Emergency medicine

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Field hospital (model)
Care of an emergency patient in the home area

The Emergency Medicine is the branch of medicine that deals with the detection and treatment of medical emergencies is concerned and thus with the "care for patients in acute life-threatening conditions" by accident or disease. It covers the entire rescue chain and is an interdisciplinary area of ​​medicine. The following frequently used terms refer to parts of emergency medicine: Rescue medicine particularly refers to (preclinical) emergency medicine carried out outside of suitable medical facilities. However, it is neither technically nor in terms of content separate from the emergency medicine in the facility - usually a hospital  .

The disaster medicine refers to the aspect of emergency medicine, with a major incidents or a disaster due to the large number of people affected individual medical aspects in the background can occur. The transitions are fluid. Emergency medicine in the context of armed missions has a military character and is part of military medicine .

In Germany, "emergency medicine" is the name of an additional medical training course that includes "the detection of impending or occurred emergency situations and the treatment of emergencies, including restoring and maintaining acutely threatened vital functions " . In Austria and Switzerland, comparable additional medical training courses have not yet been established as a feasible professional title. In countries without an emergency doctor-supported rescue system, the medical training courses are only comparable to a limited extent.

History of Emergency Medicine

In the Middle Ages, based on religious and legal requirements, resuscitation still had the status of witchcraft , as it was seen as rebellion against God's will. That was only to change with the Renaissance . In 1543, Andreas Vesalius succeeded in a pioneering experiment in which he proved the importance of the respiratory function : A tracheotomized and thoracotomized pig survived by means of artificial ventilation . However, his contemporaries ridiculed him for his discovery. Another milestone in the development of modern emergency medicine was a decree by Louis XV in 1740 . on "The necessity and methods of resuscitation and responsibility for resuscitation and the provision of rescue equipment". Within a short time, decrees with analogous statements were issued in almost all European countries .

In 1774, the Royal Humane Society recommended mouth-to-mouth and bellows ventilation, as they “benefit many and harm no one”. In 1788, the English doctor Charles Kite († 1811) requested electrical stimulation of the heart in addition to ventilation. The Mainz doctor Jacob Fidelis Ackermann recognized the fundamental importance of oxygen in emergency medicine in 1804 and concluded that a lack of oxygen, whatever the cause, leads to death.

The intravenous infusion therapy required for the treatment of certain forms of shock was introduced in 1831 by the Scot Thomas Aitchison Latta (1796-1833) with physiological saline solution .

In 1908, at the first International Congress for Rescue Services in Frankfurt, emergency medicine was described as a special science for which doctors had to be trained accordingly. In 1947 Beck et al. a. for the first time about the successful defibrillation of a 14-year-old boy. In the second half of the 1950s, the concrete construction of an emergency doctor-centered rescue system began in many places in Germany and in 1970 the ADAC in Munich put the first rescue helicopter with an emergency doctor and paramedic into service throughout Germany .

Core competencies in emergency medicine

The content of further medical training is extensive. They include the legal and organizational basics of the rescue service . In addition, there are the procedures for mass casualties of injured and sick people including sighting (disaster medicine). Subject are also psychiatric emergencies and appropriate measures for diagnosis and treatment of acute disorders of vital functions .

Diagnostic measures

Portable ECG monitor with integrated defibrillator and external pacemaker

The reliable detection of acute, vitally threatening disorders is the basis of successful emergency medical treatment. A large part of the population is familiar with the main features of these orienting measures when first contacting an emergency patient from first aid training as a diagnostic block . Due to the short time available, devices that can be used quickly and easily are used. In addition, shortened examinations were developed for emergency medicine in order to keep the loss of time in the initiation of acutely necessary measures or the assessment of the disease / injury pattern as low as possible.

Traumacheck

The initial trauma check serves to identify vitally threatening injuries as quickly as possible , which are important for further treatment and the transport of the patient. Basically all regions of the body are examined as far as possible; the scope of the investigation is inevitably adapted to the situation. There are manually examined head, shoulder girdle, arms, hands, chest, abdomen, pelvis, legs and feet for signs of traumatic effects, with special attention to pain and pain-related reactions (such as guarding of the abdomen), abnormal joint or bone position or motility or other abnormal findings are made. In the pre-hospital emergency medicine, the examination is rather short on the most threatening four B , chest - Failed legs (thigh), in which - abdominal - pelvis emergency room in the hospital to be contrast detail.

Neurocheck

The Neurocheck is used to test the functionality of the nervous system of a physically impaired person. Here are sensitivity (pain), motor skills , strength and blood flow studied. This examination is of particular importance if a spinal column injury is suspected or if patients are not oriented.

