Emergency medicine

Scope

Emergency Medicine 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.

The field of emergency medicine encompasses care involving the acute care of internal medical and surgical conditions. In many modern emergency departments, Emergency physicians are tasked with seeing a large number of patients, treating their illnesses and arranging for disposition—either admitting them to the hospital or releasing them after treatment as necessary. The emergency physician requires a broad field of knowledge and advanced procedural skills often including surgical procedures, trauma resuscitation, advanced cardiac life support and advanced airway management. They must have the skills of many specialists—the ability to resuscitate a patient (critical care medicine), manage a difficult airway (anesthesia), suture a complex laceration (plastic surgery), reduce (set) a fractured bone or dislocated joint (orthopedic surgery), treat a heart attack (cardiology), manage strokes (neurology), work-up a pregnant patient with vaginal bleeding (obstetrics and gynecology), stop a severe nosebleed (ENT), place a chest tube (cardiothoracic surgery), and to conduct and interpret x-rays and ultrasounds (radiology). Emergency physicians also provide episodic primary care to patients during off hours and for those who do not have primary care providers.

Emergency medicine is distinct from urgent care, which refers to immediate healthcare for less emergent medical issues. However, many emergency physicians work in urgent care settings, since there is obvious overlap. Emergency medicine also includes many aspects of acute primary care, and shares with family medicine the uniqueness of seeing all patients regardless of age, gender or organ system . The emergency physician workforce also includes many competent physicians who trained in other specialties.

Physicians specializing in emergency medicine can enter fellowships to receive credentials in subspecialties such as palliative care, critical-care medicine, medical toxicology, wilderness medicine, pediatric emergency medicine, sports medicine, disaster medicine, tactical medicine, ultrasound, pain medicine, pre-hospital emergency medicine, or undersea and hyperbaric medicine.

The practice of emergency medicine is often quite different in rural areas where there are far fewer consultants and health care resources. In these areas, family physicians with additional skills in emergency medicine often staff emergency departments. Rural emergency physicians may be the only health care providers in the community, and require skills that include primary care and obstetrics.

Work patterns

Patterns vary by country and region. In the United States, the employment arrangement of emergency physician practices are either private (with a co-operative group of doctors staffing an emergency department under contract), institutional (physicians with an independent contractor relationship with the hospital), corporate (physicians with an independent contractor relationship with a third-party staffing company that services multiple emergency departments), or governmental (for example, when working within®personal service military services, public health services, veterans' benefit systems or other government agencies).

In the United Kingdom, all consultants in emergency medicine work in the National Health Service and there is little scope for private emergency practice. In other countries like Australia, New Zealand or Turkey, emergency medicine specialists are almost always salaried employees of government health departments and work in public hospitals, with pockets of employment in private or non-government aeromedical rescue or transport services, as well as some private hospitals with emergency departments; they may be supplemented or backed by non-specialist medical officers, and visiting general practitioners. Rural emergency departments may be headed by general practitioners alone, sometimes with non-specialist qualifications in emergency medicine.

History

During the French Revolution, after seeing the speed with which the carriages of the French flying artillery maneuvered across the battlefields, French military surgeon Dominique Jean Larrey applied the idea of ambulances, or "flying carriages", for rapid transport of wounded soldiers to a central place where medical care was more accessible and effective. Larrey manned ambulances with trained crews of drivers, corpsmen and litter-bearers and had them bring the wounded to centralized field hospitals, effectively creating a forerunner of the modern MASH units. Dominique Jean Larrey is sometimes called the father of emergency medicine for his strategies during the French wars.

Emergency medicine as an independent medical specialty is relatively young. Prior to the 1960s and 1970s, hospital emergency departments (EDs) were generally staffed by physicians on staff at the hospital on a rotating basis, among them family physicians, general surgeons, internists, and a variety of other specialists. In many smaller emergency departments, nurses would triage patients and physicians would be called in based on the type of injury or illness. Family physicians were often on call for the emergency department, and recognized the need for dedicated emergency department coverage. Many of the pioneers of emergency medicine were family physicians and other specialists who saw a need for additional training in emergency care.

