. If you see these patients frequently and availability of neuro-surgeons is a problem, then you should certainly get more training in it.
Whether the neurosurgeon feels that the 'world should wait for him' or not is his opinion. Perhaps he feels that he is important because he is a 'neurosurgeon', which he got by fighting a stiff competition in the qualifying exam. As EM specialists we should certainly work hard to gain the credibility and respect. I am sure we do not get it served on a silver platter.
I would still stand by what I said earlier regarding patient care and 'meaningful' intervention. Knowing our limitations and calling for help when needed does not make us less competent. What we definitely do not want is for everyone else to think of EM specialists as a bunch of 'cowboys' who have lost the plot!!!
(PS: I think I have echoed similar sentiments under the thread 'The enemies within' )
Edited by maroju on 10-02-2008 20:36
Hi Maroju,
After all said and done i think my point remained unanswered..
i agree to wat u hv said abt the emergency procedures as without them we wud not exist {and for that matter neither hv i performed any burr holes until now} that is how this point came to my mind that if we shud be trained to do one or not.
I am not totally convinced abt the argument that one shud be trained according to the kind of patients they see on a daily basis thats where the prob begins.
My point frm the start was if EM residents shud be trained equally in medical and surgical emergencies so as to deal with whole spectrum of patients.
Tell me...wat more can we do in a patient presenting to us with an active ongoing upper GI bleed apart from fluid resuscitation and preparing him for the surgery{lets not forget the time lost to get in touch with the surgical gastro["Timely Intervention"] as india still does not have the concept of onboard subspecialist}.Personally i feel...residents who are ready and capable to be trained as trauma surgeons shud be roped in and nursed for the benefit.
This is where the basic training comes into play{which was my point from the start} that "SHOULD" EM residents be trained equally in surgical and allied surgical branches as they are being done for medical emergencies or not.
I think I have voiced my opinion regarding your query quite lucidly.
To go back to your example of upper GI bleed, my first and most important priority would be Resuscitate the patient well (mind you, it is just not fluid resuscitation!!!). This itself could take a good amount of time. Based on your assessment you may consider other options like 'terlipressin/vasopressin/octreotide' etc. You also have the choice of using a 'Sengstaken tube'. Possibly a 'gastro-enterologist' is enough rather than Surgical Gastro. All he may need is an Upper GI scope and a sclerosing injection.
The point I am trying to make is that, there are a lot of things you could do as part of resuscitation and patient stabilisation. And also, there are a lot of things you wish you could do but are not humanly possible. It is good to be firmly in touch with reality.
In Major Trauma Centres say in South Africa/Aus/UK, they have Trauma Surgeons as part of the 'Trauma Team', who are trained in emergency surgical procedures. Usually these are vascular surgeons. They are incorporated into the roster and are available 24/7 at a very short notice. Mind you, not all centres have them. One has to improvise the system to meet the local demands.
Coming to the specifics, even if, say you are trained in surgical gastroenterology/urology/CT surgery/Neurosurgery/Obs-Gyn etc etc as part of your curriculum, you need to still see and perform these procedures on a fairly frequent basis to keep up your skill levels. Being able to do a procedure does not mean you are competent in it. Being able to do it consistently well, time and again on par with a specialist in that field would be close to being competent. Anything less than this could amount to negligence. This is the reason that I suggested in my earlier response that you learn to do a procedure only if you see such patients frequently and can keep up with the skills.
If you work in a hospital that calls itself a Trauma Centre, then you / your managers should ensure that the relevant specialists/facilities are available at very short notices. It needs a certain rigor to enforce this. Unless this discipline and commitment exists, your centre shouldn't even be called or accredited as a trauma centre.
At this point of time in the evolution of EM, I would certainly say that it is totally unnecessary for a EM specialist to be trained in 'all' the surgical specialties. On the contrary, it may prove to be detrimental to patient care. The core skills have to be defined by the governing body (hopefully SEMI) based on feasibility and necessity. I am aware that the 'goal-posts' keep shifting and I may be totally wrong twenty years hence!!!
Having talked about trauma scenarios and surgery for so long, let us not forget that EM is not all about cutting and doing fancy interventions. Majority of the emergencies (more than 70%) happen to be medical emergencies.
These are only my opinions. What do other members feel?
Edited by maroju on 10-02-2008 20:34
