Emergency rooms
Emergency rooms (ERs) are critical healthcare facilities designed to provide immediate medical care for acute illnesses and life-threatening conditions. Recognized as a distinct medical specialty since 1979, emergency medicine has evolved in response to the increasing demand for urgent care, particularly following World War II. ERs serve as primary access points for a diverse patient population, treating individuals regardless of their ability to pay. The process begins with triage, where trained personnel assess the severity of a patient's condition, which determines the urgency of their care.
Emergency physicians, who undergo extensive residency training, are skilled in a wide range of life-saving procedures and are equipped to handle various emergencies, from heart attacks to traumatic injuries. ERs are typically structured with specialized areas to accommodate different medical needs, including resuscitation rooms and trauma care areas. However, challenges persist, such as the inappropriate use of ER services for non-emergent issues, which can strain resources.
The field is supported by various organizations that set standards for care and promote effective emergency medical practices. The ongoing development in emergency medicine aims to ensure that timely and appropriate care is available to those in critical need, reinforcing the vital role that ERs play in the healthcare system.
Emergency rooms
Also known as: ERs, trauma centers
Anatomy or system affected: All
Definition: Sites that provide twenty-four-hour emergency medical care. Metropolitan trauma centers often have more than fifty patient care areas and treat hundreds of patients daily. Rural or community hospital ERs may be as small as several rooms but usually have many treatment areas available.
Background
Emergency medicine is one of twenty-four medical specialties recognized by the American Board of Medical Specialties (ABMS). A board-certified specialist in emergency medicine meets training and certification requirements established by the American Board of Emergency Medicine (ABEM). Emergency medicine became a medical specialty in 1979 and is well established as a recognized body of medical specialists and knowledge.
After World War II, emergency rooms became primary healthcare access points for an increasing number of people. Many factors contributed to this change, including increasing specialization among physicians, along with decreasing numbers of primary care and general practitioners. The resultant decrease in hospital on-call physicians available to treat ER patients fostered the concept of full-time ER specialists, whose primary duties involve treating patients coming to ERs.
The first plans for full-time emergency room physician coverage originated in the 1960s. A model featuring dedicated ER doctors proved to be the most attractive among hospitals and patients. Emergency physicians limit their practice to the emergency department while providing 24/7 coverage. Emergency physicians treat all patients, regardless of their ability to pay, while establishing contractual relationships with hospitals. This model for emergency care fostered the development of emergency medicine, setting standards of care for the new specialty. (Michael T. Rapp and George Podgorny provided a detailed consideration of the many factors in the developmental history of emergency medicine in their 2005 article “Reflections on Becoming a Specialist and Its Impact on Global Emergency Medical Care: Our Challenge for the Future” in Emergency Medicine Clinics of North America.)
The National Academy of Sciences and the National Research Council raised concern with a 1966 report titled Accidental Death and Disability: The Neglected Disease of Modern Society. More rapid prehospital response, along with better emergency care standards, were needed to improve emergency care in the United States. Emergency physicians from Michigan, including John Wiegenstein, founded an organization fostering the national development of emergency medicine, the American College of Emergency Physicians (ACEP), in 1968.
Emergency physicians integrate medical care in a variety of settings, including military, disaster, community, and academic settings. Emergency physicians are experts in emergent cardiovascular care, including resuscitative medicine and the various highly specialized procedures that accompany that care. Accident and trauma stabilization is another area of ER expertise. Emergency medicine residency training is three to four years in length. This training occurs after a doctor has completed medical school and undergraduate education. During that time, a well-trained ER doctor becomes proficient in many complex, lifesaving procedures, such as thoracotomies (opening the chest to correct emergent heart and lung problems), pacemaker placement (correcting heart rate and rhythm problems), intubation (allowing airway access), chest tube insertion (draining blood and fluid from the lungs), and lumbar puncture (assessing neurological problems). Rapid recognition, prompt emergent care, and effective triage are emergency medicine physician characteristics.
Emergency physicians treat life-threatening and severe emergent medical problems, such as myocardial infarctions (heart attacks), strokes, drug overdoses, and diabetic ketoacidosis. Traumatic injuries, such as stabbings, shootings, industrial accidents, and automobile accidents, are also treated and stabilized in the emergency department, which is the major care location for disaster care. Emergency physicians treat all age groups and all conditions at all hours of the day simultaneously. This ability to treat a wide variety of emergent problems distinguishes ER doctors as the group of specialists best suited to assess and properly treat the greatest number of acutely ill patients.