During this period, groups of physicians began to emerge who had left their respective practices in order to devote their work completely to the ED. In the UK in 1952, Maurice Ellis was appointed as the first "casualty consultant" at Leeds General Infirmary. In 1967, the Casualty Surgeons Association was established with Maurice Ellis as its first President. In the US, the first of such groups was headed by Dr. James DeWitt Mills in 1961 who, along with four associate physicians; Dr. Chalmers A. Loughridge, Dr. William Weaver, Dr. John McDade, and Dr. Steven Bednar at Alexandria Hospital, Virginia, established 24/7 year-round emergency care, which became known as the "Alexandria Plan".

It was not until the establishment of American College of Emergency Physicians (ACEP), the recognition of emergency medicine training programs by the AMA and the AOA, and in 1979 a historical vote by the American Board of Medical Specialties that emergency medicine became a recognized medical specialty in the US. The first emergency medicine residency program in the world was begun in 1970 at the University of Cincinnati and the first Department of Emergency Medicine at a US medical school was founded in 1971 at the University of Southern California.

In 1990 the UK's Casualty Surgeons Association changed its name to the British Association for Accident and Emergency Medicine, and subsequently became the British Association for Emergency Medicine (BAEM) in 2004. In 1993, an intercollegiate Faculty of Accident and Emergency Medicine (FAEM) was formed as a "daughter college" of six medical royal colleges in England and Scotland to arrange professional examinations and training. In 2005, the BAEM and the FAEM were merged to form the College of Emergency Medicine, now the Royal College of Emergency Medicine, which conducts membership and fellowship examinations and publishes guidelines and standards for the practise of emergency medicine.

Reimbursement

Many hospitals and care centers feature departments of emergency medicine, where patients can receive acute care without an appointment. While many patients are treated for life-threatening injuries, others utilize the emergency department (ED) for non-urgent reasons such as headaches or a cold. (defined as “visits for conditions for which a delay of several hours would not increase the likelihood of an adverse outcome”). As such, EDs can adjust staffing ratios and designate an area of the department for faster patient turnover to accommodate a variety of patient needs and volumes. Policies have been developed to better assist ED staff(such as Emergency Medical Technicians, paramedics, and mid level providers such as nurses and physicians assistants) direct patients towards more appropriate medical settings, such as their primary care physician, urgent care clinics or detoxification facilities. The emergency department, along with welfare programs and healthcare clinics, serves as a critical part of the healthcare safety net for patients who are uninsured, cannot afford medical treatment or do not understand how to properly utilize their coverage.

Compensation

Emergency physicians are compensated at a higher rate in comparison to some other specialities, ranking 10th out of 26 physician specialties in 2015, at an average salary of $306,000 annually. They are compensated in the mid-range (averaging $13,000 annually) for non-patient activities, such as speaking engagements or acting as an expert witness; they also saw a 12% increase in salary from 2014 - 2015 (which was not out of line with many other physician specialties that year). While emergency physicians work 8-12 hour shifts and do not tend to work on-call, the high level of stress and need for strong diagnostic and triage capabilities for the undifferentiated, acute patient contributes to arguments justifying higher salaries for these physicians. Emergency care must be available every hour of every day, and requires a doctor to be available on site 24/7, unlike an outpatient clinic or some other hospital departments that have more limited hours, and may only call a physician in when needed. The necessity to have a physician on staff along with all other diagnostic services available every hour of every day is thus a costly arrangement for hospitals.

Payment Systems

American health payment systems are undergoing significant reform efforts, which include compensating emergency physicians through “Pay for Performance” incentives and penalty measures under commercial and public health programs, including Medicare and Medicaid. This payment reform aims to improve quality of care and control costs, despite the differing opinions on the existing evidence to show that this payment approach is effective in emergency medicine. Initially, these incentives were only targeted toward primary care providers (PCPs), but some would argue emergency medicine is primary care, as no one refers patients to the ED. In one such program, two specific conditions listed were directly tied to patients frequently seen by emergency medical providers: acute myocardial infarction and pneumonia.(See: Hospital Quality Incentive Demonstration.)

