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The monopolisation of emergency medicine in Europe: the flipside of the medal

De Robertis, Edoardo; Böttiger, Bernd W.; Søreide, Eldar; Mellin-Olsen, Jannicke; Theiler, Lorenz; Ruetzler, Kurt; Hinkelbein, Jochen; Brazzi, Luca; Thies, Karl-Christianon behalf of the ESAEBA taskforce on Critical Emergency Medicine

European Journal of Anaesthesiology (EJA): May 2017 - Volume 34 - Issue 5 - p 251–253
doi: 10.1097/EJA.0000000000000599

From the Department of Neurosciences, Reproductive and Odontostomatological Sciences, University of Naples ‘Federico II’, Naples, Italy (EDR); Department of Anaesthesiology and Intensive Care Medicine, University Hospital of Cologne, Cologne, North Rhine-Westphalia, Germany (BWB, JH); Department of Anaesthesiology and Intensive Care, Stavanger University Hospital, Stavanger (ES); Department of Anaesthesia, Intensive Care, and Emergency Medicine, Baerum Hospital, Sandvika, Norway (JM-O); Department of Anaesthesiology, University of Bern, Inselspital, Bern, Switzerland (LT); Departments of Outcomes Research and General Anesthesiology, Cleveland Clinic, Cleveland, Ohio, USA (KR); Department of Surgical Science, University of Turin and Department of Anaesthesia and Intensive Care, AOU Città della Salute e della Scienza, Turin, Piedmont, Italy (LB); Department of Anaesthesia and Pain Medicine, Birmingham Children's Hospital, Birmingham, UK (KCT)

Correspondence to Edoardo De Robertis, Department of Neurosciences, Reproductive and Odontostomatological Sciences, University of Naples ‘Federico II’, Naples, Italy Tel: +39 081 7463550; fax: +39 081 7463550; e-mail:

Over the past 20 years, emergency medicine has evolved as an independent medical speciality 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 out of hours. The introduction of emergency medicine has certainly improved access to care in countries where both factors hampered timely provision of emergency care. However, for countries in which 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 emergency medicine as a separate speciality would fit into existing advanced care pathways.

The promoters of emergency medicine as an independent speciality claim that the absence of emergency medicine implies poor emergency care. This polarising argument has been used as a powerful political lever in dealing with the media and national healthcare regulators and has generated significant political pressure to implement emergency medicine in several countries. However, the claim remains largely unsupported, and careful comparison of the different systems raises concerns whether the introduction of emergency medicine has paradoxically delayed the development of care for the most critically ill patients.1–3

This is not surprising, as the vast majority of patients in emergency departments present with medical conditions of low acuity (e.g. exacerbation of 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 are no clear definitions of ‘emergency’, ‘urgency’ and ‘acute’. The danger posed by the current vague definition of emergency medicine 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 speciality.

In contrast, the longitudinal approach means that the responsibility for the pathway of critical emergency patients lies primarily with the corresponding medical speciality. This principle has facilitated a direct and seamless translation from speciality expertise (anaesthesiology/intensive care medicine, surgery, internal medicine, cardiology or neurology) into the emergency department and further into the prehospital 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 prehospital services, multidisciplinary reception teams, immediate availability of massive transfusion and shock room access being only a few examples of good practice, which have been in place for decades.

In emergency medicine-led systems, the high degree of independence of emergency departments has led to the undesirable withdrawal of the acute and critical care specialities from emergency care.4 This is partly because of the vague definition of emergency medicine as a ‘speciality’ dealing with the ‘prevention, diagnosis and management of all urgent and emergency aspects of illness and injury’.5 Unfortunately, this definition does not include a function differentiation or a formula for cooperation with other specialities. Moreover, the concept of emergency medicine is not fully understood by the public. This has caused a ‘supply-generated demand’ diverting patients from primary care into emergency departments, leading to overcrowding and multiplying the hospital's emergency workload.6

In countries with established, mature and high-performing longitudinal care systems, the introduction of emergency medicine as a cross-sectional speciality, 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 speciality 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 emergency department.

