Chapter One Overview of emergency medicine

1. Chapter One Overview of emergency medicine Jia Xu The First Affiliated Hospital of College of Medicine,Zhejiang University Emergency Medicine

2. What Is Emergency Medicine? • In the words of the International Federation for Emergency Medicine : • "Emergency medicine(EM) is a medical specialty—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 a full spectrum of undifferentiated physical and behavioral disorders. It further encompasses an understanding of the development of pre-hospital and in-hospital emergency medical systems and the skills necessary for this development." 第一章 绪论： 沈洪

3. What does an emergency physician (EP) do? the core of emergency medicine assessment triage acute and urgent illness and injury (24/7) disposition management diagnosis 第一章 绪论： 沈洪

4. The needs of society 2006: 119 million； 40.5 per 100 • Numbers of emergency department visits in U.S. 36% 1996: 87 million； 34.2 per 100 With the development of medical science, timely EM is proved more effctive. EM servies are easier to access. The rates of cardio-cerebral-vascular disease are higher. “Golden Time” Old persons always have diseases refers to many organs. Urgent patients longevity dieases strategies 第一章 绪论： 沈洪

5. Emergency medical services system（EMSS） Emergency Medicine Chapter One Overview of emergency medicine

6. The constitution of EMSS prehospital emergency EMSS hospital emergency critical care 第一章 绪论： 沈洪

7. The 15 elements of EMSS (1) Personnel • In most urban areas : 1）public safety 2）ambulance personnel • in rural or wilderness areas ： 1）citizen volunteers 2）park rangers 3）ski patrols, et al. 第一章 绪论： 沈洪

8. (2) Training Ambulance crew patient assessment; give additional medications EMT paramedic (EMT-P) basic ECG interpretation, the ability to give some cardiac medications Ambulance crew EMT intermediate (EMT-I) use of AED; safe transportation; assist patients using their own medicine Ambulance crew EM Technician basic (EMT-B) CPR, spinal immobilization, bleeding control, basic emergency care procedures Non-ambulance crew First Responder (FR) 第一章 绪论： 沈洪

9. (3) Communications • the universal emergency telephone number 120 China 第一章 绪论： 沈洪

10. (4) Transportation Ground ambulances : Basic life support (BLS) ambulances EMS-B; Advanced life support (ALS) ambulances EMS-P. Air ambulances 第一章 绪论： 沈洪

11. (5) Facilities Rules: • the closest appropriate hospital • the patient's choice • a specific hospital with better resources to treat seriously ill or injured patients (e.g., trauma center, cardiac center) 第一章 绪论： 沈洪

12. (6) Critical Care Units • trauma • burns • spinal cord injury • neurosurgical • respiratory failure • cardiac care Emergency intensive care units (EICU) 第一章 绪论： 沈洪

13. (7) Public Safety Agencies • police car • fire engine • ambulance • the FR of EMSS • are needed to provide medical care in hazardous circumstances 第一章 绪论： 沈洪

14. (8) Consumer Participation • public support: political, financial • public first aid training • the implementation of a universal telephone number system. 第一章 绪论： 沈洪

15. (9) Access to Care • An important principle of EMS is that all individuals deserve timely access to the system when necessary. 第一章 绪论： 沈洪

16. (10) Transfer of Care inform relevant information Sender Receiver response and prepare 第一章 绪论： 沈洪

17. (11) Standardization of Patients' Records • use a similar reporting form by medical records and prehospital records • interpreted quickly and easily by receiving nurses and physicians 第一章 绪论： 沈洪

18. (12) Public Information and Education • Each year, India's monsoon rainy season causes massive devastation, resulting in the loss of homes, cattle, commerce and — above all — human life. Photo from《Equipping Villages for Disaster》 The villagers demonstrate proper use of lifesaving flotation devices. 第一章 绪论： 沈洪

19. (13) Independent Review and Evaluation Governing agencies should be assured that there is ongoing review of the EMS system. Needs • monitoring of radio communications Times • review of response times • review of transfer times • review of patient care records • review of positive result rate Effects 第一章 绪论： 沈洪

20. (14) Disaster Linkage Public safety agencies should keep the EMS system informed of potential disaster situations. Hospitals should keep the EMS system informed of their capacity to receive certain kinds of patients under disaster conditions. Photos from 2008 5.12 China Wenchuan earthquakes. 第一章 绪论： 沈洪

21. (15) Mutual Aid Agreements • EMSS should develop mutual aid agreements with neighboring jurisdictions so that uninterrupted emergency care is available when local agencies are overwhelmed or unable to provide services. 第一章 绪论： 沈洪

22. The 15 elements of EMSS Thus, an EMS system is the entire system to provide care to emergency patients from the initial call to definitive care. The basic elements of patients care 第一章 绪论： 沈洪

23. The development of emergency medicine Emergency Medicine Chapter One Overview of emergency medicine

24. (1) History • In 1792, a clever French army surgeon devised the “flying ambulance” during the French Revolution FrenchRevolution Dominique Jean Larrey,(1766-1842) “the father of emergency medicine” The “flying ambulance” 第一章 绪论： 沈洪

25. (1) History • Emergency medicine (EM) as a medical specialty: • Prior to the 1960s and 70s: Emergency department were generally staffed by physicians on a rotating basis, among them general surgeons, internists, psychiatrists, and dermatologists. • The “Alexandria Plan”:the first groups headed by Dr. James DeWitt Mills along with four associate physicians was established to provide 24/7 year round emergency care at Alexandria Hospital, VA, U.S.A.. 第一章 绪论： 沈洪

