Emergency Medicine in Europe – Time constraints may be universal, but are we seeing the same patients?

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Once again the contents of the current issue of this journal look at some common, and some less common, problems, always attempting to enlighten our readers.
I have previously mentioned the whole aspect of peer review as the most useful part of the modern medical literature [1]. On the basis of peer review comments from the original reviewer, I commissioned a commentary from the group at New York Poison Control Centre, which I feel clearly enunciates the lessons to be learned from the challenging case reported by Lois et al. [2]. Above all else, if the clinical pattern does not fit, it is imperative to recheck one's working diagnosis and chase the finer detail of the patient's history.
A clear knowledge of both basic physiology and the pathophysiology of disease is required to deal effectively with many patients presenting to the emergency department. This is evident from the case report by Goddet et al. [3], regarding an unanticipated response in a patient with anaphylaxis who was already β-blocked.
The message from Mazor et al. [4] is one that should be of benefit to those who have significant illicit drug usage in our populations. To use simple drug screening techniques for diagnostic assistance is useful, but not infallible. Certainly, no forensic value can be attached to such tests.
The paper from Elshove-Bolk et al. [5] is of enormous personal interest to me, especially regarding to the roles of European Society for Emergency Medicine and Union Européenes des Medecins Spécialistes in relation to training and development in Emergency Medicine.
I have also previously mentioned Directive 93/16/EC [6] in relation to harmonization of recognition of medical training in emergency medicine throughout the EU [7]. This harmonization rule relates to the free movement of labour from country to country, laying out rules for time-based training, without indicating anything in relation to harmonization of healthcare delivery.
Given the fact that the pattern of patient presentation may not be identical in different countries, is it safe to impose solutions from elsewhere?
Jolande Elshove-Bolk, reporting from the Emergency Department of Onze Lieve Vrouwe Gasthuis (OLVG) in Amsterdam, indicates that 84% of the patients were self-referred, the rest being referred by general practitioners (GPs). This is identical to my own department, of equal patient census, and would match most middle-sized departments in Ireland and the United Kingdom. The admission rate of the GP referred patients in OLVG is identical to the GP referred group in my department, but the admission rate for self-referred patients matches only that for the lowest triage category in Ireland, often known as ‘minor injuries’. It is also similar to studies reported from Australia, for the lowest acuity group [8]. The higher triage categories in self-referred patients, usually with chest pain, shortness of breath, abdominal pain and severe trauma, have a much higher admission rate than that identified by Elshove-Bolk.
What does this mean? Well, to understand it fully would require collaboration and further investigation between different departments in different countries. Of interest is the fact that OLVG has direct emergency medical service to specialty referral, and they also code patients who dial the European universal emergency access number ‘112’ as ‘emergency medical service-referred’, rather than self-referred. This may simply mean different classification of the same thing in different countries. I accept their argument that it may be inappropriate to take an emergency medicine practice model, or curriculum, from another country on the basis of its emergency department population, especially given this apparent diversity of classification, but also given the relative rates of utilization that differ so much between countries [9–11].
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