Emergency medicine demands quick decision making

 The doors of the casualty department in Hämeenlinna have been designed in a way that allows the care team to meet the patient at the door and to start the treatment immediately. Photograph: Ari Palomäki.

The doors of the casualty department in Hämeenlinna have been designed in a way that allows the care team to meet the patient at the door and to start the treatment immediately. Photograph: Ari Palomäki.

Emergency medicine is the latest medical speciality in Finland, but it is already of a high international standard. Patients with acute conditions are now receiving enhanced treatment that is organised better than ever before.

“When several patients simultaneously come to an emergency department (ED), emergency medicine specialists get the big picture and know how to prioritise the patients’ treatment to ensure their medical needs are attended to in the right order,” explains Professor Ari Palomäki.

At present, Palomäki, who works at the University of Tampere, holds the only chair in emergency medicine in Finland. Another professor will be appointed at the University of Helsinki later this year.

“Emergency medicine is a speciality whose practitioners both do clinical work and organise it. This field entails not only everyday organisation, but organisation on a wider scale.”

Caption 1: “The treatment of stroke is one topic in which we conduct research, because we can save more time and brain cells and rescue people from permanent paralysis and death,” says Ari Palomäki, professor of emergency medicine. Photograph: Jonne Renvall.

“The treatment of stroke is one topic in which we conduct research, because we can save more time and brain cells and rescue people from permanent paralysis and death,” says Ari Palomäki, professor of emergency medicine.

Palomäki’s work in emergency medicine began in 2002 with the start of the merger process of Kanta-Häme Central Hospital’s emergency department and three out-of-hours primary health care practices.

Five years later, a new emergency department was built in Hämeenlinna and Palomäki became its clinical director.

“We were not the first in Finland, but ours was the first ED to genuinely join together primary and secondary care,” Palomäki says.

In 2012, the government decided that emergency medicine would become the next medical speciality in Finland and that the training would start the following year. Palomäki and Veli-Pekka Harjola designed the training, which takes roughly six years to complete after the Licentiate of Medicine degree, and submitted their proposal to a working group appointed by Finnish universities.

During the transition period, seventy medical specialists fulfilling certain criteria – Palomäki among them – took an exam qualifying them as specialists in emergency medicine.

“About fifteen years ago, it was still customary to place the most inexperienced doctors in the front line of emergency medicine without proper support from their superiors. Our goal is now to get senior emergency physicians to work together with doctors who are specialising in surgery, internal medicine and emergency medicine,” Palomäki explains.

He predicts that within five years, a new era will dawn at the top clinics.

“Specialising physicians will work together with medical specialists and clinical directors who organise the education and administration. Because of the new medical speciality, the clinics will become real knowledge hubs.”

Important patient groups in EDs in Finland include people who break bones on icy pavements, patients with stomach or chest pain, patients with atrial fibrillation and other arrhythmias, and stroke patients for whom every minute of care counts.

“Emergency medicine requires a hands-on attitude; the doctors must be able to think on their feet and get down to business. Another plus is an ability to stay awake, because the work is often done in the night-time,” Palomäki explains.

“In addition, the doctors must grasp the big picture, organise the day-to-day of patient care and think about how the care systems work as a whole. Of course, the doctors also need to have a healthy interest in their own speciality, be highly motivated and love what they are doing.”

Many of the practices used have been updated at the emergency department in Hämeenlinna where Palomäki still works as the clinical director.

For example, the responsibility for the care of stroke patients has largely been transferred to emergency physicians.

“After the first three months following the organisational change in Hämeenlinna, the median time for starting the thrombolysis treatment of stroke patients was twenty minutes. We have since then been able to shave a couple more minutes off the interval before the treatment is administered. We are now almost even with Helsinki University Hospital, which is number one in the world in the treatment process of stroke patients and which has a separate on-call neurology ring for commencing thrombolysis treatments.”

Low-risk appendicitis patients come to the ED, and after their operations, they are placed in an observational unit instead of a regular ward. They are then discharged if all goes well.

“Sometimes we can adjust the care process on emergency medical terms, sometimes on surgical, internal medical, or neurological terms, but it’s best when we implement such adjustments together. The patients benefit from this approach and we also save hospital resources. For example, the beds can be given to other patients so that they can be placed in proper rooms and not in extra beds or in the corridors.”

The doctors in the ED in Hämeenlinna are also actively involved in research.

“The first study on the treatment of stroke patients is already under review and the next two studies are being written as we speak. These findings will result in at least five international research articles,” Palomäki says.
Palomäki also studies the functioning of emergency care, improvements to the processes of on call duty, changes in the care practices and costs of emergency departments, and the application of new technology in emergency medicine.

There are only few international publications in some of these fields.

“Improving the processes of ED as a whole had been researched in Finland even before this speciality was established, but we will not be able to take major leaps forward until we have more senior know-how in the front line,” Palomäki says.

Finland is the world leader in how quickly the thrombolysis treatment of stroke patients can be started, and it also seems likely that the country will attain the top international position in emergency medicine as a whole. Experts in international contexts have been astonished by Palomäki’s reports on how rapidly the field has developed here.

“The central hospitals in Hämeenlinna and Jyväskylä have taken this medical speciality the furthest. Apart from Turku, they were the first hospitals to start the training in emergency medicine.”

The seventy medical specialists who took the emergency medicine test are now mainly working as chief physicians, and they simultaneously train new specialists in the field.

The first emergency medicine specialist, Teemu Koivistoinen, graduated from the University of Tampere in February 2016. Besides working as a clinician, he is now teaching trainees of emergency medicine in Hämeenlinna and completing his doctoral dissertation in medicine and technological sciences at the two universities in Tampere.

In emergency medicine, 140 students have signed up for the training, which will include both theoretical studies and practical work at an emergency department. In Hämeenlinna, the training also includes a scientific module.

“When we started training the specialists, we took it as our starting point that the training should be of a top quality and that each doctor graduating from our programme must work on at least one scientific journal article,” Palomäki says.

“Science is not an entity working in isolation. When our practitioners undertake at least a little bit of research themselves, they are more able to read the scientific articles on which our daily work is based. As they possess the ability to read research critically, they will not follow all the false leads; instead they are able to implement treatments that are grounded on sound research without undue delays.”

Text: Pirjo Achté
Photographs: Jonne Renvall and Ari Palomäki