The examination includes: pupils (light sensitivity etc.), sensitivity (e.g. pain reaction in the extremities due to pinching in both hands / legs), motor skills (moving hands and legs), muscle strength (handshake should be the same on both hands), blood circulation (Pressure on fingernail).

Apparatus diagnostics

EKG recording of ventricular fibrillation

Apparatus options are also available for emergency medical diagnostics. However, the equipment can vary from location to location in individual cases.

By means of EKG monitoring, the continuous display of the heart's actions on a screen, a patient can be continuously monitored, including diagnosis of cardiac arrhythmias relevant to emergency medicine, and a further differentiation of, for example, chest pain in acute situations using a 12-channel EKG recording.

Pulse oximeter to measure the arterial oxygen saturation of the blood

The measurement of the oxygen content in the blood, the pulse oximetry , is generally used as a further parameter for patient monitoring during transport or artificial ventilation, during cardiopulmonary resuscitation to verify the sufficiency of the measures and after the administration of medication to identify hypoxic conditions.

The capnography , the continuous measurement of CO 2 in the exhaled air is used to optimize the ventilation in ventilation and also for estimating the body metabolism during resuscitation treatment.

Semiquantitative measurement methods, typically a test for blood sugar to detect hypoglycaemia or hyperglycemia , for troponin to detect cardiac involvement (e.g. heart attack, severe angina pectoris ) and, if necessary, for toxic substances ( e.g. if drug or sleeping pill poisoning is suspected) also use.

Therapeutic measures

Resuscitation training on a dummy

The aim of emergency medical therapy is to restore vital bodily functions and minimize permanent impairment of the emergency patient . The first step in treatment is therefore to initiate immediate life-saving measures. In the event of cardiac arrest , cardiopulmonary resuscitation is carried out immediately , if necessary (in the case of ventricular fibrillation, flutter or pulseless ventricular tachycardia) including defibrillation.

Typically, manifest or threatening shock states of different causes are treated by suitable combinations of measures (puncture and catheterization techniques including the creation of central venous access ) and medication ( shock therapy ).

To ensure breathing , clearing the airways (removal of foreign bodies - manually or by means of suction), ( endotracheal or supraglottic) intubation , cricothyrotomy or tracheotomy, as well as manual and mechanical ventilation and, if necessary, chest drainage are necessary.

In the event of injuries, a. a professional immobilization and reduction of joint and bone injuries or the containment of blood loss by applying a pressure bandage to vascular surgery measures. Existing or foreseeable intolerable pain conditions require suitable analgesia and sedation procedures ( anesthesia ).

The therapeutic measures also include professional rescue and storage of emergency patients. Special aids such as a shovel stretcher or rescue corset are available for rescuing people from vehicles or other comparable situations . In special exceptional cases, an emergency amputation may be necessary. The vacuum mattress is often used for the gentle storage of the injured and suitable for transport . In the domestic area, it is worth mentioning the need to position the patient on a hard surface suitable for cardiac massage in the event of cardiovascular arrest .

organization

Preclinical emergency medicine

Shovel stretcher for recovery; the two halves can be inserted independently of each other like two shovels under the person to be rescued and then connected again to form a unit
Despite the mostly limited medical options, the helicopter is a preferred means of transport, especially in rough terrain

The doctor-assisted rescue system in Germany and Austria has a special position in a global comparison. In many other countries (for example in the Anglo-American region) the preclinical care of emergency patients is carried out by specially trained non-medical staff - so-called paramedics  . These undergo extensive training, which, in contrast to the training of paramedics or emergency paramedics in Germany or emergency paramedics and paramedics in Austria, is designed to carry out the entire care of the patients alone and without medical help. In contrast to Germany, they rely on so-called standing orders , i.e. guidelines for action from which they may not deviate under any circumstances, and in some cases they have to make a telephone agreement with a doctor for certain measures .

Primary emergency medical care usually takes place outside medical facilities. The core tasks of emergency medicine also include the professional rescue and storage of patients, the establishment and maintenance of transportability as well as the care and treatment of emergency patients under the transport conditions in a hospital that is at least suitable for primary therapy (alternatively, another suitable location); Transport times of several hours are possible, especially in rural regions. In the USA, the preclinical intervention of emergency doctors is limited to air rescue and mobile intensive care units .

Depending on the size and scope of the medical facilities approached by the rescue service, an emergency room is available as an interface (suitable premises available in good time, suitable staff, suitable equipment) in order to direct the patients primarily treated with preclinical emergency medicine to further medical care as quickly as possible .

