Hem > English > Emergency medicine in the slow lane

Emergency medicine in the slow lane

Emergency medicine is a new specialty in Sweden, only recognized in 2006 as a supra specialty. Basically that means you need around nine years of postgraduate training to qualify as a specialist, but still get very little emergency medicine training and exposure. The emergency departments are run by the respective departments, which can add up to eight separate sections under one roof. And I think it’s safe to say that none of the doctors working there follow the EM literature. It’s like evidenced based medicine is reserved for their patients upstairs. To get them to accept that emergency physicians take over their on call work is not a problem, but to make them realize that that will mean a change in practice is much more difficult. They are all willing to teach us their part of emergency medicine, but there are no role models to convey the integrated knowledge. Instead we have looked to international bloggers and podcasters. It has been hard to see how this could be translated to our setting, so I wanted to go somewhere where emergency medicine was an established specialty and my first choice was Australia. Unfortunately that turned out to be too complicated and expensive and I ended up in Botswana instead.

It is fair to say that my experience in Botswana fundamentally changed my perspective on emergency medicine. Talk about culture clash! I knew that Sweden was a developing country when it comes to emergency medicine, but I didn’t expect the gap to be so wide. Of couse it was tough to get used to the heavy burden of disease in this relatively wealthy country, but it was being caught in the interface between advanced, anglosaxian emergency medicine and the more improvised, basic emergency care that made me realize that I didn’t know what I was aiming for in Sweden.

I had tried to describe to the EM specialists in Botswana beforehand, how I lacked training and experience in certain areas. Like Gyn/OB, for instance. We don’t see these patients in Sweden since there is a separate ED for them. As a resident you will do a rotation there, which I hadn’t done yet, but you will be taught by gynecologists who don’t really see the point in your learning something that you won’t be dealing with once you leave their department. Another thing is trauma. I work in the largest ED in Sweden and we don’t see severe trauma cases. Of course the occasional patient wanders in after being stabbed or stomped by a mousse (actually that only happened once, to my knowledge), but it is definitely not part of our daily life. And in fact, hardly a part of our training. Of course we take ATLS and other courses, but in terms of exposure we get two weeks at the trauma center, where they see around 300 severely injured patients per year.

But it is not only the trauma cases that seem to be a lot less frequent here. I have only seen one crashing asthmatic patient. We mostly get old COPD patients with exacerbations. DKA is rare, too, in adult patients. It is hard to find another explanation than that these patients are being adequately treated in primary health care.
We have a high suicide rate in sweden, but I have never seen a serious intoxication on TCA, beta blockers or calcium channel blockers. When I was talking to the second year residents the other day, most of them had never seen a blood transfusion given in the resuscitation room.

I tried to tell this to my EM specialist colleagues in Botswana, but I don’t think they believed me. Admitting everything you don’t know is never pleasant, especially not when people are surprised that you don’t know the basic things. Like placing a chest tube. I have never seen a chest tube placed in the ED. The same goes for central lines, but maybe we just missed that train, since CVP is going out of fashion and IO is gaining ground for the really acute cases. But if one was to be placed, someone from anesthesiology would come and do it, in no time. Just like they come and intubate the patient if necessary, which is rarely done in the ED. Cardiac arrests are often intubated in the field by a nurse anesthetist. (I won’t go into whether that is optimal practice or not.) If the critically ill patient needs to be intubated, they will mostly be taken to the ICU and have the procedure performed there. An emergency medicine program director even questioned that intubation skills were necessary for emergency physicians!

My hospital only has around twenty ICU beds and it is hard to get a patient admitted there. The STEMIs go there of course, but they bypass the ED and go straight to cath lab, so we only see the not so obvious ones.

What it all comes down to is that as much as we need to increase our resuscitation skills for the really sick patients, these cases are not common enough for us to train a large number of emergency physicians. Our work is more of preventive emergency medicine and driving in the slow lane. And even though I would love to bring upstairs care downstairs, I have to ask myself if the outcomes won’t be better if we keep bringing downstair patients upstairs.

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  1. februari 19, 2012 kl. 6:22 f m

    It is interesting reading your article, especially your last sentence… because here in Australia the focus at the moment is all about how to move the downstairs patients upstairs (to the medical ward, ICU etc) more quickly! To many Aussie doctors and administrators, your system, where patients get whisked away quickly and there are few DKAs and ODs, would seem like a heaven on earth.

