The term CRitical Emergency Medicine (CREM) was initially created to define competencies in the acute management of life-threatening emergencies. Anaesthesiologists are the best trained experts to take responsibility of these activities as they do on a daily basis in the operating room environment. Moreover, as stated in the Helsinki Declaration on Patient Safety in Anaesthesiology, anaesthesiologists should play a leading role in the multidisciplinary management of life-threatening emergencies regardless of the model of emergency medicine delivery adopted by different countries.
This concept has been clearly re-affirmed by Edoardo De Robertis and a group of members of the Scientific Subcommittee on Critical Emergency Medicine of the European Society of Anaesthesiologists (ESA) in an Editorial published on the European Journal of Anaesthesiology (EJA) in 2017. In the manuscript, the Authors clearly stated that: ‘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 specialties must stay involved from the outset in emergency care in the emergency department’.
Concluding the editorial, the Authors even encouraged: ‘[…]the national societies of anaesthesiology to embed CREM more visibly into their training programs to secure access to early vital function expertise for the sickest of our patients in the future’.
Members of the ESA Scientific Subcommittee on Critical Emergency Medicine decided to publish the aforementioned editorial mainly because, over the past 20 years, emergency medicine has evolved as an independent medical specialty in most of Europe. It has been hypothesised that the introduction of emergency medicine could have improved the quality of care in countries where either poor access to primary care for patients with acute conditions or the shortage of medical specialists may have hampered a timely provision of emergency care. But this does not seem to be true for countries in which emergency medical care is routinely delivered in a longitudinal way by the acute and critical care specialties, namely anaesthesiology, surgery, neurology, internal medicine/cardiology and paediatrics. In these countries, where a well-established and high-performing longitudinal care system exists, it could be that the introduction of emergency medicine as a cross-sectional specialty, without a clear function differentiation, might result in fragmentation of existing pathways putting critical patients at risk.
A great discussion followed the publication of the editorial highlighting how unclear still remain the roles of different specialised physicians in the initial and advanced management of emerging and severe cases within the emergency departments.
Among the activities carried out by the scientific subgroup 10 in 2018, one of the most important has been the publication of a first draft of the ten principles underlying CREM. These are:
- Optimal patient care – especially in life-threatening critical emergencies – should be the key concern for everyone taking care of critically ill or injured patients
- It is a ‘patient’s right’ to get the best and safest medical care
- Medical care in emergencies covers a wide spectrum, from the new-born to the very old, from less severe to life-threatening illnesses, from a mild infection to sepsis, from minor injuries to severe trauma, cardiac arrest and cardiopulmonary resuscitation. The critically unwell are a small, but distinct group amongst all emergency patients; they require special attention
- In countries that had poor access to medical services, implementation of emergency medicine as a specialty has improved medical care
- In countries with highly developed and easily accessible medical services, the implementation of emergency medicine as an additional primary specialty has resulted in new inter-specialty ‘barriers’ and pathway disruption resulting in poor access to specialty care
- Critical patients presenting with life-threating emergencies require coordinated, collaborative and continuous management, which includes vital function support, as well as diagnosis and treatment of the underlying disease
- In life-threatening conditions, patients must have immediate access to doctors who have these competences and the corresponding interpersonal skills
- Expertise in the support of vital functions with particular attention to airway management, vascular access and haemodynamic stabilisation represent the key competences of anaesthesiologists
- Anaesthesiologists are exposed on a daily basis to vital function challenges in the unique environment of the operating room and in the ICU. It is this endless exposure that has shaped the expertise needed in CREM
- Only those who practice life-support skills on a daily basis can safely and effectively apply them in emergency settings
Due to the fact that, in countries with established, mature and high-performing longitudinal care systems, the introduction of emergency medicine as a cross-sectional specialty, without a clear function differentiation, might result in a fragmentation of existing pathways leading to an increase risk for patients, the Scientific Subcommittee on Critical Emergency Medicine of the European Society of Anaesthesiologists continues to work to have the ten principles reported above officially recognised by the scientific community.