Emergency competence

The emergency competence of the paramedics in Germany was derived from Section 3 of the Paramedic Act : "In accordance with the task of the profession as a doctor's helper, the training should enable, in particular, to carry out life-saving measures for emergency patients at the emergency location until the doctor takes over the treatment ..." .

The term describes the targeted initiation of first medical measures by the non-medical rescue service personnel before the emergency doctor arrives, especially with regard to the averting of impending dangers from the patient, such as death or permanent disability. Measures within the framework of the emergency competence may only be taken when all other measures have been exhausted. In addition, the measure must serve to directly avert danger to life and may only be carried out by trained personnel. In Germany, emergency competence is provided in the Paramedic Act, but not in the so-called Heilpraktikergesetz .

Which measures are to be regarded as emergency competence is incumbent on the respective medical director of the rescue service in Germany. This establishes a list of measures for his area of ​​responsibility and ensures regular training and further education for non-medical staff in the implementation of these measures. In Austria, emergency paramedics are allowed to perform various activities (venipuncture, administering medication, intubation) depending on their level of training.

Disaster medicine

ICE accident near Eschede

All medical measures that are necessary in the event of a mass attack of injured or sick people are summarized as disaster medicine. In such a case, it is the link between the rescue service and disaster control and is based on the respective rescue service or disaster control law of the federal states .

Under such conditions, individual medical aspects can only be taken into account to a limited extent, so that the so-called triage of those affected has to take place. The aim of the screening is to determine the treatment priority of the individual patients in order to enable as many as possible to survive, taking into account the available resources ; At the same time, existing medical care options are maintained or expanded as required.

In the event of a disaster, the chief emergency doctor and the organizational head of the rescue service form the medical emergency management (example: Bavaria) . She is then subordinate to the “local head of operations” on an equal footing with the fire brigade , police , other authorities and organizations. In turn, the medical operations management is responsible for all of the on-site emergency services, emergency medical services, medical and care services of the voluntary aid organizations, as well as all other doctors (e.g. general practitioners, surgeons) who are involved in patient care. In practice, major incidents and disasters are often not immediately recognizable as such. In this way, the regular rescue service is first alerted together with the fire brigade or police . The first emergency doctor and rescue service personnel are therefore already on site in the event of a disaster and form a provisional management team until the first emergency medical services are established.

The first medical care is guaranteed by the rescue service, but in the event of a disaster or major damage, local doctors, regardless of their specialization, are also called in to provide assistance. In general, however, the doctor cannot refuse treatment if he is qualified. If not enough doctors are available, first aid and treatment of minor injury patterns are transferred to members of the rescue service and aid organizations , but also to health care professionals and volunteers .

Clinical emergency medicine

In countries without notation based rescue system, the emergency doctors work (Engl. Emergency Physician ) principle in the emergency room of a hospital. You are responsible for the care of acute cases. They specialize in advanced life support , treating injuries such as fractures and soft tissue damage, and other life-threatening situations.

In the clinical area, interdisciplinary emergency medicine has gained in importance. More and more central emergency rooms are being set up under independent management. The resolution of the Federal Joint Committee on the initial version of the regulations on a tiered system of emergency structures in hospitals in accordance with Section 136c (4) SGB V even mandatorily stipulates that the emergency department should be "a professionally independent, distinct and organizationally independent organizational unit at the hospital location" must act. In addition, the doctor responsible for emergency care should have additional training in "Clinical Emergency and Acute Medicine" as soon as this is available in the country. In May 2018, the German Society for Interdisciplinary Emergency and Acute Medicine (DGINA) reported a breakthrough in the implementation of this additional training in Germany: The German Medical Association has included the additional training "Clinical Acute and Emergency Medicine" in the model training regulations (MWBO). In the federal system of the Federal Republic of Germany, however, the state medical associations must each introduce additional training for themselves. This is currently still in a few federal states such as B. Berlin and Hesse the case. The transitions from in-hospital emergency and acute medicine to intensive care medicine , trauma surgery , internal medicine , neurology / psychiatry , neurosurgery , pediatrics, etc. are fluid. Most in-hospital emergency teams are provided by anesthesia or intensive care medicine. In some hospitals, the emergency rooms are traditionally separated according to specialty, so that internal and surgical emergency patients, for example , are cared for at different facilities. Interdisciplinary emergency rooms were increasingly set up in which doctors from different disciplines work together. This is also required by the G-BA resolution, which explicitly demands that “emergencies are recorded predominantly in a central emergency room.” Since even with a moderate rush of patients, a treatment sequence is not based on the first in, first out principle but rather must be based on the severity of the disease in order to avert harm to seriously ill patients, an initial assessment is also sought within the hospital, which has now been prescribed by the Federal Joint Committee and developed and underlined in a position paper by the responsible specialist society, DGINA .

further education

For doctors in Germany to use the field title "Emergency Medicine", they have to complete a regulated further training course . These further training courses can vary depending on the state medical association, as the regulatory authority in Germany is subject to the respective medical associations .

