Emergency Medicine

The emergency medicine , gathers the medical and surgical techniques to face a vital urgency, i.e. a situation where the patient, for lack of care, are likely to die or to have irreversible after-effects within times short. The concept of “times short” is very relative; in the acute cases, one has only a few minutes to react, but in a general way in France, one regards as concerning urgency a risk with 6 or 12:00 In Canada and the United States, one rather uses a definition centered on the need for the patient: thus, like an urgency any perception of an urgent situation by a person is defined, being able risk to endanger its survival or the survival of a member.

Such situations can occur in an hospital structure (the patient can be already hospitalized and its state becomes complicated), in residence, on the public highway or in a public place or deprived (Malayan, disease, accident in the home, accident on the public highway, industrial accident).

In addition to the General medicine, the specific competences implemented within the framework of emergency medicine are

  • the Anesthesia-reanimation: a certain number of problems can occur under anesthesia (in particular because of anesthesia), for example at the time of an operation or an medical examination; but the treatment of the urgency also frequently calls upon the anesthesia (to allow painful care or causing reflexes of rejection) and with the reanimation (maintenance and restoration of the vital Fonctions)

  • the Traumatology: many accidents cause traumatisms: fractures, luxations, distorsions, wounds, burns, Drowning S…

  • the Toxicology: many situations result from accidental or voluntary intoxications (suicide attempt, of assassination, drug-addiction): food poisonings, by gas emanation, medicamentous, by narcotics, alcoholic, poisoning…

In addition to the purely medical concepts, emergency medicine requires Logistique (to have the good equipment and the good personnel at the good moment and the good place) and co-operation with other structures, is which will be intended to accommodate the patient, that is to say which can advise the urgentist in his step. That can utilize concepts of Télémédecine (transmission of the data on the patient, possibly of the parameter vital and images, Télédiagnostic).

The medicine of catastrophe is a branch of the emergency medicine which relates to the accidents or catastrophes implying a massive number of victims: accident of train, Earthquake, Attentat… the catastrophe is defined by the inadequacy of the needs for help and the means available (average exceeded). It requires an organization and “doctrines” different from medicine urgently usual.

France lived fortunately very little catastrophes, but medical teams are trained to intervene in other countries (for example the Unités of intervention and instruction of the civil security in the earthquakes), but also to face, if possible with the situations of catastrophe in France (collapse of the platform of the stage of Furiani, accident of train at the Gare de Lyon, explosion of factory AZF of the site of Large-Parish with Toulouse).

The term oxyology seems to be used for the first time by Gabor in 1970; it is thus about a neologism, formed starting from the Greek roots oxus , acute and Logos , science (to be brought closer to the term “acute medicine” used in Belgium). It is not used in Canada or the United States in this direction.

Real urgency or felt urgency?

In medicine, one typically classifies the urgencies in four categories:

  • vital urgency: pathology bringing into play the vital prognosis immediately, top priority or extreme urgency
  • true urgency: acute pathology engraves threatening the vital prognosis
  • relative urgency: subacute pathology not putting concerned the vital prognosis
  • differed urgency: pathology being able to be neat with time

For the citizens, an urgency is an unexpected and sudden situation making fear for the life of the person; however, certain impressive situations are in fact benign, and others pass unperceived whereas they are alarming (for example, certain signs of Myocardial infarction or Cerebral vascular accident can seem benign). This stresses the importance of the role of council and orientation -   of régulation  - of Samu, and the early detection of situations at the risk by the private doctor, to see by the patient himself or his entourage (thus importance of the formations to first aid where one learns how to recognize the alarming signs).

More and more of people use the urgencies of the hospital like an open doctor's office twenty-four hours out of twenty-four/seven days out of seven, “consume” urgency. This type of behavior harms the system effectiveness, “the true” urgencies are likely to be dealt with delay because of the obstruction of the system, and tires it personnel generated by this extra work is harmful with the quality of the care. Let us note that this behavior is also a bad calculation for the patient, because this one would be perhaps better to rest at his place (while waiting for the arrival of the doctor of guard or the opening of a liberal cabinet the following day) rather than to wait the urgencies, with the nuisances and the risks to catch the diseases of the others… On the other hand, one should not either neglect the importance to have a medical opinion in certain situations (cf above). In addition, the poor ones can profit in France from the cover universal disease (CMU) which enables them to have free care without advance of expenses, including in liberal cabinets.

To see on this subject the Alphabet of the false urgencies (the General practitioner n° 2193 - April 16th, 2002, version HTML).