There are some challenges with implementing these quality-based incentives in emergency medicine in that patients are often not given a definitive diagnosis in the ED, making it difficult to allocate payments through coding. Additionally, adjustments based on patient risk-level and multiple co-morbidities for complex patients further complicate attribution of positive or negative health outcomes, and it is difficult to assess whether much of the costs are a direct result of the emergent condition being treated in acute care settings. It is also difficult to quantify the savings due to preventive care during emergency treatment (i.e. workup, stabilizing treatments, coordination of care and discharge, rather than a hospital admission). Thus, ED providers tend to support a modified fee-for-service model over other payment systems.

Overutilization

Some patients without health insurance utilize EDs as their primary form of medical care. Because these patients do not utilize insurance or primary care, emergency medical providers often face problems of overutilization and financial loss, especially since many patients are unable to pay for their care (see below). ED overuse produces $38 billion in wasteful spending each year (i.e. care delivery and coordination failures, over-treatment, administrative complexity, pricing failures, and fraud), and unnecessarily drains departmental resources, reducing the quality of care across all patients. While overuse is not limited to the uninsured, the uninsured comprise a growing proportion of non-urgent ED visits – insurance coverage can help mitigate overutilization by improving access to alternative forms of care and lowering the need for emergency visits. A common misconception pegs frequent ED visitors as a major factor in wasteful spending. However, frequent ED users make up a small portion of those contributing to overutilization and are often insured.

Uncompensated care

Injury and illness are often unforeseen, and patients of lower socioeconomic status are especially susceptible to being suddenly burdened with the cost of a necessary ED visit. If they are unable to pay for the care they received, then the hospital (which under the Emergency Medical Treatment and Active Labor Act (EMTALA), as discussed below, is obligated to treat emergency conditions regardless of ability to pay) faces an economic loss for this uncompensated care. Fifty-five percent of emergency care is uncompensated, and inadequate reimbursement has led to the closure of many EDs. Policy changes (such as the Affordable Care Act) designed to decrease the number of uninsured people have been projected to drastically lower the amount of uncompensated care.

In addition to decreasing the uninsured rate, ED overutilization might be mitigated by improving patient access to primary care and increasing patient flow to alternative care centers for non-life threatening injuries. Financial disincentives, patient education, as well as improved management for patients with chronic diseases can also reduce overutilization and help to manage costs of care. Moreover, physician knowledge of prices for treatment and analyses, discussions on costs with their patients, as well as a changing culture away from defensive medicine can improve cost-effective use. A transition towards more value-based care in the ED is an avenue by which providers can contain costs.

EMTALA

Doctors that work in the EDs of hospitals receiving Medicare funding are subject to the provisions of EMTALA. EMTALA was enacted by the US Congress in 1986 to curtail “patient dumping,” a practice whereby patients were refused medical care for economic or other non-medical reasons. Since its enactment, ED visits have substantially increased, with one study showing a rise in visits of 26% (which is more than double the increase in population over the same period of time). While more individuals are receiving care, a lack of funding and ED overcrowding may be impacting quality. To comply with the provisions of EMTALA, hospitals, through their ED physicians, must provide a medical screening and stabilize the emergency medical conditions of anyone that presents themselves at a hospital ED with patient capacity. If these services are not provided, EMTALA holds both the hospital and the responsible ED physician liable for civil penalties of up to $50,000 each. While both the Office of Inspector General, U.S. Department of Health and Human Services (OIG) and private citizens can bring an action under EMTALA, courts have uniformly held that ED physicians can only be held liable if the case is prosecuted by OIG (whereas hospitals are subject to penalties regardless of who brings the suit). Additionally, the Center for Medicare and Medicaid Services (CMS) can discontinue provider status under Medicare for physicians that do not comply with EMTALA. Liability also extends to on-call physicians that fail to respond to an ED request to come to the hospital to provide service. While the goals of EMTALA are laudable, commentators have noted that it appears to have created a substantial unfunded burden on the resources of hospitals and emergency physicians. As a result of financial difficulty, between the period of 1991-2011, 12.6% of EDs in the US closed.

