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board certified in other fields, usually internal medicine or surgery. In smaller hospitals, just about anyone (including psychiatrists) could provide ER coverage for anything from a minor cut to an inflamed appendix. Some of these doctors left their original specialty to work full time in emergency rooms and grandfa-thered their way into becoming emergency medicine specialists.

During the 1960s, physicians began to realize that patients would have better clinical outcomes if they received prompt and appropriate care from the moment they entered the hospital. This small group of physicians recognized the need for formal study and training in emergency medicine and subsequently founded the American College of Emergency Physicians in 1968. Over the next 5 years, they worked to establish the first residency program at the University of Cincinnati and lobbied Congress to pass the Emergency Medical Services Act. As a result, emergency medicine began to expand rapidly, using federal funds to develop prehospital emergency systems and to expand emergency departments. In 1979, the American Board of Medical Specialties recognized emergency medicine as an official clinical specialty.

Today, only physicians who have completed an emergency medicine residency are hired in the nation's emergency rooms. All across the country, ER docs provide immediate recognition, evaluation, care, and disposition of a diverse adult and pediatric population. When dealing with acute problems, whether nonurgent or life threatening, their primary role is to stabilize the patient. They evaluate the ABCs (airway, breathing, circulation), take quick histories, perform focused physical examinations, order relevant laboratory and radiology tests, and contact consultants. In the contemporary ED, these specialists must be completely sure that all life-threatening causes of particular symptoms are completely worked up and ruled out. Despite being such a young arm of medical practice, emergency medicine has matured into a rigorous clinical specialty. You will receive formal training to handle just about anything that may walk through that door.

WHAT MAKES A GOOD

EMERGENCY PHYSICIAN?

✓ Likes working with his or her hands.

✓ Is an adventurous, action oriented leader and team player.

✓ Can make logical decisions during rapidly changing situations.

✓ Likes variety and the unexpected.

/ Is capable of juggling multiple tasks at once.

THE INSIDE SCOOP

A typical shift in the ED is full of variety, drama, and excitement. As you greet the frequent fliers, who often come for both food and medical care, the chart boxes begin filling up with new patients to be seen. First might be a man clutching his stomach due to abdominal pain caused by pancreatitis. The next patient may be a pregnant woman who presents with vaginal bleeding and cramping abdominal pain — possible signs of an ectopic pregnancy. In this case, you take on the role of gynecologist, conducting a pelvic examination to see if the cervix is open or closed. You may even, depending on your training, take on the role of radiologist in such a case, using a hand-held ultrasound device to determine if the patient has a viable intrauterine pregnancy. Obviously, the emergency medicine physician has to love juggling dozens of different problems, situations, and treatments while teaching and interacting with patients at the same time. At any time, a code blue (cardiac arrest) or trauma could bring this somewhat orderly environment crashing down. You are generally the first doctor to arrive in the resuscitation room, a place where patients in respiratory distress—with dropping oxygen saturation and pink frothy liquid coming out of their mouths — need immediate endotracheal intubation.

The practice of modern emergency medicine does not formally include any continuity of patient care. Because EM doctors work in shifts and only focus on acute medical problems, there is no patient follow up. (Unless, of course, the patient returns to your emergency room a few days later.) After admitting or discharging a patient, the emergency physician moves on to the next one sitting in the waiting room or being flown in by helicopter. Thus, medical students interested in this specialty should carefully consider whether having their own group of long-term patients is important. Unlike world-renowned experts in other specialties, emergency physicians—and other hospital-based specialists like radiologists and anesthesiologists—are behind-the-scenes doctors who may remain largely anonymous to health care consumers.

Working in an ED does not necessarily mean that all patient interactions are curtailed by shift work and acute care. Although emergency physicians do not develop long-standing ties with their patients, they often establish a strong relationship with the community in which they practice. Plenty of patients, especially uninsured indigent persons looking for warmth, food, a place to sleep, and regular medical care, visit the emergency room regularly and form bonds with its staff. "Do I get to have a primary care-type relationship with all patients? Of course not, but I do get to know my community and many of the people in it," commented an emergency medicine specialist at an inner-city hospital. "This is 'their' hospital and for many of them I, or one of my colleagues, actually end up taking the role of the family doc. It's hard to do in a busy ED, but building good rapport and relating with some of our most challenging patients is one of the more rewarding aspects of emergency medicine."

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