EMERGENCY medicine (EM) has been the inspiration for a string of medical dramas from ER in the US to the BBC staple Casualty – and certainly the specialty offers an exciting and varied career choice ideal for quick-thinking doctors who thrive on challenge.
EM is the only hospital-based specialty where a complete spectrum of illness and injury is managed. Emergency physicians are generalists in the broadest sense of the term – responsible for assessing and resuscitating patients with serious illness and injury before their transfer to hospital wards or operating theatres, as well as treating patients with minor ailments who may be sent home for follow-up care with their GP as required.
EM doctors are based in hospital emergency departments (EDs) where they must be prepared to deal with medical emergencies, major traumas and sudden deaths. They often face the added challenge of coping with violent patients with drug or alcohol problems as well as those suffering from psychiatric illness or social problems.
The specialty first emerged in 1952 when Mr Maurice Ellis was appointed as an Accident & Emergency (A&E) Medicine consultant in the UK at Leeds General Infirmary. However, it wasn’t until 1972 that the specialty of A&E Medicine was officially established with the launch of a pilot project that created 30 consultant posts.
There are currently around 1300 doctors at consultant level in the UK, making it one of the smallest of the medical specialties.
The College of Emergency Medicine lists the following personal qualities as essential for EM doctors:
• capacity to be alert to dangers or problems, particularly in relation to clinical governance
• ability to function under pressure
• good teamwork and leadership skills
• good problem-solving and decisionmaking skills
• ability to have empathy and sympathy with others
• good communication skills
• excellent time-management.
Junior doctors looking for an appointment as a specialty registrar in EM will have completed two years’ general professional training as a Foundation doctor, during which time they will usually have completed four to six months in EM. Training is facilitated through the College of Emergency Medicine and it is essential for trainees to pass the College’s membership and fellowship exams to proceed through training and receive a Certificate of Completion of Training (CCT).
Training usually lasts six years after completion of FY1 and 2 and is divided into three years’ core specialty training (CT1-3) and three years’ higher specialty training (ST4-6). In Scotland the programme runs seamlessly through from years one to six (ST1-6).
Core training involves two years’ learning and experience in EM, acute medicine, anaesthetics and intensive care medicine followed by one year’s learning and experience in how to care for children in the ED and how to care for musculoskeletal problems. Higher training is spent in EDs gaining additional clinical competencies and other EM-related skills.
Most emergency physicians provide hands-on clinical care in EDs (including review clinics) and clinical decision units. As a trainee there may be some on-call, but the majority of training programmes run as a full or partial shift system. Team working is key in a busy ED and doctors must learn to work alongside nursing staff, paramedics, in-patient specialists and GPs.
EM as a specialty lends itself to flexible training and working. The nature of the work is intense, but each patient contact is relatively short and follow-up responsibility is limited.
EM offers the opportunity to maintain a good general knowledge of most specialties. Additionally, emergency physicians may subspecialise or even dual accredit in fields such as paediatric emergency medicine, acute medicine, pre-hospital emergency medicine or intensive care medicine. Others develop interests in fields such as academic emergency medicine, poisoning or sports medicine.
EM is expected to expand enormously in the coming years.
The Department of Health in England has committed to having eight consultants in each major ED by 2010 which will need a considerable expansion in consultant numbers. It is anticipated that consultant numbers will rise in line with the number of trainees expected to achieve specialist registration from 2011 onwards.
EM is one of the few specialties embracing a consistent 24/7 level of care while others are moving away from it. Consultants should expect to work late shifts, weekends and possibly even night shifts in the future to keep up with these changes. Many emergency physicians view the future as bright, presenting enormous opportunities for those prepared to continue to change and innovate.
Joanne Curran is associate editor of FYi
Q&A - Dr Fiona Burton, Specialty Registrar in Emergency Medicine
• What attracted you to emergency medicine? I initially began my training in the surgical specialties with the intention of becoming an Orthopaedic surgeon. However, having spent a lot of time in the Emergency Department (ED) I found I worked well there. I was surrounded by positive role models who worked hard, enjoyed their job and always found the time to teach. I enjoy the camaraderie and being part of the team that is the ED. In the ED you see a huge variety of problems, from a sick baby to a polytrauma and an MI or two along the way. You have to be in a constant state of ‘ready’ because you never know what’s coming through the door.
• Now that you’re in the job, what do you enjoy most? I find it difficult to choose one thing I enjoy the most because I love my job and being an emergency physician. Perhaps the most enjoyable thing for me is the people I meet, both patients and staff. Stabilising and treating a patient who is peri-arrest is pretty satisfying too.
• What is the most challenging part of the job? Working in the ED presents daily challenges. I find dealing with young people who are involved in drink, drugs and violence difficult. Glasgow has a high rate of violence particularly with regards to ‘stabbing’ injuries. Trying to talk to and educate these youngsters is difficult. A challenge that many people talk of is the shift work. Personally I enjoy shift work and people have to remember that medicine is changing and this will feature in most people’s roles in the future.
• What’s your most memorable experience so far? My first night on call as the senior doctor in the department when the standby phone went off four times in a row with one ambulance after another calling in sick patients. We had a couple of trauma patients, a couple of medical patients and our resuscitation room was full. Everyone in both the ED and other specialties worked as a team. The nightshift ended well. It made me realise what care should be like and how I want my department to run to ensure the best care for all.
• Has anything about the role surprised you? I feel that working in the ED has really opened my eyes to my home city and all of its problems. There are problems with deprivation, drinking, drugs, violence, homelessness etc – problems you would find in most cities. You are often in a position where you can speak up and make people aware of the problems on their doorstep. Many of my colleagues are currently involved in the group Medics Against Violence and are visiting schools. Hopefully through education we will see a decrease in future numbers
• Do you have any advice for young doctors interested in a career in emergency medicine? Every job you do is important and offers something that can be brought to the ED. Get as much experience in the ED as you can, whether it be requesting it as part of your rotation or as a taster week. If you don’t know, ask. If your senior is doing a procedure, volunteer and ask if they will supervise you. Keep up to date with your resuscitation courses. Be like a sponge and soak up everything because one day you will use it in the ED.