322 COMMENTARIES Gunn, Grenvik • CRITICAL CARE CERTIFICATION

Emergency Medicine andCritical Care Certification

As early as 1543, in his clas-sical work De Humani Cor-

poris Fabrica, Vesalius describedan experiment in which an ani-mal was kept alive by rhythmicinsufflation of air into the tra-chea.1 This is perhaps the firstscientific attempt to maintainlife by artificial means. FlorenceNightingale was the first healthcare professional to utilize an in-tensive care unit (ICU) for man-agement of the sickest patientsduring the Crimean War (1854–1856). During World War II,shock wards were established toresuscitate soldiers injured inbattle and after major surgery.The nursing shortages that fol-lowed World War II forced thegrouping of postoperative pa-tients in recovery rooms to allowfor close observation and inten-sive therapy. The obvious bene-fits in improved patient carewould soon result in the spreadof postoperative recovery roomsto nearly every hospital.

However, modern ICUs didnot appear in European andAmerican hospitals until the po-lio epidemics of the 1950s, wheretracheostomy and prolonged ven-tilatory support were used tosupport patients in the most se-vere cases.2 Peter Safar at Bal-timore City Hospital initiatedthe first physician-staffed ICUproviding 24-hour-a-day life sup-port in 1958.3 Because life-threatening illness can resultfrom a wide variety of medical,surgical, or traumatologic prob-lems, it became clear that manydifferent professionals wouldneed to be involved in the man-agement of critically ill patients.In 1970, an internist/cardiologist(Max Harry Weil), an anesthesi-ologist (Peter Safar), and a sur-geon (William Shoemaker) to-gether with 25 other specialistsof different disciplines founded

the Society of Critical Care Med-icine. They defined critical caremedicine as ‘‘the multidiscipli-nary healthcare specialty thatcares for patients with acute,life-threatening illness or in-jury.’’4

Many have criticized the termcritical care medicine; perhapsmost notably Peter Safar, as crit-ical care not only takes place inthe ICU, but begins at the onsetof critical illness or at the sceneof life-threatening trauma.5 Mod-ern critical care continues duringtransportation to a selected hos-pital capable of managing thecritically ill or injured patient.With resuscitation and life sup-port already in progress, a rapidpursuit of diagnosis or cause ofthe life-threatening condition isnecessary and frequently beginsin the emergency department(ED). The patient may then go tothe operating room or directly toan ICU. Mortality is high amongthese patients and death may oc-cur in any phase of the manage-ment. When and if these criti-cally ill patients are dischargedfrom the ICU, they may end upon regular hospital wards. How-ever, there are also an increasingnumber of patients transferredto intermediate care or step-down units for prolonged inten-sive care and mechanical venti-lation, when the critical illnessmay have reached a chronic statewith a more stable condition.

During recent years, in theUnited States and other coun-tries (e.g., Austria), EDs at majortertiary care hospitals have beenintroducing short-term ICUs orobservation units.6–8 Many of thepatients treated in these ED/ICUs may not need formal ad-mission to the hospital if imme-diate diagnosis and therapy leadto timely stabilization and recov-ery.9–11 Because critical care be-

gins when the critically ill pa-tient first comes in contact withthe health care system and be-cause many EDs currently uti-lize short-term ICUs or observa-tion units, many emergencymedicine (EM) specialists wouldbenefit from critical care medi-cine (CCM) training. Theyshould be offered the opportunityto become certified subspecialistsin this field. Indeed, the Ameri-can Board of Emergency Medi-cine (ABEM) has repeatedly re-quested the right to examinationand certification in CCM, a priv-ilege that so far ABEM has beendenied by the American Board ofMedical Specialties (ABMS).

In the 1980s, efforts weremade in the United States toprovide a joint CCM certificationexam for those physicianstrained and practicing in thisfield.12 However, the four majordisciplines involved in criticalcare at that time (anesthesiology,internal medicine, pediatrics,and surgery) decided to developtheir own subspecialty exams incritical care, and at least tempo-rarily the door was closed toAmerican physicians of otherdisciplines to obtain certificationin CCM as a subspecialty. Thecurrent system leaves a numberof other physicians such as neu-rosurgeons and neurologistswith special interest in CCMwithout the right for certificationin this field. This is unfortunatebecause many specialized neu-rological and neurosurgical ICUsalready exist.

