What are emergency rooms?

Background

Emergency medicine is one of twenty-four medical specialties recognized by the American Board of Medical Specialties (ABMS). A board-certified specialist in emergency medicine meets training and certification requirements established by the American Board of Emergency Medicine (ABEM). Emergency medicine became a medical specialty in 1979 and is well established as a recognized body of medical specialists and knowledge.

After World War II, emergency rooms became primary health care access points for an increasing number of people. Many factors contributed to this change, including increasing specialization among physicians, along with decreasing numbers of primary care and general practitioners. The resultant decrease in hospital on-call physicians available to treat ER patients fostered the concept of full-time ER specialists, whose primary duties involve treating patients coming to ERs.

The first plans for full-time emergency room physician coverage originated in the 1960s. A model featuring dedicated ER doctors proved to be the most attractive among hospitals and patients. Emergency physicians limit their practice to the emergency department while providing 24–7 coverage. Emergency physicians treat all patients, regardless of ability to pay, while establishing contractual relationships with hospitals. This model for emergency care fostered the development of emergency medicine, setting standards of care for the new specialty. (Michael T. Rapp and George Podgorny provide a detailed consideration of the many factors in the developmental history of emergency medicine in their 2005 article “Reflections on Becoming a Specialist and Its Impact on Global Emergency Medical Care: Our Challenge for the Future” in Emergency Medicine Clinics of North America.)

The National Academy of Sciences and the National Research Council raised concern with a 1966 report titled Accidental Death and Disability: The Neglected Disease of Modern Society. More rapid prehospital response along with better emergency care standards were needed to improve emergency care in the United States. Emergency physicians from Michigan, including John Wiegenstein, founded an organization fostering the national development of emergency medicine, the American College of Emergency Physicians (ACEP), in 1968.

Emergency physicians integrate medical care in a variety of settings, including military, disaster, community, and academic settings. Emergency physicians are experts in emergent cardiovascular care, including resuscitative medicine and the various highly specialized procedures that accompany that care. Accident and trauma stabilization is another area of ER expertise. Emergency medicine residency training is three to four years in length. This training occurs after a doctor has completed medical school and undergraduate education. During that time, a well-trained ER doctor becomes proficient in many complex, lifesaving procedures, such as thoracotomies (opening the chest to correct emergent heart and lung problems), pacemaker placement (correcting heart rate and rhythm problems), intubation (allowing airway access), chest tube insertion (draining blood and fluid from the lungs), and lumbar puncture (assessing neurological problems). Rapid recognition, prompt emergent care, and effective triage are emergency medicine physician characteristics.

Emergency physicians treat life-threatening and severe emergent medical problems, such as myocardial infarctions (heart attacks), strokes, drug overdoses, and diabetic ketoacidosis. Traumatic injuries, such as stabbings, shootings, industrial accidents, and automobile accidents, are also treated and stabilized in the emergency department, which is the major care location for disaster care. Emergency physicians treat all age groups and all conditions, at all hours of the day, simultaneously. This ability to treat a wide variety of emergent problems distinguishes ER doctors as the group of specialists best suited to assess and properly treat the greatest number of acutely ill patients.

Features and Procedures

Emergency rooms vary in size, but most share uniform characteristics. The first ER assessment is triage, a term with French roots meaning “to pick or cull.” In triage, health care personnel, usually nurses, determine the severity of a patient’s injury or illness and record the patient’s chief complaint or medical problem. They measure and record vital signs, including pulse, temperature, respiratory rate, and blood pressure. If the patient’s condition is stable, then triage personnel obtain other important information, such as medications taken, a brief medical history, and any patient allergies.

The most important triage duty determines the severity of an illness. Usually, there are three main categories: critical and immediately life threatening, such as a myocardial infarction; urgent but not immediately life threatening, such as most abdominal pain; and less urgent, such as a minor leg laceration, known as the “walking wounded” in military triage. ER personnel often refer to these categories as Cat I, Cat II, or Cat III. After assessing the patient’s condition, triage personnel advance patients to appropriate care areas. A new category I patient may be wheeled on a gurney directly to the critical area, with the nurse announcing to any doctors on the way, “new Cat I patient in 101.” These patients need immediate emergency care.