Rural

Despite the practice emerging over the past few decades, the delivery of emergency medicine has significantly increased and evolved across diverse settings as it relates to cost, provider availability and overall usage. Prior to the Affordable Care Act (ACA), emergency medicine was leveraged primarily by “uninsured or underinsured patients, women, children, and minorities, all of whom frequently face barriers to accessing primary care”. While this still exists today to an extent as mentioned above, it is critical to consider the location in which care is delivered to understand the population and system challenges related to overutilization and high cost. In rural communities where provider and ambulatory facility shortages exist, a primary care physician (PCP) in the ED with general knowledge is likely to be the only source of health care for a population, as specialists and other health resources are generally unavailable due to lack of funding and desire to serve in these areas. Unfortunately as a result, the incidence of complex co-morbidities not managed by the appropriate provider results in worse health outcomes and eventually costlier care that extends beyond rural communities. Though typically quite separated, it is crucial that PCPs in rural areas partner with larger health systems to comprehensively address the complex needs of their community, improve population health, and implement strategies such as telemedicine to positively impact health outcomes and reduce ED utilization for preventative illnesses. (See: Rural health.)

Urban

Alternatively, emergency medicine in urban areas consists of diverse provider groups including PCPs, nurse practitioners, physicians, and registered nurses who coordinate with specialists in both inpatient and outpatient facilities to address patients’ needs, more specifically in the ED. For all systems regardless of funding source, EMTALA mandates EDs to conduct a medical examination for anyone that presents at the department, irrespective of paying ability. Fortunately, non-profit hospitals and health systems - as required by the ACA - must provide a certain threshold of charity care “by actively ensuring that those who qualify for financial assistance get it, by charging reasonable rates to uninsured patients and by avoiding extraordinary collection practices”. While there are limitations, this mandate provides support to many in need. That said, despite policy efforts and increased funding and federal reimbursement in urban areas, the triple aim (of improving patient experience, enhancing population health, and reducing the per-capita cost of care) remains a challenge without providers' and payers' collaboration to increase access to preventive care and decrease in ED usage. As a result, many experts support the notion that emergency medical services should serve only immediate risks in both urban and rural areas.

Patient-Provider Relationships

As stated above, EMTALA includes provisions that protect patients from being turned away or transferred before adequate stabilization. Upon making contact with a patient, EMS providers have a responsibility to diagnose and stabilize a patient’s condition without regard for ability to pay. In the prehospital setting, providers must exercise appropriate judgement in choosing a suitable hospital for transport. Hospitals can only turn away incoming ambulances if they are on diversion and incapable of providing adequate care. However, once a patient has arrived on hospital property, care must be provided. At the hospital, contact with the patient is first made by a triage nurse who determines the appropriate level of care needed.

According to the Mead v. Legacy Health System, a patient-physician relationship is established when “the physician takes an affirmative action with regard to the care of the patient”. Initiating such a relationship forms a legal contract in which the physician must continue to provide treatment or properly terminate the relationship. This legal responsibility can extend to physician consultations and on-call physicians even without direct patient contact. In emergency medicine, termination of the patient-provider relationship prior to stabilization or without handoff to another qualified provider is considered abandonment. In order to initiate an outside transfer, a physician must verify that the next hospital can provide a similar or higher level of care. Hospitals and physicians must also ensure that the patient’s condition will not be further aggravated by the transfer process.

