Emergency medicine in Scandinavia - an outstanding opportunity for research

Editorial It was not long ago that emergency medicine (EM) was only something for the rest of the world. Emergency patients in the Scandinavian countries were still being handled by young and poorly trained doctors from many specialties and no doctor tended especially to the undiagnosed patient in the emergency department (ED). The work environment was hostile, and the nurses had to make do with temporary physicians who did nothing to improve it. In Norway doctors from different specialities ran the ED, in Denmark it more or less was managed by the orthopaedic surgeons and in Sweden general surgeons were often in charge, but few doctors really took ownership of the ED. However, in 1999 the Swedish Society for Emergency Medicine (SWESEM) was established and things started to change. The Danish Society for Emergency Medicine (DASEM) was established in 2006 and the work to improve the care of emergency patients began. Finland also has a society but no speciality, whereas in Norway there seem to be no plans to establish EM as a specialty. Sweden is the country that has now come the longest way in implementing emergency medicine and Denmark is following close behind. In Sweden, the EDs are now starting to be populated by designated doctors working only there, and specialists in EM are increasing. In Denmark the National Board of Health has recently proposed major changes in the organisation of the entire emergency care system. This will lead to a completely new way of organising the EDs and admission units at most hospitals in Denmark. As EM is still in its infancy in our region of the world, there is an outstanding opportunity for conducting research. Now, before changes are implemented in all EDs, is the chance to design before versus after studies, and several important fields of research are opening up. First, we believe the implementation of EM as a specialty is a good idea, but we basically don’t know if this is true. Evidence-Based Medicine is now the universal credo for all specialties, but no physician speciality in medicine was originally established based on solid evidence. Nor will this be the case for EM, but we now have a rare chance to test whether EM as a speciality and a higher level of competence in the ED makes a difference. There is evidence from previous studies that emergency physicians are at least as competent as their counterparts from the established specialities [1]. Emergency physicians improve the time to revascularization of patients with acute coronary syndrome, interpret ECG’s equally to or even better than residents in internal medicine and are equally good at treating cardiac or respiratory arrest as others. In Scandinavia we now have a chance to design studies on the effect of EM specialists on the quality of care, on patient flow and on throughput in the ED. Will EM specialists reduce mortality, morbidity and the cost of treatment, and will they improve patient safety? Second, which ED organisation is best? Hospital owners are using billions of Kroner on building new hospitals and refurbishing existing EDs. But how much do we know on how to design and run these departments? Not much! Should they contain their own observation units for in-patients? Should the specialist in EM greet the patient at the door or should it be a nurse? Or could perhaps a secretary do it equally well? Should we do triage or is streaming the answer? Is the goal of a four hour maximum stay in the ED well founded? Can these large amounts of money be used better? Would it be better to invest in physician training than in buildings? Perhaps the improvement of the in-hospital organisation of emergency care provides no benefit to the patients? Let’s use this golden opportunity to find out! Third, EDs differ from other departments in the need for specialist coverage around the clock. Acutely ill patients need optimal care and treatment, whatever the time. This is one of the major hallmarks of EM; the * Correspondence: [email protected] Medical Admission Unit 272, Sydvestjysk Sygehus Esbjerg, Denmark Brabrand and Ekelund Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine 2010, 18:5 http://www.sjtrem.com/content/18/1/5