A stable patient is registered by front-desk personnel. Registration clerks obtain insurance and contact information. New medical charts are generated for new patients, or old records are requested if they already exist at that hospital. Patients arriving by ambulance or critically ill category I patients bypass this step until after treatment or stabilization in the critical care area of the emergency room.

Most emergency departments have many patient care areas, reflecting the wide variety of patients seen in the ER. These areas include resuscitation rooms for patients needing cardiopulmonary resuscitation; trauma care areas for patients with severe injuries like gunshot wounds or accident victims; critical care areas for patients needing cardiac monitoring along with ongoing critical care; pediatric ERs for the care of children; chest-pain evaluation areas; and suture rooms for the repairs of lacerations (cuts). Rooms for the examination of women with gynecological problems are available. ERs usually have a fast track or urgent care area for minor illness (such as sore throats) and an observation unit for patients waiting for hospital admission or diagnostic tests.

Many personnel contribute to the wide variety of care provided in emergency departments. Emergency physicians, nurses, physician assistants, medical technologists, and medical assistants have specified health care roles. Unit clerks help with the paperwork, and laboratory personnel assist with radiological and laboratory procedures. Administrative people help with staffing issues, equipment purchasing, facility maintenance, and scheduling of workers. These are some of the important roles necessary to deliver emergency care. To a varying degree, ERs will also have social workers, psychological care providers, and patient advocates available as full-time ER personnel.

Perspective and Prospects

Many agencies promote effective, more standardized emergency and trauma care. In addition to the American Board of Emergency Medicine and the American College of Emergency Physicians, many other agencies promote effective emergency care, such as the American Academy of Emergency Medicine. The American Heart Association takes a lead in cardiopulmonary resuscitation (CPR) guidelines. The American College of Surgeons (ACS) develops standards for trauma care. Nursing organizations, emergency medical technician (EMT) agencies, and other professional organizations develop standards for improving emergency care.

The American College of Surgeons provides trauma center designation guidelines. Trauma center designation requires various important resources and characteristics. Although the ACS provides consultants and guidelines for this process, other agencies designate trauma centers, such as local or state governments. Three main trauma center levels exist in ACS guidelines.

In level I, comprehensive 24–7 trauma care specialists are available in the hospital, including emergency medicine, general surgery, and anesthesiology. Various surgical specialists are available, including neurosurgery, orthopedic surgery, and plastic surgery. Level I designation requires intensive care units (ICUs) along with operating rooms staffed and ready to go twenty-four hours daily, all year round. These are major referral centers, often known as tertiary care facilities.

Level II offers comprehensive trauma and critical care, but the full array of specialists may not be as readily available as those found in a level I trauma center. Trauma volume levels are usually lower than the level I trauma centers.

In level III, resources are available for critical care and stabilization of trauma victims. Patient volume, array of specialists, and 24–7 availability vary. Transfer protocols with level II and I trauma centers allow comprehensive care after stabilization. Community or rural hospitals may have this designation.

The efforts of all these groups enhance emergency care, in all of its various forms. Emergency medicine is at the front lines of medical care. Like any forward-moving group, backup and support improve the ultimate goal—available and effective emergency care delivered when needed the most.

Bibliography

Arnold J. L. “International Emergency Medicine and the Recent Development of Emergency Medicine Worldwide.” Annals of Emergency Medicine 33 (1999): 97–103.

"Emergency Medical Services." MedlinePlus, 6 Aug. 2013.

"FAQ for Resources for Optimal Care of the Injured Patient: 2006." American College of Surgeons Trauma Programs, 5 Oct. 2011.

Heller, Jacob L., and David Zieve. "Recognizing Medical Emergencies." MedlinePlus, 5 Jan. 2011.

"Meet the Medical Emergency Team." Emergency Care for You. American College of Emergency Physicians, n.d.

National Academy of Sciences and the National Research Council. Accidental Death and Disability: The Neglected Disease of Modern Society. Washington, D.C.: Government Printing Office, 1966.

Rapp, Michael T., and George Podgorny. “Reflections on Becoming a Specialist and Its Impact on Global Emergency Medical Care: Our Challenge for the Future.” Emergency Medicine Clinics of North America 23, no. 1 (February, 2005): 259–269.

"Verified Trauma Centers." American College of Surgeons Trauma Programs, 5 Aug. 2013.

"When Should I Go to the Emergency Department?" Emergency Care for You. American College of Emergency Physicians, n.d.