The unique setting of emergency medicine practice presents a challenge for delivering high quality, patient-centered care. Clear, effective communication can be particularly difficult due to noise, frequent interruptions, and high patient turnover. The Society for Academic Emergency Medicine has identified five tasks that are essential to patient-physician communication: establishing rapport, gathering information, giving information, providing comfort, and collaboration. The miscommunication of patient information is a key source of medical error; minimizing shortcoming in communication remains a topic of current and future research.

Medical error

Many circumstances, including the regular transfer of patients in the course of emergency treatment, and crowded, noisy and chaotic ED environments, make emergency medicine particularly susceptible to medical error and near misses. One study identified an error rate of 18 per 100 registered patients in one particular academic ED. Another study found that where a lack of teamwork (i.e. poor communication, lack of team structure, lack of cross-monitoring) was implicated in a particular incident of ED medical error, “an average of 8.8 teamwork failures occurred per case [and] more than half of the deaths and permanent disabilities that occurred were judged avoidable.” Unfortunately, certain cultural (i.e. “a focus on the errors of others and a ‘blame-and-shame’ culture”) and structural (i.e. lack of standardization and equipment incompatibilities) aspects of emergency medicine often result in a lack of disclosure of medical error and near misses to patients and other caregivers. While concerns about malpractice liability is one reason why disclosure of medical errors is not made, some have noted that disclosing the error and providing an apology can mitigate malpractice risk. Ethicists uniformly agree that the disclosure of a medical error that causes harm is the duty of a care provider. The key components of disclosure include “honesty, explanation, empathy, apology, and the chance to lessen the chance of future errors” (represented by the mnemonic HEEAL). The nature of emergency medicine is such that error will likely always be a substantial risk of emergency care. Maintaining public trust through open communication regarding harmful error, however, can help patients and physicians constructively address problems when they occur.

Treatments

Emergency Medicine is a primary, or first-contact point of care for patients requiring the use of the health care system. Specialists in Emergency Medicine are required to possess specialist skills in acute illness diagnosis and resuscitation.

Training

There are a variety of international models for emergency medicine training. Among those with well developed training programs there are two different models: a "specialist" model or "a multidisciplinary model". Additionally, in some countries the emergency medicine specialist rides in the ambulance. For example, in France and Germany the physician, often an anesthesiologist, rides in the ambulance and provides stabilizing care at the scene. The patient is then triaged to the appropriate department of a hospital, so emergency care is much more multidisciplinary than in the Anglo-American model.

In countries such as the US, the United Kingdom, Canada and Australia, ambulances crewed by paramedics and emergency medical technicians respond to out-of-hospital emergencies and transport patients to emergency departments, meaning there is more dependence on these health-care providers and there is more dependence on paramedics and EMTs for on-scene care. Emergency physicians are therefore more "specialists", since all patients are taken to the emergency department. Most developing countries follow the Anglo-American model: 3 or 4 year independent residency training programs in emergency medicine are the gold standard. Some countries develop training programs based on a primary care foundation with additional emergency medicine training. In developing countries, there is an awareness that Western models may not be applicable and may not be the best use of limited health care resources. For example, specialty training and pre-hospital care like that in developed countries is too expensive and impractical for use in many developing countries with limited health care resources. International emergency medicine provides an important global perspective and hope for improvement in these areas.

A brief review of some of these programs follows:

Argentina

In Argentina, the SAE (Sociedad Argentina de Emergencias) is the main organization of Emergency Medicine. There are a lot of residency programs. Also it is possible to reach the certification with a two-year postgraduate university course after a few years of ED background.

Australia and New Zealand

The specialist medical college responsible for Emergency Medicine in Australia and New Zealand is the Australasian College for Emergency Medicine (ACEM). The training program is nominally seven years in duration, after which the trainee is awarded a Fellowship of ACEM, conditional upon passing all necessary assessments.

Dual fellowship programs also exist for Paediatric Medicine (in conjunction with the Royal Australasian College of Physicians) and Intensive Care Medicine (in conjunction with the College of Intensive Care Medicine). These programs nominally add one or more years to the ACEM training program.

