What Is Emergency Medicine? Research, Consent, and Training

Emergency medicine is the medical specialty concerned with the immediate evaluation, stabilization and initial treatment of illness and injury in patients who arrive without an appointment, of any age and with any problem. It is also a research field with an unusual difficulty built into it: the patients who most need new treatments are often too ill, too fast-moving or too unaware to give the informed consent that ordinary clinical research depends on. This guide explains what emergency medicine covers and how it divides into subspecialties, then adds the research-administration layer that generic overviews leave out: how emergency research is regulated, how its multi-center networks and funders are organized, which societies and journals anchor the field, and the typical training path. It is educational, not medical advice.

What Is Emergency Medicine?

Emergency medicine is defined less by an organ system than by a situation. An emergency physician sees undifferentiated patients, often with incomplete information and under time pressure, and must decide quickly who is critically ill, who can safely go home, and who needs a specialist. Several features set the discipline apart from its neighbors:

• Undifferentiated presentation. A patient arrives with chest pain, a fall, confusion or a fever, not with a diagnosis. The task is to rule out the dangerous causes first and treat the immediate threat.
• Breadth. Emergency physicians work across resuscitation, airway management, trauma, cardiac and respiratory emergencies, infection, poisoning, obstetric and pediatric emergencies, and acute psychiatric crises, as well as routine low-acuity problems.
• Time sensitivity. Many conditions, such as stroke, cardiac arrest, sepsis and major trauma, have narrow windows in which treatment works best.
• Access. The emergency department is open around the clock to everyone, which makes it a safety net for the health system and a rich, if difficult, setting for population-level research. In the United States, the legal duty to screen and stabilize patients is covered separately in our guide to EMTALA.

Emergency medicine is practiced in hospital emergency departments, and also in prehospital emergency medical services (EMS), urgent care settings, disaster response and, in some systems, in air and ground transport.

Scope of Practice

Resuscitation and critical care

Resuscitation is the discipline’s core skill: managing the airway, breathing and circulation of a critically ill patient in the first minutes. Severity scoring tools used in and around the emergency setting include the Glasgow Coma Scale, the Modified Early Warning Score and the SOFA and qSOFA scores. Hospitals keep equipment ready for these events, as described in What Is a Crash Cart?

Trauma and injury

Injury is a major share of emergency care. Clinical decision rules developed through emergency research, such as the Canadian C-Spine Rule, the NEXUS criteria and the Ottawa Ankle Rules, help clinicians decide who needs imaging and who does not.

Time-critical medical emergencies

Stroke, heart attack, pulmonary embolism, sepsis and poisoning all depend on fast recognition. Tools such as the Cincinnati Prehospital Stroke Scale and the PERC rule for pulmonary embolism are examples of instruments built for the emergency setting and studied extensively there.

Prehospital care and disaster response

Emergency medical services extend emergency care into the community, and emergency physicians help design EMS protocols, supervise paramedics and plan for mass-casualty events. Institutional readiness planning is covered in What Is Emergency Preparedness?

Subspecialties and Areas of Focus

In the United States, the American Board of Emergency Medicine (ABEM) certifies emergency physicians and, according to its website, offers subspecialty certification in medical toxicology, emergency medical services and advanced emergency medicine ultrasound. Other recognized areas of focus, some certified through other boards, include:

• Pediatric emergency medicine, the care of acutely ill and injured children, which has its own research network (described below).
• Critical care, in which emergency physicians apply resuscitation skills in the intensive care unit.
• Disaster medicine and public health preparedness.
• Sports medicine and wilderness medicine, which draw on emergency skills in specific environments.
• Emergency ultrasound, the use of bedside imaging to answer focused clinical questions in real time.
• Medical toxicology, which overlaps with toxicology as a scientific field.

Other fields cover related ground: neurology for stroke and seizures, pulmonology for respiratory failure, and anesthesiology for airway and perioperative care. Emergency medicine differs from each in that it owns the first hours of the patient’s course rather than a single organ system or procedure.