Anaesthesiology is a speciality 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 recognised as Critical Emergency Medicine (CREM)7 and is an integral part of our speciality. Outside the hospital, the importance of anaesthesiologists as CREM experts is even more prominent than in hospital.8 Working without the backup of the hospital team, it is crucial that the out-of-hospital critical care provider is proficient in all aspects of acute vital function care. It is easier for the anaesthesiologist as a highly experienced vital function specialist to fill this role than for any other specialist. This includes taking care of complex intensive care patients of all ages during interhospital transport.

In most countries, CREM is seen as a natural extension of the anaesthesiologist's role in the operating room and the ICU. 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 nonlife-threatening emergencies remains the task of the corresponding speciality or the general practitioner. It is notable that in some European countries, emergency medicine has been established as a supraspeciality, where anaesthesiologists, surgeons, internal medicine doctors and others can opt for 2 years of emergency medicine training following their primary specialisation. This concept combines the longitudinal approach with the cross-sectional requirements of overcrowded emergency departments and retains the multidisciplinary aspects of emergency care. In Germany, this supraspeciality has just been established as an excellent additional perspective for anaesthesiologists and others. This model could also be a complementary option to alleviate the overwhelming medical staff shortages currently experienced in the emergency departments of emergency medicine-led systems.9

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. This should also be reflected in national training programmes as suggested by the European Board of Anaesthesiology in its emergency medicine curriculum proposal10 and in training requirements for the speciality of anaesthesiology, pain and intensive care medicine.11

Anaesthesiologists are involved in teaching, training and research in the field of CREM in all European countries. Anaesthesiologists are thus a central and crucial element in emergency medicine.12

Therefore, although we acknowledge that the vast majority of emergency department patients do not require anaesthesiological input, monopolisation of emergency medicine does not appear to be the best answer to the current challenges in urgent and acute care. A well functioning chain of care depends on an expert primary care system to prevent crowding of emergency departments and also on immediate access to vital function care if required. In contrast, monopolisation of emergency medicine creates a real danger that the most critical patients will be deprived of expert vital function care. As a consequence, we need to clarify the terms of cooperation between the specialities in the emergency departments at a European level. We should also 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.

This article is endorsed by the Board of the European Society of Anaesthesiology

Statement of the European Section and Board of Anaesthesiology:

The European Section and Board of Anaesthesiology (EBA UEMS) agreed, at their meeting in Budapest on 3 December 2016, to adopt the term CRitical Emergency Medicine (CREM) to define anaesthesiologists’ competencies and role in the acute management of life-threatening emergencies, which to date has been termed Emergency Medicine in the anaesthesiology speciality European training requirements.

As stated in the Helsinki Declaration on Patient Safety in Anaesthesiology, anaesthesiologists share responsibility for quality and safety in anaesthesia, intensive care, emergency medicine and pain medicine. Accordingly, anaesthesiologists have a leading role in the multidisciplinary management of life-threatening emergencies regardless of the model of emergency medicine delivery adopted by different countries.

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Acknowledgements relating to this article

Assistance with the editorial: none.

Financial support and sponsorship: none.

Conflicts of interest: EDR is a board member of the EBA and the Chair of the Guidelines Committee of the ESA, JM-O is a EBA member and a board member of the ESA, LT is a member of the ESA Scientific Subcommittee on Critical Emergency Medicine, ES is a member of the ESA Scientific Subcommittee on Intensive Care Medicine, BWB is a member of the ESA Scientific Subcommittee on Critical Emergency Medicine, LB is a member of the ESA Scientific Subcommittee on Critical Emergency Medicine, JH is a member of the ESA Scientific Subcommittee on Critical Emergency Medicine and KCT is a member of the ESA Scientific Subcommittee on Critical Emergency Medicine. BWB is an associate editor of the European Journal of Anaesthesiology.

Comment from the Editor: this Editorial was checked by the editors but was not sent for external peer review. BB is an Associate Editor of the European Journal of Anaesthesiology.

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