For medical doctors not (and not wishing to be) specialists in Emergency Medicine but have a significant interest or workload in emergency departments, the ACEM provides non-specialist certificates and diplomas.

Canada

The two routes to emergency medicine certification can be summarized as follows:

1. A 5-year residency leading to the designation of FRCP(EM) through the Royal College of Physicians and Surgeons of Canada (Emergency Medicine Board Certification - Emergency Medicine Consultant).
2. A 1-year emergency medicine enhanced skills program following a 2-year family medicine residency leading to the designation of CCFP(EM) through the College of Family Physicians of Canada (Advanced Competency Certification). The CFPC also allows those having worked a minimum of 4 years at a minimum of 400 hours per year in emergency medicine to challenge the examination of special competence in emergency medicine and thus become specialized.

CCFP(EM) emergency physicians outnumber FRCP(EM) physicians by a ratio of about 3 to 1, and they tend to work primarily as clinicians with a smaller focus on academic activities such as teaching and research. FRCP(EM) Emergency Medicine Board specialists tend to congregate in academic centers and tend to have more academically oriented careers, which emphasize administration, research, critical care, disaster medicine, and teaching. They also tend to sub-specialize in toxicology, critical care, pediatrics emergency medicine, and sports medicine. Furthermore, the length of the FRCP(EM) residency allows more time for formal training in these areas.

China

The current post-graduate Emergency Medicine training process is highly complex in China. The first EM post-graduate training took place in 1984 at the Peking Union Medical College Hospital. Because specialty certification in EM has not been established, formal training is not required to practice Emergency Medicine in China.

About a decade ago, Emergency Medicine residency training was centralized at the municipal levels, following the guidelines issued by The Ministry of Public Health. Residency programs in all hospitals are called residency training bases, which have to be approved by local health governments. These bases are hospital-based, but the residents are selected and managed by the municipal associations of medical education. These associations are also the authoritative body of setting up their residents' training curriculum. All medical school graduates wanting to practice medicine have to go through 5 years of residency training at designated training bases, first 3 years of general rotation followed by 2 more years of specialty-centered training.

Germany

In Germany, emergency medicine is not handled as a specialisation (Facharztrichtung), but any licensed physician can aquire an additional qualification in emergency medicine through an 80-hour course monitored by the respective "Ärztekammer" (medical association, responsible for licensing of physicians). A service as emergency physician in an ambulance service is part of the specialisation training of anaesthesiology. Emergency physicians usually work on a volunteering basis and are often anaesthesiologists, but may be specialists of any kind.

India

India is an example of how family medicine can be a foundation for emergency medicine training. Many private hospitals and institutes have been providing Emergency Medicine training for doctors, nurses & paramedics since 1994, with certification programs varying from 6 months to 3 years. However, emergency medicine was only recognized as a separate specialty by the Medical Council of India in July 2009.

Malaysia

There are three universities (Universiti Sains Malaysia, Universiti Kebangsaan Malaysia, & Universiti Malaya) that offer master's degrees in emergency medicine - postgraduate training programs of four years in duration with clinical rotations, examinations and a dissertation. The first cohort of locally trained emergency physicians graduated in 2002.

Saudi Arabia

In Saudi Arabia, Certification of Emergency Medicine is done by taking the 4-year program Saudi Board of Emergency Medicine (SBEM), which is accredited by Saudi Council for Health Specialties (SCFHS). It requires passing the two-part exam: first part and final part (written and oral) to obtain the SBEM certificate, which is equivalent to Doctorate Degree.

United States

Most programs are three years in duration, but some programs are four years long. There are several combined residencies offered with other programs including family medicine, internal medicine and pediatrics. The US is well known for its excellence in emergency medicine residency training programs. This has led to some controversy about specialty certification.