Features and Procedures
Emergency rooms vary in size, but most share uniform characteristics. The first ER assessment is triage, a term with French roots meaning “to pick or cull.” In triage, healthcare personnel, usually nurses, determine the severity of a patient’s injury or illness and record the patient’s chief complaint or medical problem. They measure and record vital signs, including pulse, temperature, respiratory rate, and blood pressure. If the patient’s condition is stable, then triage personnel obtain other important information, such as medications taken, a brief medical history, and any patient allergies.
The most important triage duty determines the severity of an illness. Usually, there are three main categories: critical and immediately life-threatening, such as a myocardial infarction; urgent but not immediately life-threatening, such as most abdominal pain; and less urgent, such as a minor leg laceration, known as the “walking wounded” in military triage. ER personnel often refer to these categories as Cat I, Cat II, or Cat III. After assessing the patient’s condition, triage personnel advance patients to appropriate care areas. A new category I patient may be wheeled on a gurney directly to the critical area, with the nurse announcing to any doctors on the way, “new Cat I patient in 101.” These patients need immediate emergency care.
A stable patient is registered by front-desk personnel. Registration clerks obtain insurance and contact information. New medical charts are generated for new patients, or old records are requested if they already exist at that hospital. Patients arriving by ambulance or critically ill category I patients bypass this step until after treatment or stabilization in the critical care area of the emergency room.
Most emergency departments have many patient care areas, reflecting the wide variety of patients seen in the ER. These areas include resuscitation rooms for patients needing cardiopulmonary resuscitation; trauma care areas for patients with severe injuries like gunshot wounds or accident victims; critical care areas for patients needing cardiac monitoring along with ongoing critical care; pediatric ERs for the care of children; chest-pain evaluation areas; and suture rooms for the repairs of lacerations (cuts). Rooms for the examination of women with gynecological problems are available. Some ERs have a fast track or urgent care area for minor illnesses (such as sore throats) and an observation unit for patients waiting for hospital admission or diagnostic tests. However, one common problem of ER management is the misuse of the facility by some patients for minor illnesses that are not emergent and can be resolved by a visit to a primary care physician. These patients often take important services and personnel away from patients who are truly experiencing an emergency. During the COVID-19 pandemic, because many of the early symptoms of the virus mimicked common upper respiratory infections, ERs were inundated with patients who feared they had contracted the COVID-19 virus but were experiencing widespread respiratory infections and viruses, such as the seasonal flu or common cold.
Many personnel contribute to the wide variety of care provided in emergency departments. Emergency physicians, nurses, physician assistants, medical technologists, and medical assistants have specified healthcare roles. Unit clerks help with the paperwork, and laboratory personnel assist with radiological and laboratory procedures. Administrative people help with staffing issues, equipment purchasing, facility maintenance, and scheduling of workers. These are some of the important roles necessary to deliver emergency care. To a varying degree, ERs will also have social workers, child protective services workers, psychological care providers, and patient advocates available as full-time ER personnel.
Perspective and Prospects
Many agencies promote effective, more standardized emergency and trauma care. In addition to the American Board of Emergency Medicine and the American College of Emergency Physicians, many other agencies promote effective emergency care, such as the American Academy of Emergency Medicine. The American Heart Association takes the lead in cardiopulmonary resuscitation (CPR) guidelines. The American College of Surgeons (ACS) develops standards for trauma care. Nursing organizations, emergency medical technician (EMT) agencies, and other professional organizations develop standards for improving emergency care.
The American College of Surgeons provides trauma center designation guidelines. Trauma center designation requires various important resources and characteristics. Although the ACS provides consultants and guidelines for this process, other agencies designate trauma centers, such as local or state governments. Three main trauma center levels exist in ACS guidelines.
In level I, comprehensive 24/7 trauma care specialists are available in the hospital, including emergency medicine, general surgery, and anesthesiology. Various surgical specialists are available, including neurosurgery, orthopedic surgery, and plastic surgery. Level I designation requires intensive care units (ICUs) along with operating rooms staffed and ready to go twenty-four hours daily, all year round. These are major referral centers, often known as tertiary care facilities.
Level II offers comprehensive trauma and critical care, but the full array of specialists may not be as readily available as those found in a level I trauma center. Trauma volume levels are usually lower than the level I trauma centers.
In level III, resources are available for critical care and stabilization of trauma victims. Patient volume, array of specialists, and 24/7 availability vary. Transfer protocols with level II and I trauma centers allow comprehensive care after stabilization. Community or rural hospitals may have this designation.
The efforts of these groups enhance emergency care in all its forms. Emergency medicine is at the front lines of medical care. Like any forward-moving group, backup and support improve the ultimate goal—available and effective emergency care delivered when needed the most.
Bibliography
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National Academy of Sciences and the National Research Council. Accidental Death and Disability: The Neglected Disease of Modern Society. Washington: Government Printing Office, 1966. Print.
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