Urgent and Emergent Care

This document has been endorsed by the American Academy of Family Physicians and was developed in cooperation with the Association of Departments of Family Medicine, the Association of Family Practice Residency Directors and the Society of Teachers of Family Medicine

Preamble

The family physician is the most broadly trained specialist in the health care profession. There is considerable overlap in the patient populations served by the family physician and emergency physician and a natural overlap in the knowledge, skills and attitudes necessary to succeed in this setting. These guidelines seek to identify the unique and critical elements that might not be adequately addressed in other curricular areas (e.g. medicine, pediatrics, surgery, obstetrics, orthopedics, and ophthalmology). It is assumed that management of acute emergent conditions in each required specialty rotation is adequately addressed within those curricula. Future unique practice settings (solo emergency practice, rural / remote settings requiring significant stabilization for distant transport) will determine the need for additional knowledge, procedural skills, and mastery of these elements.

Prompt assessment, intervention, and disposition are critical elements of the emergency medicine experience and this is frequently performed in the face of multiple simultaneous patient encounters. The resident will need to become more comfortable in managing these patients as a member of a health care team and learn the appropriate use of consultants in their management.

Attitudes

The resident should demonstrate attitudes that encompass:

An ability to communicate effectively and compassionately with patients and families.
A capacity to work quickly and efficiently to assess the patient according to the urgency of the patient's problem.
An ability to work effectively with other members of the health care team.

Knowledge

Principles of Care
1. Pre-hospital emergency care
  1. Emergency medical systems
  2. Communication systems and protocols
2. Prioritization and triage
3. Resuscitation and stabilization
4. Reassessment and monitoring
5. Consultation
6. Disposition
Assessment and management of
1. Trauma
  1. Primary and secondary assessment
  2. By mechanism of injury
    1. Blunt trauma (e.g. heart, lung, intra-abdominal organ rupture)
    2. Penetrating trauma (gunshot, stab wounds)
2. By site of injury
  1. Head and neck
  2. Spine and spinal cord
  3. Facial
  4. Soft tissue (lacerations, avulsions, contusions)
  5. Chest
  6. Abdomen
  7. Extremities
  8. Genital/urinary
3. Neurologic Emergencies
  1. Altered consciousness /coma
  2. Cerebrovascular disorders
    1. Stroke (TIA, hemorrhagic v. ischemic stroke)
    2. Aneurysm
  3. Cranial nerve disorders
  4. Infectious / inflammatory disorders including meningitis
  5. Seizure disorders
  6. Acute headache
  7. Spinal cord compression
4. Psychiatric emergencies
  1. Thought disorders / acute presentations
  2. Mood disorders / suicidal ideation / homicidal ideation
  3. Acute anxiety / panic
  4. Somatoform disorders / hysterical conversion / hypochondriasis
  5. Addictive disorders / overdose / drug seeking behaviors
  6. Delirium/dementia/altered mental status
  7. Risk assessment and involuntary commitment
5. Environmental disorders
  1. Burns (chemical, thermal, electrical)
  2. Electrocution/lightening injuries
  3. Heat and cold injuries
  4. Bites and stings / management of human and animal bites
  5. Poisonous plants
  6. Hypersensitivity reactions / anaphylaxis
6. Toxicologic emergencies
7. Obstetric and gynecological emergencies
  1. Sexual assault
  2. Ectopic pregnancy
  3. Threatened or spontaneous abortion
  4. Precipitous delivery / pre-eclampsia / eclampsia
  5. Vaginal hemorrhage
  6. Emergency contraception
8. Victims of violence
9. Recognition and management of acute life threatening conditions
  1. Acute respiratory disorders
    1. Acute respiratory distress
    2. Pulmonary embolism
    3. Pulmonary infections
    4. Pleural effusions / empyema / pneumothorax
    5. Obstructive / restrictive lung disease (asthma, COPD)
  2. Acute cardiovascular disorders
    1. Life threatening dysrhythmias
    2. Cardiac arrest
    3. Ischemic heart disease (angina, acute infarction)
    4. Thoracic or abdominal aortic aneurysms
    5. Acute thrombolytic therapy
  3. Toxicologic emergencies
    1. Acute overdose / pharmacokinetics
    2. Accidental poisonings / ingestion
    3. Access to databases / poison control
    4. Treatments and antidotes
  4. Mass casualty
    1. Environmental/natural disaster
    2. Nuclear
    3. Biological
    4. Chemical
  5. Special circumstances
    1. Resuscitations (coordination, communication, recording)
    2. Drowning and near drowning
    3. Sudden infant death syndrome
  6. Metabolic disorders, acid / base imbalance
  7. Shock (hypovolemic, neurogenic, cardiogenic, septic)
  8. Acute infectious emergencies
10. Indications and interpretation of diagnostic tests
  1. Electrocardiograms
  2. Radiology imaging of
    1. Acute head and cervical spine injuries
    2. Chest pathology
    3. Acute abdominal conditions
    4. Pelvis and extremity injuries
11. Medical-Legal Issues
  1. Informed consent and competency
  2. Withholding / termination of treatment
  3. Laws (commitment, Good Samaritan, reportable conditions)
  4. Liability (Duty to treat, negligence and standard of care, risk management)
12. Disease prevention
  1. Active and passive immunization
  2. Antibiotic prophylaxis