There are three ways to become board-certified in emergency medicine:

A number of ABMS fellowships are available for Emergency Medicine graduates including pre-hospital medicine (emergency medical services), critical care, hospice and palliative care, research, undersea and hyperbaric medicine, sports medicine, pain medicine, ultrasound, pediatric Emergency Medicine, disaster medicine, wilderness medicine, toxicology, and critical care medicine.

In recent years, workforce data has led to a recognition of the need for additional training for primary care physicians who provide emergency care.

This has led to a number of supplemental training programs in first hour emergency care, and a few fellowships for family physicians in emergency medicine.

Funding for Training

“In 2010, there were 157 allopathic and 37 osteopathic emergency medicine residency programs, which collectively accept about 2,000 new residents each year. Studies have shown that attending emergency physician supervision of residents directly correlates to a higher quality and more cost-effective practice, especially when an emergency medicine residency exists.” Medical education is primarily funded through the Medicare program; payments are given to hospitals for each resident. "Fifty-five percent of ED payments come from Medicare, fifteen percent from Medicaid, five percent from private payment and twenty-five percent from commercially insured patients." However, choices of physician specialties are not mandated by any agency or program, so even though emergency departments see many Medicare/Medicaid patients, and thus receive a lot of funding for training from these programs, there is still concern over a shortage of specialty-trained Emergency Medicine providers.

United Kingdom

In the United Kingdom, the Royal College of Emergency Medicine has a role in setting the professional standards and the assessment of trainees. Emergency medical trainees enter specialty training after five or six years of Medical school followed by two years of foundation training. Specialty training takes six years to complete and success in the assessments and a set of five examinations results in the award of Fellowship of the Royal College of Emergency Medicine (FRCEM).

Historically, emergency specialists were drawn from anaesthesia, medicine, and surgery. Many established EM consultants were surgically trained; some hold the Fellowship of Royal College of Surgeons of Edinburgh in Accident and Emergency — FRCSEd(A&E). Trainees in Emergency Medicine may dual accredit in Intensive care medicine or seek sub-specialisation in Paediatric Emergency Medicine.

Turkey

Emergency Medicine residency lasts for 4 years in Turkey. These physicians have a 2-year Obligatory Service in Turkey to be qualified to have their diploma. After this period, EM specialist can choose to work in private or governmental ED's.

Pakistan

Emergency Medicine training in Pakistan lasts for 5 years. The initial 2 years involve trainees to be sent to three major areas which include Medicine and allied, Surgery and Allied and critical care. It is divided into six months each and the rest six months out of first two years are spent in emergency department. In last three years trainee residents spend most of their time in emergency room as senior residents. Certificate courses include ACLS, PALS, ATLS, and research and dissertations are required for successful completion of the training. At the end of 5 years, candidates become eligible for sitting for FCPS part II exam. After fulfilling the requirement they become fellow of College of Physicians and Surgeons Pakistan in Emergency Medicine.

Presently there are two institutions where you can acquire this training which are Shifa International Hospitals Islamabad and Aga Khan Hospital Karachi. there are approximately 30 residents in different years of training, while the College has conducted its first exit examination for the FCPS in Emergency Medicine during December 2015.

Iran

The first residency program in Iran started in 2002 at Iran University of Medical Sciences, and there are now three-year standard residency programs running in Tehran, Tabriz, Mashhad, Isfahan, and some other universities. All these programs work under supervision of Emergency Medicine specialty board committee. There are now more than 200 (and increasing) board-certified Emergency Physicians in Iran.

Ethical and medicolegal issues

Ethical and medico-legal issues are embedded within the nature of Emergency Medicine. Issues surrounding competence, end of life care, and right to refuse care are encountered on a daily basis within the Emergency Department. Of growing significance are the ethical issues and legal obligations that surround the Mental Health Act, as increasing numbers of suicide attempts and self harm are seen in the Emergency Department The Wooltorton case of 2007 in which a patient arrived at the Emergency Department post overdose with a note specifying her request for no interventions, highlights the dichotomy that often exists between a physicians ethical obligation to 'do no harm' and the legality of a patients right to refuse.