The focus of professional training is on the core competencies of emergency medicine. Doctors organizationally need before they are approved for professional examination at the Medical Association, at least two years of clinical activity or training in an appropriate medical facility (eg. As a teaching hospital , while at least six months of use in the areas of critical care , anesthesia and emergency ) prove . In addition, after an 80-hour theory course, at least 50 assignments in the ambulance or rescue helicopter must be performed under the guidance of an emergency doctor and the relevant activities must be documented. The progress of the further training is regularly checked by the competent, authorized doctor.

Use of a rapid response group (SEG)

Active groups of people

The groups of people who are particularly qualified in emergency medicine are also referred to as rescue specialists . In particular, these are emergency physicians or chief emergency physicians , paramedics (Germany and Austria), paramedics (Germany), paramedics , rescue workers . In addition, for example, other paramedics , nurses and so-called first - aiders are involved in emergency management.

public perception

The basic idea of ​​“helping people in need concretely” is also partially presented in television series such as Medicopter 117 and Emergency Room - The Emergency Room . Aid organizations such as the Arbeiter-Samariter-Bund , the Malteser Hilfsdienst , the German Red Cross or the Johanniter-Unfall-Hilfe also aim at this basic idea when recruiting members for voluntary medical and rescue services.

The economic efficiency requirement of Section 12, Book Five of the Social Security Code also applies to emergency medicine. The focus is no longer solely on optimizing the possibilities of medical assistance, but increasingly also on economic aspects. While economic efficiency is the responsibility of the operator in the clinical area, in the preclinical area, specific measures such as the closing of rescue stations are suggested. However, such measures can often not be carried out without public attention.

See also

literature

  • Jonathan Kaplan: Emergency supplies. Argon, Berlin 2003, ISBN 3-87024-558-1 . (English: The dressing station. Translated by Elvira Willems).
  • Rolando Rossi, Günter Dobler: Emergency pocket book for the rescue service. 13., completely revised. and exp. Edition. Edewecht Stumpf + Kossendey 2017, ISBN 978-3-943174-79-3 .
  • Johann Wilhelm Weidringer (Red.), Federal Ministry of the Interior (Ed.): Disaster Medicine: Guidelines for medical care in the event of a disaster. 5th, totally. revised Federal Ministry of the Interior, Berlin 2010, ISBN 978-3-939347-25-5 .
  • Jens Scholz: Emergency Medicine. Thieme, Stuttgart 2008, ISBN 978-3-13-112782-2 .
  • Klaus Ellinger: Course book emergency medicine. German Doctors-Verlag, Cologne 2007, ISBN 978-3-7691-0519-3 .
  • Jürgen Bengel: Psychology in emergency medicine and rescue services. Springer, Berlin 2004, ISBN 3-540-40778-2 .
  • Thomas Schneider: Pocket Atlas Emergency & Rescue Medicine. Springer, Berlin 2004, ISBN 3-540-01363-6 .
  • Peter Sefrin : Emergency Therapy. 6., rework. and exp. Edition. Urban & Schwarzenberg, Munich 1998, ISBN 3-541-08156-2 .
  • Andreas Thierbach: Lexicon of emergency medicine. Springer, Berlin 2002, ISBN 3-540-65798-3 .
  • Jonathan P. Wyatt: Oxford handbook of accident and emergency medicine. Oxford Univ. Press, Oxford 1999, ISBN 0-19-262751-1 .

