chapter one overview of emergency medicine
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Chapter One Overview of emergency medicine. Jia Xu. The First Affiliated Hospital of College of Medicine, Zhejiang University. Emergency Medicine. What Is Emergency Medicine?. In the words of the International Federation for Emergency Medicine : - PowerPoint PPT PresentationTRANSCRIPT
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Chapter One Chapter One Overview of emergency Overview of emergency
medicinemedicine
Chapter One Chapter One Overview of emergency Overview of emergency
medicinemedicine
Jia XuThe First Affiliated Hospital of College of Medicine, Zhejian
g University
Emergency Medicine
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What Is Emergency Medicine? 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."
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What does an emergency What does an emergency physician (EP) do?physician (EP) do?
assessment
disposition
acute and urgent illness and injury
(24/7)
acute and urgent illness and injury
(24/7)
the core of the core of emergency medicineemergency medicine
diagnosis
triage
management
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The needs of societyThe needs of society
Numbers of emergency department visits in U.S.
strategies
Old persons always have diseases refers to many organs.
Urgent patients
dieaseslongevity
The rates of cardio-cerebral-vascular disease are higher.
“Golden Time”
With the development of medical science, timely EM is proved more effctive. EM servies are easier to access.
1996:
87 million ;34.2 per 100
2006:
119 million ;40.5 per 100
36%
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Emergency medical Emergency medical
services systemservices system
(( EMSSEMSS ))
Emergency medical Emergency medical
services systemservices system
(( EMSSEMSS ))
Emergency Medicine
Chapter One Overview of emergency medicineChapter One Overview of emergency medicine
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The constitution of The constitution of EMSS EMSS
prehospital emergency
hospital emergency
critical care
EMSSEMSS
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(1) Personnel (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.
The 15 elements of EMSSThe 15 elements of EMSS
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(2) Training(2) Training
First Responder (FR)
EMT paramedic (EMT-P)
EMT intermediate (EMT-I)
EM Technician basic (EMT-B) CPR, spinal immobilization, bleeding control, basic emergency care procedures
Non-ambulance crew
Ambulance crew
Ambulance crew
Ambulance crew
use of AED; safe transportation; assist patients using their own medicine
patient assessment; give additional medications
basic ECG interpretation, the ability to give some cardiac medications
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(3) Communications(3) Communications
the universal emergency telephone number
120120ChinaChina
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(4) Transportation(4) Transportation
Ground ambulances :Ground ambulances :
Basic life support (BLS) Basic life support (BLS)
ambulances EMS-B;ambulances EMS-B;
Advanced life support (ALS) Advanced life support (ALS)
ambulances EMS-P.ambulances EMS-P.
Air Air ambulancesambulances
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(5) Facilities(5) Facilities
Rules:Rules:the closest
appropriate hospital the patient's choicea specific hospital
with better resources to treat seriously ill or injured patients (e.g., trauma center, cardiac center)
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(6) Critical Care Units(6) Critical Care Units
traumaburnsspinal cord
injuryneurosurgical respiratory
failure cardiac care
Emergency intensive care units (EICU)
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(7) Public Safety Agencies(7) Public Safety Agencies
police carfire engineambulance
1) the FR of EMSS
2) are needed to
provide medical
care in hazardous
circumstances
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(8) Consumer Participation(8) Consumer Participation
public support: political, financial
public first aid training
the implementation of a universal telephone
number system.
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(9) Access to Care(9) Access to Care
An important principle of EMS is that all
individuals deserve timely access to the
system when necessary.
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(10) Transfer of Care(10) Transfer of Care
ReceiverReceiverSenderSender
inform relevant inform relevant informationinformation
response and prepareresponse and prepare
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(11) Standardization of Patients' (11) Standardization of Patients' RecordsRecords
use a similar reporting form by medical records and prehospital records
interpreted quickly and easily by receiving nurses and physicians
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(12) Public Information and (12) Public Information and EducationEducation
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.
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(13) Independent Review and (13) Independent Review and EvaluationEvaluation
Governing agencies should be assured that there is ongoing review of the EMS system.
NeedsNeeds • monitoring of radio communicationsmonitoring of radio communications
TimesTimes• review of response timesreview of response times • review of transfer timesreview of transfer times
• review of patient care recordsreview of patient care records • review of positive result ratereview of positive result rateEffectsEffects
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(14) Disaster Linkage(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.
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(15) Mutual Aid Agreements(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.
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The 15 elements of EMSSThe 15 elements of EMSS
The basic elements of patients care
Thus, an EMS system is the entire system to provide care to emergency patients from the initial call to definitive care.
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The development of The development of emergency medicineemergency medicineThe development of The development of emergency medicineemergency medicine
Emergency Medicine
Chapter One Overview of emergency medicineChapter One Overview of emergency medicine
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(1) History(1) History In 1792, a clever French army surgeon devised the
“flying ambulance” during the French Revolution
Dominique Jean Larrey,(1766-1842)
“the father of emergency medicine”
French Revolution
The “flying ambulance”
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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..