    So the questions in my head are:
    1) Does Sweden need EM? If care is already so well streamlined, how will EM there improve patient outcomes or healthcare efficiency?
    2) Are the reforms in Australia heading full circle? If we achieve 4-hour goals for getting patients upstairs, will we be heading back towards a ‘pre-EM state’? Will it cause Australian EM specialists to become deskilled in procedures such as chest tubes and central lines (as is happening with pleural taps and LPs)?

    • februari 19, 2012 kl. 9:39 f m

      Thanks for your input, Sally! Unfortunately our EDs aren’t that streamlined either and overcrowding is a serious problem here, too. It’s only the critical patients who get admitted straight away. The remaining mix of not-yet critical and will-never be critical accumulate in the ED and the waiting times can be horrendous.

      We definitely need emergency medicine! Junior doctors who alternate between the wards and the ED, where they work relatively unsupervised, can’t provide adequate care. In the larger hospitals subspecialisation makes the different specialists unfit to take care of the undifferentiated patient. How do you know if the seizing patients should be seen by neurology or medicine? Or even surgery?

      In my last hospital they bought a new CPAP machine. The doctors on the floor were never involved in the process and I was a bit annoyed that we didn’t get one that could do BiPAP. The nurses objected that if we had the equipment, patients would only stay longer in the ED. I guess they were right.

      Every change you make in the system has consequences. You just need to consider them and make sure that what you are aiming for is what you really want.

  2. februari 20, 2012 kl. 1:49 e m

    Hi Katrin – this is a great article. I also appreciate reading your honest description about the lack of experience you felt you had in some procedural areas – and the difficulties gaining it in your medical set-up. I have also felt similar feelings regarding doing the bigger scarier procedures (eg putting in chest drains, and central lines) as a junior doctor. I remember my first chest drain was in my 3rd post graduate doctor where I was heavily supervised and my first central line was under supervision whilst on elective in a New York ER, but in reality I only became confident in these procedures in my 5th year post graduation when I did an ICU tern in Waikato, New Zealand- this was ”despite” a super keen interest in trauma and critical care at the time.

    Recently I have spent a lot of time studying and reflecting upon training in rural hospital settings (in many different countries around the world) and I think it is a goal mine for not only gaining practical experience, but also getting enough supervision to develop good practice. I wonder if the same holds for Sweden?

    I found as an intern in Wellington, New Zealand, it was difficult to get the same clinical exposure and responsibility (including direct supervision by specialists) as my counter parts who chose to do their internship in rural locations. Don’t get me wrong – I thought Wellington was a great place to work, and years later when I worked in the ED as registrar I had a great experience, but in general I find any bigger city hospital has less to offer than it’s rural counterparts in terms of experience and responsibility. The sad thing is that training and supervision can also be limited at times -so there is always a fine balance between getting lots of clinical exposure and responsibility and being professionally isolated (as the latter situation was one of the findings of qualitative research done by one of my colleagues
    http://www.biomedcentral.com/1471-2458/8/373 – this article is an interesting read!)

    When I was in Sri Lanka carrying out research on medical education, I saw more interesting cases of medicine in one morning with the physician who was in charge of half the 300 patients in the two medical wards for the hospital. Similarly, in one day at the hospital there would be more resuscitations (which isn’t surprising taking into account the 2-4 daily admission with organophosphate poisoning or venomous snake bite injuries that would present). So perhaps the Indian subcontinent might be a good place to do some training for experience, for whilst Emergency Medicine is still an emerging speciality,
    ( http://www.ncbi.nlm.nih.gov/pubmed/18251732 http://www.ncbi.nlm.nih.gov/pubmed/17655628)

    the medical systems are still well developed in the more traditional specialities – and I think there are some great learning experiences to be had in these countries if one is fortunate enough to be able to work there. Also, both India and Sri Lanka are currently developing their PG training in Emergency medicine full steam ahead, and it may be that in the future there will more opportunities for such exchange to occur.

    Thanks for sharing your interesting reflections and I would be interested to hear what you think!?

    Best wishes
    Bishan 🙂

  3. nicholas aujalay
    mars 12, 2012 kl. 11:54 f m

    There is definately a limit as to how many residents can be trained in one program in order to get the proper balanced exposure to skills and procedures. To augment exposure programs need to 1. Own the ED and it’s procedures including central lines, intubation, sedation etc. 2. Send residents to rotations where certain exposure is more common (mainly anesthesia, ICU, trauma settings etc). 3 Larger urban ED’s need to be combined with smaller community settings as to get the advantage of a different training environment.
    In all, I think this is to be better established when EM gains status as a speciality of it’s own. At present, no Swedish ED owns it’s work environment, which is the biggest drawback as far as training goes and you where wise to seek experience elsewhere.

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