Although the need for CCMsubspecialty training and certi-fication for EM and other spe-cialists exists, the current sys-tem does not allow them toobtain subspecialty certificationin CCM. Recently, the AmericanBoard of Internal Medicine(ABIM) offered a compromisethrough which physicians mayobtain combined training in EM,internal medicine, and CCM.13

Such training will take placeover six years, instead of the

ACADEMIC EMERGENCY MEDICINE • April 2002, Volume 9, Number 4 • www.aemj.org 323

seven that would normally be re-quired to complete all three.These physicians will be permit-ted to sit for the CCM exam pro-vided by the ABIM. This may bean indication that in the futurewe will see possibilities for EMphysicians with appropriate ad-ditional CCM training to becomeCCM-certified by an ABEM ex-amination.

The current model of CCMtraining as a subspecialty in theUnited States is certainly not theonly valid approach. In Europe,the examination is availablethrough the European Society ofIntensive Care Medicine to any-one completing a base specialtycertification and two years of ad-ditional training in CCM.14 Inthe United States, the ABMScould provide such an exam. Inaddition, there are other coun-tries, (e.g., Japan) that have cho-sen to combine EM and CCM,commonly placing the ICU in theED. Academic departments ofCCM at American medicalschools are currently being es-tablished. In the future, thismight lead to CCM primaryboard certification in the United

States, as is already the case inSpain. Solutions to the CCM di-lemma vary in different parts ofthe world, and the American sys-tem is not necessarily the bestone. Nevertheless, we live in anera of rapid change, which is cer-tainly true in medicine. There-fore, future changes are likely inCCM examination and certifica-tion as well.—SCOTT GUNN, MD(gunnsr@anes.upmc.edu), andAKE GRENVIK, MD, Departmentof Critical Care Medicine, Uni-versity of Pittsburgh, Pittsburgh,PA

Key words. critical care; certifica-tion; emergency medicine; subspe-cialty.

References

1. Vesalius A. De Humani CorporisFabrica. Basel, 1543.2. Ibsen B. The anesthetist’s viewpointon treatment of respiratory complica-tions in poliomyelitis during the epi-demic in Copenhagen, 1952. Proc R SocMed. 1954; 47:72–4.3. Safar P, DeKornfield T, Pearson J,Redding J. Intensive care unit. Anesthe-sia. 1961; 16:275–84.4. Weil MH. The Society of Critical CareMedicine, its history and its destiny. CritCare Med. 1973; 1:1–4.5. Safar P. The critical care medicine

continuum from scene to outcome. In:Parillo JE, Ayres SM (eds). Major Issuesin Critical Care Medicine. Baltimore:Williams and Wilkins, 1984. pp 71–84.6. Counselman FL, Schafermeyer RW,Garcia R, Perina DG. A survey of aca-demic departments of emergency medi-cine regarding operation and clinicalpractice. Ann Emerg Med. 2000; 36:446–50.7. Nguyen HB, Rivers EP, Havstad S, etal. Critical care in the emergency de-partment: a physiologic assessment andoutcome evaluation. Acad Emerg Med.2000; 7:1354–61.8. Bur A, Mullner M, Sterz E, Hirschl M,Laggner A. The emergency departmentin a 2000-bed teaching hosptial: savingopen ward and intensive care facilities.Eur J Emerg Med. 1997; 4:19–23.9. Martinez E, Reilly BM, Evans AT,Roberts RR. The observation unit: a newinterface between inpatient and outpa-tient care. Am J Med. 2001; 110:274–7.10. Ross MA, Naylor S, Compton S,Gibb KA, Wilson AG. Maximizing use ofthe emergency department observationunit: a novel hybrid design. Ann EmergMed. 2001; 37:267–74.11. Grenvik A. Alternative modes of fi-nancing health care technology. Singa-pore Med J. 2001; 30:222–5.12. Grenvik A, Leonard JJ, Arens JF,Carey LC, Disney FA. Critical care med-icine. Certification as a multidisciplinarysubspecialty. Crit Care Med. 1981; 9:117–25.13. American Board of Internal Medi-cine. Internal Medicine/Emergency Med-icine/Critical Care Medicine TrainingGuidelines. www.abim.org; 2001.14. European Society of Intensive CareMedicine. European Diploma in Inten-sive Care. www.esicm.org; 2001.