Emergency medical services: A new subspecialty on the horizon

The increasing expectation of excellence from our health care system extends to care provided by paramedics in the prehospital setting. 

Some physicians may remember the 1970s TV show Emergency! with paramedics Johnny and Roy, and Dr Kelly Bracket (surgeon) and Dr Joe Early (neurosurgeon) who staffed the emergency department. Emergency medicine and prehospital care have evolved in the ensuing 40 years, with emergency medicine being recogniz­ed as a specialty and an expansion in the paramedic scope of practice. To­day’s paramedics are expected to make complex decisions at the scene regarding treatment and transport. 

To achieve this high level of care outside the hospital requires sound medical oversight for paramedic systems. Like emergency medicine, medical oversight has matured from volunteer physicians making suggestions based on emergency department experience to the integration of physician leadership into the emergency medical services (EMS) operation itself. The scope of practice for EMS phy­sicians has grown, and represents a practice with a unique, definable, and growing body of scientific and operational knowledge. 

The EMS physician provides specialized medical oversight in the development and admin­istration of EMS systems, and is an essential liaison with local public service agencies, hospitals, and professional organizations. The EMS phy­sician also provides essential medical leadership, system oversight, development of practice guidelines and protocols for routine and disaster care, identification and implementation of best practices, system quality im­provement, and research unique to the prehospital environment. Finally, the EMS physician has the core skills and competencies that enable him or her to provide hands-on emergency and resuscitative care in the out-of-hospital setting.

BC’s Emergency and Health Services Commission employs full- and part-time physicians who work closely with BC Ambulance Service Operations in decision making and strategic planning, and who liaise with hospitals, emergency departments, and the public health and emergency planning communities. 

EMS physicians are a community with an organized structure. The Na­tional Association of EMS Physicians (NAEMSP) was founded in the US in 1984 and currently numbers 1200 members internationally. The Canadian group within NAEMSP has 75 members representing services across Canada. This group, along with the EMS section of the Canadian Association of Emergency Physicians and the EMS Chiefs of Canada, liaise closely to foster development of EMS nationally. 

In September 2010 the American Board of Emergency Medicine an­nounced that EMS medicine would be recognized as the sixth subspecialty of emergency medicine in the US. Subspecialty designation recognizes that EMS comprises a discrete body of knowledge, requiring training that is specific and broad and beyond what is included in an emergency medicine residency training program. The first EMS subspecialty board certification exam will sit in 2014. 

The Royal College of Physicians and Surgeons of Canada recently made available a new diploma track to recognize training programs that focus on a specialized area of knowledge and competence. This new track is intended to formally recognize training that was once only accessible via the specialty or subspecialty process. 

A Canadian EMS Diploma Working Group was formed in 2008 in anticipation of this new Royal College process. The Working Group includes Canada’s national leaders and content experts in EMS, with university faculty appointments at 10 of Canada’s Royal College Emergency Medicine Training programs. It intends to submit an application to the Royal College of Physicians and Surgeons of Canada for recognition of EMS as a diploma discipline. The formal submission will occur in 2013, with a view to formal Royal College recognition in 2014. If successful, the EMS diploma program will be developed in the faculties of medicine at several Canadian universities to provide formal training for physicians pursuing EMS as a career path. 

For more information about the Working Group or the proposed EMS diploma program, contact Dr Russell MacDonald at rmacdonald@ornge.ca.

This article is the opinion of the Council on Health Promotion and has not been peer reviewed by the BCMJ Editorial Board.

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Dr Wanger is a clinical associate professor in the Department of Emergency Medicine at UBC and physician member-at-large on the Board of Directors of the National Association of EMS Physicians. She is a former medical director with the BC Ambulance Service. Dr MacDonald is an associate professor in the Department of Medicine at the University of Toronto and co-director of the Emergency Medicine Fellowship Program. He is medical director for Ornge Air Transport in Ontario.