Emergency medicine in France

Organization of emergency medicine

The Samu is composed in each department of a center 15 (CRRA, Center of reception and regulation of the calls), and of several Smur (emergency Mobile service and reanimation) allowing team sending of reanimation on board a UMH (hospital mobile Unité).

However, the answer of center 15 is not univocal, and at the conclusion of the dialog between the appealing one and the regulating doctor , the decision can go from the simple telephone council to the sending of a SMUR per helicopter. Various the effector possible are:

  • the attending physician (or a doctor of guard)
  • S.O.S Doctors in the great agglomerations
  • Medical emergency of Paris in Paris
  • a doctor fireman (general practitioner)
  • a private Ambulance
  • an ambulance of the firemen (VSAV)
  • a team SMUR (car, ambulance of reanimation, helicopter)
  • Patient addressed towards the medical house of guard.

If the situations remain still variable from one department to another, the current trend in France east that any call apart from the hours and business days passes by center 15, including having the doctor of guard, or when this last wishes to obtain an ambulance. Certain standards of associations of permanence of care (S.O.S doctors) are entitled to receive calls directly, subject to a interconnection with Center 15 (direct phone line).

In the case of a call to the 18 (firemen), the operator who is not doctor can decide sending of a VSAV in prompt help, if the situation seems to him serious, then must inform center 15 at once of it. In the case of a call not seeming urgent, it transfers directly the call to center 15.

S.O.S Médecins is a network of 70 associations of liberal urgentists, divided on the whole of the French territory, and represented by a federal level: S.O.S Doctors France. These associations function 24:00 /24 in close cooperation with Samu of which it are one of principal the effector. They have their own standard accessible by a single national number (0820.33.24.24), and are inter-connected with center 15 by the means of a direct phone line.

In certain departments as in north the Seine and Marne S.O.S Doctors S.O.S Doctors Seine north and Marne proposes to the patients to go in open consultation during the hours of permanence of care.

But nothing prevents a patient from shorting-circuit the pre-hospital system to go in the services of the urgencies of the hospitals or the private clinics, which thus receive the people presenting itself spontaneously, as well as the people brought by the first-aid organizations above.

Emergency medicine ensures the bond between the outside of the hospital and the other services of the hospital (surgery, radiology, pneumology, cardiology, neurology…), but also the bond between these services, for the unexpected and sudden situations of distress.

Formations

; An initial training in change: Until 2004, the speciality " medicine d'urgence" did not exist in France. " urgentistes" (sometimes called " oxyologues") were doctors resulting from different backgrounds, (primarily general practitioners of formation), having supplemented their course by 2 years an optional teaching: capacity of emergency Medicine, and sometimes of a Capacity of Medicine of Catastrophe (see will infra). Since back to university 2004/2005, France founded a Diploma of Study Specialized Complementary (DESC) to emergency Medicine 2 years. Contrary to the capacity, followed by doctors in continuing education, the DESC is a prolongation of the boarding school (3rd specialized cycle of medicine), and is thus followed by interns in initial training. The great contribution of this new formation is to homogenize the initial level of the urgentists at the beginning of career, and to allow a recognition at the European level of the speciality (that only the Britanniques and Irish currently have within the EEC).

; A rich continuing education: The doctors urgentists have a vast choice of additional trainings in the field of the urgency: Diploma of university from 1 to 2 years, Training courses & Seminars of a few days to a few weeks, Congress… These formations can relate to a technique (echography…), a pathology (polytraumatism, pediatry…) or any other aspect of emergency medicine. They are optional… but continuing education is a professional duty.

Capacities

  • Capacity with emergency medicine (Camu)
The purpose of this capacity is to affirm the training of the doctors in the optics of the hospital and pre-hospital urgencies. It is often ensured within Samu (Césu). It is held over two years, with a preliminary recruitment on grading examination. It is organized around theoretical courses and of obligatory training courses (urgencies, reanimation, Samu/smur). It is validated by written training courses and examinations (with eliminatory notes). It became with the wire of quasi obligatory time to work with the urgencies and the smur. Its recognition does that the die of the urgencies will become in the long term ( a priori ) a true speciality, which it is already in practice.