Skills

Airway management
1. Heimlich maneuver
2. Optimizing airway patency/bag-mask ventillation
3. Oral, nasotracheal esophageal-obturator, and intubations in children and adults
4. Needle thoracentesis and tube thoracostomy
5. Initiation of mechanical ventilation
6. Cricothyroidotomy
Anesthestic techniques
1. Local anesthesia
2. Regional and digital nerve blocks
3. Intravenous sedation and analgesia
Hemodynamic techniques
1. Arterial catheter insertion / blood gas sampling
2. Central venous access (jugular, femoral, subclavian)
3. Venous cut-down
4. Intraosseous infusion
Diagnostic / therapeutic procedures
1. Control of epistaxis (anterior and posterior packing)
2. Peritoneal tap and lavage
3. Culdocentesis
4. Lumbar puncture
5. Arthrocentesis
6. Pericardiocentesis
7. Nasogastric intubation
8. Thoracentesis
Skeletal procedures
1. Spine immobilization and traction techniques
2. Fracture / dislocation immobilization techniques
3. Fracture / dislocation reduction techniques
Other
1. Repair of skin lacerations, including plastic closure
2. Mass casualty triage
3. Multiple patient management
4. Grief and loss counseling
5. Critical incident stress debriefing

Implementation

A significant portion of management of emergencies will be obtained from services other than the emergency department.
Although much of the content of these guidelines may be fulfilled while the resident is working in the emergency department, coordination of off-site experiences (e.g., helicopter or ground-transport exposure) may be of additional educational value.
Residents should have the opportunity to concentrate their time spent in the emergency department on evaluation and management of patients with presentations atypical of their other outpatient experiences.
Knowledge and skill acquisition may be supplemented through an additional lecture series or additional course work, including advanced burn life support, advanced cardiac life support, advanced life support in obstetrics, advanced trauma life support, pediatric advanced life support and other such courses.

Resources

American College of Emergency Physicians. Core content for emergency medicine Ann Emerg Med 1991; 20:920-34.
Rosen P, Barkin RM, Braen GR, eds., Emergency Medicine: Concepts and Clinical Practice. 4th ed. St. Louis: Mosby Year Book, 1998.
Tintinalli JE, Stapczynski JS, Kelen GD. Emergency Medicine: A Comprehensive Study Guide. 5th ed. New York: McGraw-Hill, 2000.
Taylor AS. Emergency Medicine Educational Objectives for the Undifferentiated Physician. J Emerg Med 1994;12:255-62.
Knoop KJ, Stack LB, Storrow AB. Atlas of Emergency Medicine. New York: McGraw-Hill, 1997
Fontanerosa PB. Evidence based emergency medicine evaluation and diagnostic testing. Emergency Medicine Clinics of North America. Philadelphia: WB Saunders, Vol. 1, No.1, Feb, 1999.