(1) History(1) History
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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.
(1) History(1) History
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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 (2) The Development of Emergency Medicine WorldwideMedicine Worldwide
Emergency medicine development models
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Reasons for the influence of the Reasons for the influence of the Anglo-American modelAnglo-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”
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(3) Stages(3) Stages in the development of in the development of emergency care systemsemergency care systems
Features Underdeveloped Developing Mature
Specialty systems
National organization No Yes Yes
Residency training No Yes Yes
Board certification No Yes Yes
Official specialty status No Yes Yes
Academic emergency medicine
Specialty journal No Yes Yes
Research No Yes Yes
Databases No No Yes
Subspecialty training No No Yes
Patient-care systems
Emergency physicians House staff, other physicians Emergency medicine residency–trained Emergency medicine residency–trained
ED director Other physician Emergency physician Emergency physician
Prehospital care Private car, taxi BLS/EMT ambulance Paramedic/physician ambulance
Transfer system No No Yes
Trauma system No No Yes
Management systems
Quality assurance No No Yes
Peer review No No Yes
Such as Armenia, China, Israel, the Philippines, Saudi Arabia, South Korea, and Turkey.
Include Australia, Canada, the United Kingdom, and the United States
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Unique Aspects of Unique Aspects of Emergency Emergency
Medicine PracticeMedicine Practice
Unique Aspects of Unique Aspects of Emergency Emergency
Medicine PracticeMedicine Practice
Emergency Medicine
Chapter One Overview of emergency medicineChapter One Overview of emergency medicine
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(1) Time and Volume Pressure(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)
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(2) Variety of Conditions(2) Variety of Conditions
must master comprehensive knowledge must manage a wider variety of conditions must shift cognitive frames rapidly
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(3) Paucity of Information(3) Paucity of Information
unaware of patients’ history
old records are often unavailable
history be provided from bystanders
or EMS providers
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(4) Limited Therapeutic Options(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.
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(5) Constraint of Disposition(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?
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(6) Work in an environment (6) Work in an environment in which patients diein 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 viol
ent reaction by survivors.
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General General PPrinciplesrinciples of Emergency Mediciof Emergency Medici
ne Practicene Practice
General General PPrinciplesrinciples of Emergency Mediciof Emergency Medici
ne Practicene Practice
Emergency Medicine
Chapter One Overview of emergency medicineChapter One Overview of emergency medicine
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The Principles of EMThe 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.
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(1) Is the Patient About to Die?(1) Is the Patient About to Die?
( Critical patient )
( Emergent patient )
( Nonurgent patient )
illness or injury that may illness or injury that may progress in severity if progress in severity if treatment is not begun quicklytreatment is not begun quickly
have a low probability have a low probability of progression to a of progression to a more serious conditionmore serious condition
a life-threatening illness or injury a life-threatening illness or injury with a high probability of death if with a high probability of death if immediate intervention is not begunimmediate intervention is not begun
Look for symptoms of a life-threatening emergency, not a specific disease.
Anticipate impending life-threatening emergencies in the apparently stable patient.
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(2) What Steps Must Be Undertaken (2) What Steps Must Be Undertaken to Stabilize the Patient?to Stabilize the Patient?
Breathing Circulation
Airway Neurologic deficits
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?
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(3) What Are the Most Potential (3) What Are the Most Potential Serious Causes of the Patient? Serious Causes of the Patient?
Develop a list of "What will kill my patient the fastest?"
the vital signs
history
physical examination
ancillary assessments
Suspiciouscauses
What is the life threatening symptom for a bowel obstruction with septic shock?
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(4) Could There Be Multiple Causes (4) Could There Be Multiple Causes of the Patient's Presentation? 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?
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Example 2:
Near-syncope and abdominal pain in an apparently intoxicated college coed
a ruptured ectopic pregnancy? or perhaps a ruptured spleen secondary to undisclo
sed physical abuse by her BF? or...?
(4) Could There Be Multiple Causes (4) Could There Be Multiple Causes of the Patient's Presentation? of the Patient's Presentation?
Frequent reassessment the Frequent reassessment the multiple possibilities responsible for multiple possibilities responsible for
patient's condition is imperative. patient's condition is imperative.
Frequent reassessment the Frequent reassessment the multiple possibilities responsible for multiple possibilities responsible for
patient's condition is imperative. patient's condition is imperative.
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(5) Does This Patient Need to (5) Does This Patient Need to Be Admitted to the Hospital?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?
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(6) How to Treat the D(6) How to Treat the Dischargedischarged P Patient?atient?
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.
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(6) How to Treat the D(6) How to Treat the Dischargedischarged P Patient?atient?
Example: Glacial acetic acid accidental overdose
patient:
burning pharyngeal mucosa esophageal stenosis in six months