Critical Emergency Medicine (CREM) – A most important part of Anaesthesiology

Critical Emergency Medicine (CREM) – A most important part of Anaesthesiology

  • Issue 69

Bernd W. Böttiger and Karl Thies

In most European countries, anaesthesiology represents – and anaesthesiologists are working in – anaesthesia, intensive care medicine, emergency medicine, and pain medicine. Many of us are experts in these fields, and many became anaesthesiologists because of these different pillars of our specialty. For residents and young colleagues, intensive care and emergency medicine are of particular interest and importance. Besides, it is a fact that emergency medicine has become a separate specialty in some countries. To highlight and clarify the role, interest, and key competences of anaesthesiologists in emergency medicine, members of the ESA subcommittee Critical Emergency Medicine, Trauma and Resuscitation developed a statement that has been endorsed by the Board of the European Society of Anaesthesiology (ESA) and is supported by the anaesthesiology section of the UEMS, the European Board of Anaesthesiology (EBA). It has been published with free access in the European Journal of Anaesthesiology (EJA; and is entitled: The Monopolisation of Emergency Medicine in Europe – the flipside of the medal.

Over the past 20 years Emergency Medicine (EM) has evolved as an independent medical specialty in Europe. This development was mainly driven by poor access to primary care for patients with acute conditions and a shortage of medical specialists to look after patients presenting to emergency departments (EDs) out of hours. The introduction of EM has certainly improved access to care in countries where both factors hampered timely provision of emergency care. However, for countries where emergency medical care is delivered in a longitudinal way by the acute and critical care specialties, namely anaesthesiology, surgery, neurology, internal medicine/cardiology, and paediatrics, it is not yet clear how EM as a separate specialty would fit into existing advanced care pathways.

The vast majority of patients in EDs present with medical conditions of low acuity (e.g., exacerbating chronic diseases or minor injuries); only a very small proportion are critically ill or injured and require urgent or immediate vital function support. Confusion remains, because there is no clear definition of ‘emergency’, ‘urgency’, and ‘acute’. The danger posed by the current vague definition of EM is that emergency patients, requiring immediate critical care intervention to avoid death or disability, and patients requiring acute care without being at immediate risk are placed under the umbrella of one single specialty.

The longitudinal approach, by contrast, means that the responsibility for the pathway of critical emergency patients lies primarily with the corresponding medical specialty. This principle has facilitated a direct and seamless translation from specialty expertise (anaesthesiology/ICM, surgery, internal medicine/cardiology or neurology) right into the emergency department and further into the pre-hospital field.

Immediate access to expert vital function support must be the highest priority of every emergency medical system. The longitudinal care systems have performed remarkably well in achieving this, with advanced pre-hospital services, multidisciplinary reception teams, immediate availability of massive transfusion, and shock-room access being only few examples of good practice that have been in place for decades.

In EM-led systems, the high degree of independence of EDs has led to the undesirable withdrawal of the acute and critical care specialties from emergency care. This is partly due to the vague definition of emergency medicine as a ‘specialty’ dealing with the ‘prevention, diagnosis and management of all urgent and emergency aspects of illness and injury’. Unfortunately, the concept of EM is not fully understood by the public, which has caused a ‘supply generated demand’ diverting patients from primary care into EDs leading to overcrowding and multiplying the hospital’s emergency workload.

In countries with established, mature, and high performing longitudinal care systems, the introduction of EM as a cross-sectional specialty, without a clear function differentiation, might trigger similar developments with a resultant fragmentation of existing pathways. This would inevitably put critical patients at risk.

As anaesthesiologists, who have had responsibility for the immediate care of critically ill or injured patients for many decades, we are very concerned that creating a monopoly by putting emergency medical care in the hands of one single specialty runs the risk of depriving the most critical patients of immediate expert vital function support. These patients benefit greatly from a team approach, where all players know their roles, responsibilities, and limitations. To secure timely and effective treatment, all acute and critical care specialities must stay involved from the outset in emergency care in the ED.

Anaesthesiology is a specialty with defined areas of expertise, as highlighted by the European Society of Anaesthesiology (ESA): Anaesthesia, Perioperative Medicine, Critical/Emergency Care, Intensive Care Medicine, and Pain Medicine. The Critical/Emergency Care elements entail management of emergency patients inside and outside the hospital. The necessary life-saving skill set is acquired and maintained under the controlled conditions of an operating room. Anaesthesiological expertise in this area has been recognized as CRitical Emergency Medicine (CREM) and is an integral part of our specialty. Outside the hospital, the importance of anaesthesiologists as CREM experts is even more prominent than in-hospital. It is easier for the anaesthesiologist as a highly experienced vital function specialist to fill this role than for any other specialist.

In most countries CREM is seen as a natural extension of the anaesthesiologist’s role in the operating room and the intensive care unit. At the same time, it is important to understand that anaesthesiologists are only experts in dealing with critical (immediately life-threatening) emergency conditions. The acute care for non-life-threatening emergencies remains the task of the corresponding specialty or the General Practitioner.

It is notable that in some European countries, EM has been established as a supra-specialty, where anaesthesiologists, surgeons, internal medicine doctors, and others can opt for two years of EM training following their primary specialization. This concept combines the longitudinal approach with the cross-sectional requirements of over-crowded EDs and retains the multidisciplinary aspects of emergency care. In Germany this supra-speciality has just been established, as an excellent additional perspective for anaesthesiologists and others.

Today, anaesthesiologists are the best-trained experts available to take responsibility for critical emergencies and coordinating activities of other specialists as they do on a daily basis in the operating room environment. Anaesthesiologists are thus a central and crucial element in emergency medicine.

We strongly encourage the national societies of anaesthesiology to embed CREM more visibly into their training programmes to secure access to early vital function expertise for the sickest of our patients in the future.

In collaboration with: E. De Robertis, E. Søreide, J. Mellin-Olsen, L. Theiler, K. Ruetzler, J. Hinkelbein, L. Brazzi



De Robertis E, Böttiger BW, Søreide E, Mellin-Olsen J, Theiler L, Ruetzler K, Hinkelbein J, Brazzi L, Thies KC. The monopolisation of emergency medicine in Europe: the flipside of the medal, Eur J Anaesthesiol 2017;34(5):251-3. doi: 10.1097/EJA.0000000000000599. FREE ACCESS – available at