Emergency Medicine/Protocols and initial diagnosis and treatment

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Protocols

EM physicians have training to deal with most medical emergencies, and usually maintain certifications in CPR, at least the first two of the following:

• Advanced Cardiac Life Support (ACLS)
• Advanced Trauma Life Support (ATLS)

For those who also operate in the extramural (pre-hospital) setting:

• PreHospital Trauma Life Support (PHTLS)
• PreHospital Pediatric Emergency Care (PPEC)

For those who specialize in pediatric trauma care:

• Advanced Pediatric Trauma Life Support (APTLS)

The management of both emergency department (ED) and inpatient medical emergencies are guided by the basic ACLS and ATLS principles and protocols. Irrespective of the nature of the clinical emergency, maintenance of adequate blood pressure, adequate blood flow to vital organs and adequate oxygenation and ventilation are important guiding principles. (Although sometimes these principles must be deliberately broken, as in the deliberate clamping of an arterial bleeder to prevent exsanguination).

Triage

The first step in emergency medicine is triage: determining who (if there are multiple casualties) requires medical assistance first. Triage is done at multiple stages in the care process, especially in case of incidents involving many casualties.

• On-site personnel decides which victims are treated on the scene and which are to be taken to a hospital, and in which order.
• At the entrance to the ED, an ED worker (usually a nurse) determines to which treatment room each victim should be taken.
• The ED physician checks which patient he needs to attend to first.

There are specific protocols for triage also.

Initial diagnosis and treatment

Initial diagnosis and treatment is based on the following principles.

• Circulation
• Airway
• Breathing
• Disability (neurologic)

These point are known as the CAB(D)'s of Emergency Medicine.

Then the general steps of practicing Emergency Medicine:

• Assessment
• Diagnosis
• Treatment
• Disposition

The CABs of emergency medicine are basic to life support. Every time one enters into an emergency one should determine whether the patient has an adequate pulse (circulation), determine if there is open airway, if they are breathing in an unobstructed manner, if they have any obvious sources of bleeding, and if they have any (neurologic) disability (e.g. a broken neck that has led to neurological injury.)

Assessment using the CABs is the cornerstone of emergency care and it should be a continous and ongoing process. Just because initally someone's airway is patent doesn't mean it necessarily will stay that way. So the key point is to stay flexible in assement and treament. The mark of an ED physician is someone who can manage the airway (intubate), someone who can manage the breathing of a patient (set a ventilator) and somone who can provide cardiac or respiratory support (ACLS treatment of cardiac problems like shock, myocardial infarction or arrhythmias.)

Disposition

The famous GOMER (Get out of my ER) applies here. The EM physician must decide where a patient should go after stabilization: home, to the operating room for surgery, to a regular nursing floor, to a step-down unit, to the Intensive Care Unit (ICU), to a psychiatric emergency unit, etc. Thus a role central to the EM physician is triage, and his or her best tool is often the telephone, in asking for advice and help. If, for instance, the EM physician encounters a patient suffering from a myocardial infarction, he might start MONA (Morphine, Oxygen, Nitroglycerine and Aspirin) and promptly contact a cardiologist to take over care since "time is myocardium".

Emergency room physicians

However, it cannot be assumed that all ER physicians do is send patients to other departments, and other floors. Depending on the country, ER physicians may work in an Emergency Room, but can also be trained in another specialty (such as Pulmonology, Anesthesiology, Critical Care, Cardiology, or any multitude of specialties), and so commonly end up treating patients in the Emergency Room and then continuing their long-term care afterwards. In the US, emergency medicine is recognized as a separate medical specialty, equal to other specialties. In most other countries, this is not the case, and the ER is staffed mostly by surgery and general practice residents.

If we take our example myocardial infarction (heart attack) patient, and our Emergency Room physician is a cardiologist, he would stabilize the patient, give the disposition orders, and then add his own treatment information to the protocol to treat the myocardial infarction, rather than contacting an outside cardiologist.