More Science for the New Subspecialty

The growth and maturation of the newly recognized subspecialty of emergency medical services (EMS) is recognized and celebrated in this special content focus issue of Academic Emergency Medicine. The seven articles on EMS in this issue represent the breadth and depth of this emerging subspecialty of emergency medicine (EM). A similar issue, also with seven EMS articles, was published in September 2010, and we typically publish about a dozen EMS articles per year. Essentially all general EM journals publish EMS papers at least occasionally. There are also two dedicated EMS journals: Prehospital Emergency Care, the journal of the National Association of EMS Physicians (NAEMSP); and Prehospital and Disaster Medicine, the journal of the World Association for Disaster and Emergency Medicine. In addition to reflecting on the interactions of emergency physicians with EMS, which occur on a daily basis in the emergency department, and recognizing the crucial role that EMS plays in clinical outcomes for our patients, this attention to EMS in the medical literature also reflects the vital role that emergency physicians (and physicians in many other specialties) play in providing medical oversight for EMS systems, agencies, and personnel.1 As most EMS physicians are already aware, EMS was granted subspecialty recognition by the American Board of Medical Specialties in September 2010. The Accreditation Council for Graduate Medical Education (ACGME) had approved the concept of EMS as a physician specialty and the need for accredited EMS fellowship programs a few months earlier. At the time of this writing, they are drafting fellowship program requirements, and formal accreditation of EMS fellowship programs will begin in a few years. In parallel, the American Board of Emergency Medicine (ABEM) has begun the item-writing process for a certification exam, which is scheduled to be offered for the first time in autumn 2013. NAEMSP has formed the Council of EMS Fellowship Directors, analogous to the Council of Emergency Medicine Residency Directors, to aid fellowship directors in adaptation to this growth. While EMS is a subspecialty of EM with ABEM as the sponsoring board, graduates of any ACGME-approved residency program will be eligible to complete an EMS fellowship program and take the EMS certification exam. Trauma surgeons, pediatricians, cardiologists, family physicians, obstetricians, anesthesiologists, orthopedists, neurologists, and many others have been invaluable in teaching prehospital personnel and advancing the science of prehospital emergency care. While the majority of the articles in this month’s content focus are from emergency physicians, several authors represent other specialties, and the articles themselves illustrate the academic activity under way in EMS. A paper from the EMS Interest Group of the Society for Academic Emergency Medicine outlines current teaching in EMS for EM residents in the United States, with survey data illustrating surprising variability in the three main components of resident EMS education (didactic, field, and direct medical oversight).2 While all residency programs in the United States adhere to the same core content, it appears that there is much variation in how this content is actually delivered. Fellowship programs will be faced with similar content delivery issues as they look to implement the “new curriculum” (draft available on the Council website at http://www.naemsp.org/CEMSFD.html) and prepare for accreditation. Elsewhere in this issue, a group of authors from the United States and Canada present a model for developing evidence-based guidelines for EMS.3 Leonard and colleagues,4 however, recognized the limited success of efforts to enhance EMS research productivity and the resulting paucity of evidence to support such guidelines. They present qualitative data from interviews and focus groups with EMS personnel and agency leaders regarding barriers to conducting field-based clinical research. Lerner and colleagues5 provide a “toolkit” for calculating costs in EMS—a process that can be very useful for the researcher examining such issues as cost-effectiveness of various EMS interventions and systems, as well as for EMS administrators examining operational and budgetary issues. Several other articles are operational in nature, including a study by McMullan and colleagues6 suggesting that activation of helicopter EMS by ground personnel for patients with ST-segment elevation myocardial infarctions can reduce the time to reperfusion, although in their model, few patients would be reperfused within 90 minutes of EMS contact. Sasson and colleagues7 report on their use of three different geostatistical techniques to analyze out-of-hospital cardiac arrest (OHCA) patterns in Columbus, Ohio. They identify census tracts that have a combination of high OHCA and low bystander cardiopulmonary resuscitation rates as possible targets for intervention. Finally, a group of authors from Singapore describe their use of geospatial analysis to relate ambulance call volumes with socioeconomic status throughout their city-state. They also offer suggestions on how such analyses might be used to improve the operational efficiency of an urban EMS system.8 The recognition of EMS as a physician subspecialty is already having far-reaching results as noted above. One of the most important aspects of maturation of EMS will be the need for ongoing continued growth in the research basis for subspecialty practice as evidenced by the quality work highlighted in this issue.

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