Perspectives ‒ Accident and Emergency

7. April 2016

Accident and Emergency is the strangest unit of any hospital I have ever visited. Even though our specialty has come as far as to have ER (the world’s most award-winning TV series) based on it, we can’t say that the field of emergency medicine is fully understood.


This is no surprise ‒ it is the youngest clinical specialty, recognised in the USA in 1973 but in the European Union only in 1993. Anglo-Saxon countries have been at the forefront of emergency medicine. Estonia has caught up with them in great leaps, as the partly English-language studies in our department have broken down language barriers. The main clinical information on emergency medicine comes from British and American publishers.


In a life-threatening situation, a person usually has the option of choosing between three places to die if they don’t get any help. The first is the place where the person takes ill. To compensate for situations on location, our country has ambulances. The second place, where a person may be almost dead by the time they reach it, is the hospital waiting room. The third place from which to leave this world is the in-patient part of the hospital. Over a long period of time, providing help was an impaired process in both ambulances and hospitals. The Americans, once again, when cars were becoming more popular, thought to themselves that they should transfer their experience from the Vietnam War to ambulances. The ambulance brigades that reached the hospitals however found themselves in waiting rooms that lacked both competence and motivation. There have been negative examples in Estonia as well, where for example an insufficiently monitored psychiatric patient hanged himself in an understaffed hospital waiting room. At 15-year intervals, innovators in the USA, UK and Estonia said that in a country where you can call a plumber 24/7, emergency medicine and consistent health care must also be available at all hours. Accident and emergency units were born.


Emergency medicine units are a continuation of pre-hospital treatment and the response to the second place of dying. A person who gets to a hospital should not have to die in the vestibule. Emergency doctors, nurses and paramedics take the sick in and stabilise their condition. Their airways are secured using special techniques. Treatment that cannot be postponed is started there and then, and the patient’s condition is stabilised. This does not mean that once patients are admitted to in-patient care they are more or less well already.


The joy and sorrow of emergency medicine is that we have sat in every chair. Sometimes I’m surprised how the doctors in our unit still manage to handle the demands of different and notably more specific fields. Our job is like the endless third year of medical school. Every second you are surprised that there is still room in your head for one more fact. The same goes for nurses. It is clear that every nurse has built a model in their head to maintain some kind of system among the organised chaos of the emergency room. In a way, our people are happy in their heads. In military units, there is pre-selection when hiring. We take everyone, and the selection process in spontaneous and everyday. If you make it, then at some point you will feel great satisfaction with and a sense of accomplishment from your work. The latter especially when a patient is pulled back from the edge of the abyss as a united team. The only sad part is that more delicate decisions often go unnoticed. How can you evaluate something that didn’t happen?


Today there is a situation where people at the national level have woken up and can see the overall poor readiness of medical institutions in the event of catastrophes. Legislation was only amended two years ago. This task is bound to end up being shouldered by emergency rooms, which will become centres of triage and treatment. I just hope we can prepare ourselves before another black swan unexpectedly rears its head among the white ones.