A Brief History

Hospital emergency care was historically staffed by whoever was available, including rotating interns and on-call physicians from other specialties. Standard histories of the field describe a gradual move toward dedicated emergency physicians in the 1960s. The first emergency medicine residency in the United States is reported to have begun at the University of Cincinnati in 1970, and emergency medicine was recognized as a medical specialty by the American Board of Medical Specialties in 1979. Professional organizations, including the American College of Emergency Physicians, were central to winning that recognition. Readers who need exact dates for citation should confirm them against the primary records of ABEM and ACEP.

Why Emergency Research Is Different

Most clinical research begins with a conversation: a participant is told what the study involves, understands it and agrees. Emergency research often cannot work that way. A person in cardiac arrest, with a severe head injury or in profound shock cannot consent, a family member may be unreachable, and the treatment may need to be given within minutes to have any chance of working. If consent were required in every case, the most important emergency treatments could never be tested in the patients who need them.

Exception from informed consent under 21 CFR 50.24

In the United States, FDA regulations at 21 CFR 50.24 allow an institutional review board (IRB) to approve certain emergency studies without prospective informed consent. Our dictionary entry on exception from informed consent (EFIC) defines the concept, and 21 CFR Part 50 covers the wider regulation on protection of human subjects. The exception is narrow. Based on the text of the regulation, the IRB must find, among other things, that:

• the subjects are in a life-threatening situation in which available treatments are unproven or unsatisfactory, and the study is needed to collect valid scientific evidence;
• obtaining informed consent is not feasible, because the subjects cannot give it because of their medical condition, the intervention must begin before a representative could be reached, and eligible subjects cannot be identified in advance;
• participation holds out the prospect of direct benefit, supported by adequate preclinical and, where appropriate, clinical evidence, and the risks are reasonable in light of the condition and the alternatives; and
• the study could not practicably be carried out without the waiver.

The regulation adds protections beyond those findings. The protocol must define a therapeutic window within which investigators will try to contact a legally authorized representative; the IRB must approve an informed consent procedure to use when consent becomes feasible; and investigators must try to reach family members when a representative is unavailable, to give them the chance to object. For the representative question in ordinary research, see Legally Authorized Representative in Research Consent.

Community consultation and public disclosure

Because individual consent is replaced, the regulation substitutes community-level safeguards. The IRB is required to ensure consultation with representatives of the communities in which the study will take place and from which participants will be drawn, public disclosure of the study plan, risks and expected benefits before it begins, and public disclosure afterward of the demographics of those enrolled and the results. An independent data monitoring committee must oversee the study. Investigators must also ensure that participants, or their representatives or family, are told about enrollment at the earliest feasible opportunity. Records are kept for at least three years after completion and are available to FDA for inspection, and the study runs under a separate IND or IDE that identifies it as an exception-from-consent protocol.

Practical consequences for research administration

These requirements make emergency studies administratively heavy. Community consultation must be planned, budgeted and documented months before the first enrollment; multi-site trials need coordinated public disclosure; data monitoring committees must be constituted; and each site’s IRB must reach its own determination or rely on a reviewing IRB, a question explained in central IRB (single IRB) review. Teams should also understand the broader regulatory landscape, including the differences between FDA and HHS human-subjects rules summarized in 45 CFR 46 vs. 21 CFR 50, and the related but distinct tools of waiver of informed consent and informed consent in research. Studies of investigational products also need an IND where applicable, covered in the IND decision tree, and safety reporting follows serious adverse event rules. In the Common Rule world, 45 CFR 46 subparts add further protections for vulnerable groups, which matters in a field that regularly enrolls children and critically ill adults.

Research Networks and Funding

Multi-center networks

No single emergency department sees enough patients with a rare, time-critical condition to run a definitive trial alone, so emergency research relies on networks. The Pediatric Emergency Care Applied Research Network (PECARN) describes itself as dedicated to high-quality, multi-center research into the prevention and management of acute illnesses and injuries in children; its website states that it is supported by the Health Resources and Services Administration (HRSA) through an Emergency Medical Services for Children Data Center award, and that it operates through a network of research nodes working with HRSA’s Maternal and Child Health Bureau. In the adult setting, NIH has supported emergency-care clinical trial networks, among them the SIREN network; this guide does not describe its structure or funders in detail because those specifics were not confirmed from a primary source during preparation, and readers should consult the network’s own site.