26. (1) History • In 1970: the first emergency medicine training program at Cincinnati General Hospital was established. • During the 1970s: the establishment of American College of Emergency Physicians (ACEP) ; the recognition of emergency medicine training programs by the American Medical Association (AMA) • In 1979: a historical vote by the American Board of Medical Specialties made EM become a recognized medical specialty in America. 第一章 绪论： 沈洪

27. Anglo-American model:“brings the patient to the hospital”. Australia, China, Japan, the United Kingdom and the United States, etc. Franco-German model: “brings the hospital to the patient”. Austria, France, Germany, Russia, Sweden, and Switzerland, etc. (2) The Development of Emergency Medicine Worldwide Emergency medicine development models 第一章 绪论： 沈洪

28. Reasons for the influence of the Anglo-American model • The predominance of American academic emergency medicine: which provides the research, journals, textbooks, and practice guidelines used throughout the world (eg. American Heart Association, Advanced Cardiac Life Support, Advanced Trauma Life Support) • 24/7 year round service concept 15 years popular TV shows “ER” 第一章 绪论： 沈洪

29. (3) Stages in the development of emergency care systems Such as Armenia, China, Israel, the Philippines, Saudi Arabia, South Korea, and Turkey. Include Australia, Canada, the United Kingdom, and the United States 第一章 绪论： 沈洪

30. Unique Aspects of Emergency Medicine Practice Emergency Medicine Chapter One Overview of emergency medicine

31. (1) Time and Volume Pressure • EPs must prepared to “treat first and ask questions later.” Because in a true emergency, seconds or minutes may make the difference between life and death or serious disability. • The time available for one given patient is severely limited by the demands of other patients being managed concurrently. (10-15 mins per patient) 第一章 绪论： 沈洪

32. (2) Variety of Conditions • must master comprehensive knowledge • must manage a wider variety of conditions • must shift cognitive frames rapidly 第一章 绪论： 沈洪

33. (3) Paucity of Information • unaware of patients’ history • old records are often unavailable • history be provided from bystanders or EMS providers 第一章 绪论： 沈洪

34. (4) Limited Therapeutic Options • treatment strategies always based on limited laboratory and imaging tests. • the tolerance for therapeutic failures or misadventures is more limited than in nonemergencies. • EPs often can provide only temporizing or symptomatic treatment, while definitive management must be deferred to another specialist. 第一章 绪论： 沈洪

35. (5) Constraint of Disposition • No matter how uncertain the diagnosis or how much extended observation or testing might help, every patient encounter in the ED ultimately reduces to three binary decisions: • (1) Is the patient sick or not sick? • (2) If the patient is sick, should I treat this problem or not treat? • (3) Should I admit or discharge the patient? 第一章 绪论： 沈洪

36. (6) Work in an environment in which patients die • Why the person died? • Will the patient die? • Will the illness have an impact on survivors? • Does the illness put health-care workers and society at risk? • Should an autopsy be performed for medical or legal reasons? • Does the family desire organ donation? • Needs to be on guard for the occasional violent reaction by survivors. 第一章 绪论： 沈洪

37. General Principles of Emergency Medicine Practice Emergency Medicine Chapter One Overview of emergency medicine

38. The Principles of EM • The principles of emergency medicine are provide effective care to patients who have entrusted EPs with their care. • The questions below can be used as a simple guide for EPs. 第一章 绪论： 沈洪

39. (1) Is the Patient About to Die? a life-threatening illness or injury with a high probability of death if immediate intervention is not begun ( Critical patient ) illness or injury that may progress in severity if treatment is not begun quickly ( Emergent patient ) have a low probability of progression to a more serious condition ( Nonurgent patient ) Look for symptoms of a life-threatening emergency, not a specific disease. Anticipate impending life-threatening emergencies in the apparently stable patient. 第一章 绪论： 沈洪

40. (2) What Steps Must Be Undertaken to Stabilize the Patient? Airway Neurologic deficits Breathing Circulation Do not delay necessary primary interventions while awaiting completion of ancillary testing. What do we need to treat first for a hemoptysis patient with apnea? 第一章 绪论： 沈洪

41. (3) What Are the Most Potential Serious Causes of the Patient? • Develop a list of "What will kill my patient the fastest?" the vital signs history Suspicious causes physical examination ancillary assessments What is the life threatening symptom for a bowel obstruction with septic shock? 第一章 绪论： 沈洪

42. (4) Could There Be Multiple Causes of the Patient's Presentation? • "Is this all there is?" • Examples 1: new-onset seizure and hypoglycemia in an older diabetic patient. • intentional or accidental medication overdose? • perhaps worsening renal insufficiency? 第一章 绪论： 沈洪

43. (4) Could There Be Multiple Causes of the Patient's Presentation? • Example 2: Near-syncope and abdominal pain in an apparently intoxicated college coed • a ruptured ectopic pregnancy? • or perhaps a ruptured spleen secondary to undisclosed physical abuse by her BF? • or...? Frequent reassessment the multiple possibilities responsible for patient's condition is imperative. 第一章 绪论： 沈洪

44. (5) Does This Patient Need to Be Admitted to the Hospital? • Whether an emergency condition exists. • Does the patient have timely, accessible follow-up? • Are unresolved abuse or self-care issues involved? • Are you, as the EP, comfortable discharging the patient? 第一章 绪论： 沈洪

45. (6) How to Treat the Discharged Patient? • Recommend appropriate follow-up and provide written discharge instructions. • Instruct the patient when to return for further evaluation. • Provide the patient with information regarding treatment and diagnosis. 第一章 绪论： 沈洪

46. (6) How to Treat the Discharged Patient? • Example: • Glacial acetic acid accidental overdose patient: • burning pharyngeal mucosa • esophageal stenosis in six months 第一章 绪论： 沈洪

47. Thanks! jiaxu0@hotmail.com Emergency Medicine