  • Medicine of catastrophe (Cata)

The purpose of this formation is to acquire concepts of attitudes practical in the event of catastrophe, which is not the traditional framework of the intervention of the doctor urgentist. She addresses herself to the experts French urgentists and to foreigners wishing to be formed. She is held over one year (theoretical courses, experience feedback…) and is validated by a written examination but also by a “operation”, where the expert is put in situation of catastrophe and is evaluated. The formation tries to prepare the potentially exposed experts with a situation where the means are insufficient. An organization, a medical strategy, a logistics and a specific reasoning are necessary to manage “as well as possible” a situation of catastrophe. The catastrophe being by often unforeseeable definition, Cata makes become aware the top priority to reach with the experts, and learns how to adapt to the situation. It is an evolutionary formation which grows rich by the experiment of each catastrophic event.

Apart from Atmu, there is no specific training for the male nurses, but the speciality of male nurse anesthetist (IADE) is extremely appreciated.

In other countries

In Belgium , the male nurses can pass the emergency speciality Intensive care and medical assistance (Siamu). The doctors have two qualification levels in emergency medicine, both pennies the form of a third complete cycle. There exists also a general certificate of competence and multiple specific trainings with a field of the urgency.

  • the Speciality of Acute Medicine is a three years formation comprising of the internal medicine, pediatry, the intensive care and of course of the general urgencies.

  • the Speciality of emergency Medicine adds three years additional to the preceding one, made up of various matters the such intensive care, gynecology, emergency psychiatry and others, according to the particular centers of interest of the future urgentist.
  • the old certificates of competence, intended to bring an additional training in emergency medicine for the other specialists (internists, surgeons, pediatrists, anesthetists, general practitioners) still exist, by a primarily practical training from 1 to 2 years in service of urgencies. They make it possible to mitigate the current lack of urgentists, this formation being recent, without to put in the guards of the doctors badly prepareds to receive the patients.
  • specific trainings are not solely intended to the doctors, nor moreover with the urgentists. They are often accessible to the male nurses, ambulance men, doctors not urgentists wishing to acquire a particular competence. Let us quote inter alia the formations of the ERC (European Resuscitation Council), with the courses BASIC, Immediate and Advanced Life Support; the ARAMUS (Workshops of Advanced Reanimation and emergency Medicine) organized by the IFCSM and well of others.

In North America (the United States and Canada), the ancillary medical first-aid workers ( paramedics ) can pass the PHTLS ( Pre-Hospital Trauma Life Support ) in addition to their formation (BLS- BASIC Life Support , BTLS- BASIC Trauma Life Support , ALS- Advanced Life Support (called advanced pre-hospital Soins of maintenance of the vital functions, SAMFV, in Canada), ACLS- Advanced Cardiac Life Support ). The PHTLS is also exempted in other country, in particular in France, but there is not necessarily a legal recognition. The PHTLS is primarily based on the concept of Heure of gold: to know to recognize a situation requiring an surgical operation in the hour, and organization to evacuate the victim without delay and with the minimum of medical act ( scoop and run ).

Quotations

“the way of saving time, it is not to accelerate, but to be systematic. ” (Dr. Dontigny)

“ Good trauma care depend one getting the R ight patient to the R ight place At the R ight time ” (three R of Dr. Trunkey)
“the care adapted to the traumatisms primarily consist in bringing the good patient to the good place and the good moment”
“ diesel Trauma is treated with first. ” (proverb paramedic )
“the traumatism is initially treated with fuel” (relating to the times of intervention and transport)
“One raises a casualty, one transports one failing, one hospitalizes a death” (proverb urgentist, relating to the need for stabilizing the victim before transport)

See too

Internal bonds

External bonds

  • University campus of emergency Medicine

    • Waiter of emergency medicine (Online Urgencies - University Paris V)
  • Learned societies and off let us associaitons
    • French-speaking Société of emergency medicine
    • American college emergency physicians (Acep)
    • Samu de France
    • S.O.S Doctors France
    • S.O.S Doctors Seine north and Marne
    • Association of the doctors firemen of Paris
    • Association For the Teaching of the Care of Urgencies in Martinique
    • Urgenes Médicales of Paris
  • sites dedicated to the urgency
    • Urgence.com
    • Urgence-pratique.com
    • Urgence.net
    • Urgentiste.com
  • formations and documents
    • ATMU doctor
    • ATMU male nurse
    • Medicine of catastrophe: assessment of the catastrophe of AZF (the same document with the format pdf, 51p, 786 KB)
    • Trauma.org (in English)
    • medical Emergency service magazine (in English)
    • medical Newspaper off emergency services (in English)
    • Recommendations of Samu of Paris
  • multi-media Technology
    • Télétransmission of data between distant locations and/or mobiles: impact on decision making in critical situation (Télédec project: télétransmission for the collaborative decision)

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