Web links

Commons : Emergency medicine  - collection of images, videos and audio files

Individual evidence

  1. ↑ Martin L. Hansis: Emergency Medicine. In: Werner E. Gerabek , Bernhard D. Haage, Gundolf Keil , Wolfgang Wegner (eds.): Enzyklopädie Medizingeschichte. De Gruyter, Berlin / New York 2005, ISBN 3-11-015714-4 , p. 1056 f.
  2. ↑ a b Training Regulations for Emergency Medicine Bavaria; viewed January 14, 2007 (PDF; 464 kB)
  3. ^ A b Training Regulations for Emergency Medicine Baden-Württemberg; viewed January 14, 2007  ( page no longer available , search in web archives )@1@ 2Template: Toter Link / www.aerztekammer-koblenz.de
  4. ↑ List of specialties of the Austrian Medical Association viewed January 14, 2007.
  5. ↑ Switzerland: “Clinical Emergency Medicine” proficiency certificate  ( page no longer available , search in web archives )  Info: The link was automatically marked as defective. Please check the link according to the instructions and then remove this notice.@1@ 2Template: Dead Link / www.fmh.ch  
  6. ↑ Ludwig Brandt: The emergence of modern emergency medicine in the 17th and 18th centuries. In: Emergency Medicine. 15, 1989, No. 4-5, pp. 290-295 and 357-365.
  7. ↑ a b c d e F. W. Ahnefeld : From the Samaritan to the emergency doctor. (PDF; 184 kB). In: ADAC air rescue. 2, 2003, pp. 19-25, accessed January 20, 2008.
  8. ↑ Quotation from the decree of the Duke of Württemberg and Teck: "Whoever does not allow his neighbors the most noble human and Christian duty, who nevertheless prevails without lovelessness, hardness of heart and disobedience, will face sensitive, possibly severe corporal punishments and prison sentences."
  9. ↑ Fraunberger u. a .: Electrifying machines in the 18th and 19th centuries - a small lexicon. ( Memento of January 10, 2009 in the archive.today web archive ) accessed on February 12, 2008.
  10. ^ Rudolf Frey , Otto Mayrhofer , with the support of Thomas E. Keys and John S. Lundy: Important data from the history of anesthesia. In: R. Frey, Werner Hügin , O. Mayrhofer (Ed.): Textbook of anesthesiology and resuscitation. Springer, Heidelberg / Basel / Vienna 1955; 2nd, revised and expanded edition. With the collaboration of H. Benzer. Springer-Verlag, Berlin / Heidelberg / New York 1971. ISBN 3-540-05196-1 , pp. 13–16, here: p. 14.
  11. ^ A b Peter Sefrin : History of emergency medicine and the emergency doctor service in Germany. In: Emergency & Family Medicine (Emergency Medicine). 30 (4), 2004, pp. A 215 – A 222. doi: 10.1055 / s-2004-829610 accessed on January 20, 2008.
  12. ↑ Historical review of the development of rescue medicine in Göttingen. ( Memento of May 24, 2005 in the web archive archive.today ) Center for Anesthesiology, Rescue and Intensive Care Medicine; viewed January 21, 2008.
  13. ↑ a b Law on the Profession of Paramedic. ( Memento of the original from March 25, 2017 in the Internet Archive ) Info: The archive link was inserted automatically and has not yet been checked. Please check the original and archive link according to the instructions and then remove this notice. viewed on March 24, 2017 (PDF file). @1@ 2Template: Webachiv / IABot / www.notfallrettung.com
  14. ↑ Law on the professional practice of medicine without appointment; accessed January 15, 2007 .
  15. ↑ Disaster medicine - guidelines for medical care in the event of a disaster. ( Memento of the original from March 25, 2017 in the Internet Archive ) Info: The archive link was inserted automatically and has not yet been checked. Please check the original and archive link according to the instructions and then remove this notice. 6th edition. (PDF; 8 MB) @1@ 2Template: Webachiv / IABot / www.bbk.bund.de
  16. ↑ a b c G-BA decision (online)
  17. ↑ DGINA press release on the ZWB Clinical Acute and Emergency Medicine (online)
  18. ↑ Logbook of the ÄK Berlin on the ZWB (online)
  19. ^ AN Laggner: Clinical Emergency Medicine in Austria. In: Intensivmed. 45, 2008, pp. 282-286.
  20. ↑ M. Christ u. a .: Triage in the emergency room: Modern, evidence-based initial assessment of the urgency of treatment. In: Dtsch Arztebl Int. 107 (50), Dec 2010, pp. 892-898. Epub 2010 Dec 17. (online)
  21. ↑ Position paper on the initial assessment in integrated emergency centers (online)
  22. ↑ Further training regulations of the Lower Saxony Medical Association. 2005, last changed on September 14, 2016.
  23. ↑ Quality assurance in emergency medicine in Baden-Württemberg. ( Memento from December 22, 2005 in the Internet Archive ) Quote: “… The question of the utilization of emergency doctor locations must also be examined under the question of economic efficiency. ... “accessed on February 3, 2008.
  24. ↑ a b  ( page no longer available , search in web archives ) ... TRUST report commissioned by health insurance companies recommends closing an ambulance; Accessed February 3, 2008.@1@ 2Template: Toter Link / www.landkreis-cham.de
This version was added to the list of articles worth reading on February 19, 2008 .