Funders

Emergency research is funded by several federal agencies and by industry. NIH supports it through different institutes depending on the condition under study (for example, neurological, cardiovascular, injury or child health topics), HRSA supports pediatric emergency research infrastructure, and specialty societies and foundations offer career-development and pilot funding. SAEM, for example, states that it provides funding opportunities for research. For the application mechanics that apply across NIH awards, see the NIH data management and sharing plan guide. Because emergency trials are expensive per participant and often need large sample sizes, funders and institutions place particular weight on network infrastructure and shared data centers.

Common Research Methods

• Prospective multi-center trials that randomize patients in the field or in the emergency department, often under exception from informed consent.
• Cluster-randomized and pragmatic trials that randomize EMS agencies or hospitals rather than individuals, which can change how consent and community consultation work.
• Clinical decision rule derivation and validation, in which a rule is built on one cohort and tested on another, as with the imaging rules linked above. The accuracy of such rules depends on sampling, a point explored in spectrum bias in diagnostic accuracy studies.
• Observational and registry research using electronic health records, trauma and cardiac arrest registries and EMS data.
• Health services and implementation research on crowding, throughput, access, disparities and quality of care.
• Prehospital and disaster research, which faces its own challenges of data capture outside the hospital.

Societies, Journals and Certification

Societies

• American College of Emergency Physicians (ACEP) is the professional association for emergency physicians in the United States; its homepage emphasizes clinical policy, quality standards, advocacy and physician well-being.
• Society for Academic Emergency Medicine (SAEM) describes itself as the premier organization for high-quality research and educational innovation in emergency care, with an annual meeting, specialty academies and interest groups, and research funding opportunities.
• American Board of Emergency Medicine (ABEM) provides certification of emergency physicians and the subspecialty certificates noted above.

Journals

• Annals of Emergency Medicine and JACEP Open (published through ACEP).
• Academic Emergency Medicine and AEM Education and Training (published through SAEM).

Training Pathway

In the United States, an emergency physician completes medical school followed by an emergency medicine residency. Most programs are three years, though some are four, and combined residencies with other specialties exist. Graduates may then sit for ABEM certification and may pursue fellowships in areas such as toxicology, EMS, pediatric emergency medicine or critical care. Physician-scientists usually add research training, such as a fellowship or a funded career-development award. Training structures differ in other countries, so readers outside the US should consult their national college.

Frequently Asked Questions

What is emergency medicine in simple terms?

It is the specialty that evaluates and treats sudden illness and injury, stabilizing patients and deciding what happens next, in the emergency department and in the field.

What does an emergency physician do?

An emergency physician assesses undifferentiated patients, performs resuscitation and procedures, orders and interprets tests, treats the immediate problem, and arranges admission, discharge or transfer. Many also teach, supervise EMS systems or conduct research.

How can research be done on people who cannot consent?

In the US, 21 CFR 50.24 lets an IRB approve a narrow exception from informed consent for life-threatening emergencies, paired with community consultation, public disclosure and independent data monitoring. See the EFIC dictionary entry.

What is community consultation?

It is the process of engaging representatives of the community where an exception-from-consent study will occur, informing them of the plan and risks and gathering their views before the study starts, as the regulation requires.

What is PECARN?

PECARN is a multi-center research network for pediatric emergency care, supported through HRSA.

Is emergency medicine the same as urgent care or critical care?

No. Urgent care treats non-life-threatening problems that cannot wait for a routine appointment; critical care manages patients already admitted with organ failure. Emergency medicine covers the initial assessment and stabilization of the full range, and overlaps with both.

How long is emergency medicine residency?

Most US programs are three years, and some are four.

Related Guides

This guide is part of a series on scientific and medical disciplines from a research-administration perspective. See the overview of the branches of science and the companion guides What Is Anesthesiology?, What Is Pulmonology?, What Is Neurology?, What Is Pharmacology? and What Is Geriatrics?. For the regulatory side of emergency studies, see Humanitarian Use Device (HDE) IRB Approval.