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The 2019 Model of the Clinical Practice of Emergency Medicine

Open AccessPublished:May 28, 2020DOI:https://doi.org/10.1016/j.jemermed.2020.03.018
      Emergency Medicine has a scientifically derived and commonly accepted description of the domain of its clinical practice. That document, The Model of the Clinical Practice of Emergency Medicine (EM Model), was developed through the collaboration of six organizations: the American Board of Emergency Medicine (ABEM), the administrative organization for the project, the American College of Emergency Physicians (ACEP), the Council of Emergency Medicine Residency Directors (CORD), the Emergency Medicine Residents' Association (EMRA), the Residency Review Committee for Emergency Medicine (RRC-EM), and the Society for Academic Emergency Medicine (SAEM). Development of the EM Model was based on an extensive practice analysis of the specialty. The practice analysis relied on both empiric data gathered from actual emergency department visits and several expert panels (
      • Hockberger R.S.
      • LaDuca A.
      • Orr N.A.
      • et al.
      Creating the model of a clinical practice: the case of emergency medicine.
      ). The resulting product was first published in 2001, and has successfully served as the common source document for all emergency medicine organizations (
      Core Content Task Force II. The Model of the Clinical Practice of Emergency Medicine.
      ,
      Core Content Task Force II. The Model of the Clinical Practice of Emergency Medicine.
      ). One of its strengths is incorporating the reality that emergency medicine is a specialty driven by symptoms not diagnoses, requiring simultaneous therapeutic and diagnostic interventions.
      The task force that developed the EM Model recommended that a new task force, composed of representatives from all six organizations, be formed every 2 years to assess the success of the document in accomplishing its objective of supporting the ongoing development of the specialty of emergency medicine; to consider alterations to the EM Model suggested by the collaborating organizations; and to recommend changes to the six sponsoring organizations.
      The initial 2-year review occurred in 2003, with representatives from each of the six organizations suggesting changes and reporting how their respective organizations had used the document. The initial 2-year update was published in Annals of Emergency Medicine and Academic Emergency Medicine in 2005 (
      • Hockberger R.S.
      • Binder L.S.
      • Chisholm C.D.
      • et al.
      The Model of the Clinical Practice of Emergency Medicine: a 2-year update.
      ,
      • Hockberger R.S.
      • Binder L.S.
      • Chisholm C.D.
      • et al.
      The Model of the Clinical Practice of Emergency Medicine: a 2-year update.
      ). Subsequently, a task force met every 2 years to review the EM Model and recommend changes (
      • Thomas H.A.
      • Binder L.S.
      • Chapman D.M.
      • et al.
      The 2003 Model of the Clinical Practice of Emergency Medicine: the 2005 update.
      ,
      • Thomas H.A.
      • Binder L.S.
      • Chapman D.M.
      • et al.
      The 2003 Model of the Clinical Practice of Emergency Medicine: the 2005 update.
      ,
      • Thomas H.A.
      • Beeson M.S.
      • Binder L.S.
      • et al.
      The 2005 Model of the Clinical Practice of Emergency Medicine: the 2007 update.
      ,
      • Thomas H.A.
      • Beeson M.S.
      • Binder L.S.
      • et al.
      The 2005 Model of the Clinical Practice of Emergency Medicine: the 2007 update.
      ,
      • Perina D.G.
      • Beeson M.S.
      • Char D.M.
      • et al.
      The 2007 Model of the Clinical Practice of Emergency Medicine: the 2009 update.
      ,
      • Perina D.G.
      • Beeson M.S.
      • Char D.M.
      • et al.
      The 2007 Model of the Clinical Practice of Emergency Medicine: the 2009 update.
      ,
      • Perina D.G.
      • Brunett C.P.
      • Caro D.A.
      • et al.
      The 2011 Model of the Clinical Practice of Emergency Medicine.
      ,
      • Counselman F.L.
      • Borenstein M.A.
      • Chisholm C.D.
      • et al.
      The 2013 Model of the Clinical Practice of Emergency Medicine.
      ). In 2013, a seventh organization, the American Academy of Emergency Medicine (AAEM), was added as a collaborating organization. In 2014, the collaborating organizations made the decision to review the EM Model on a 3-year review cycle, beginning in 2016. The 2016 update was published in Journal of Emergency Medicine in 2017 (
      • Counselman F.L.
      • Babu K.
      • Edens M.A.
      • et al.
      The 2016 Model of the Clinical Practice of Emergency Medicine.
      ). In 2019, the AAAEM Resident and Student Association was added as an eighth collaborating organization.
      This article provides a brief review of the original EM Model, along with the changes to the EM Model as recommended by the 2019 EM Model Review Task Force. Significant changes occurred with the 2019 review, including the addition of oncologic emergencies in the newly renamed “Category 8, Hematologic and Oncologic Disorders.” A summary of all 2019 changes and an update on current uses of the EM Model by the seven collaborating EM organizations are also included in this article.

      The EM Model

      The EM Model is a three-dimensional description of EM clinical practice. The three dimensions are patient acuity; physician tasks; and a listing of medical knowledge, patient care, and procedural skills. All of these dimensions are interrelated and used concurrently by a physician when providing patient care. The emergency physician's initial approach is determined by the acuity of the patient's presentation. While assessing the patient, the physician completes a series of tasks in collecting information. Through this process, the physician is able to select the possible etiologies of the patient's problem from the listing of medical knowledge, patient care, and procedural skills. Through simultaneous application of all three components, the physician is able to determine the most probable diagnosis and implement a treatment plan for the patient. The three dimensions, as revised in 2019, are included in Table 1, Table 2, Table 3, Table 4.
      Table 1Matrix of Physician Tasks by Patient Acuity
      Physician TasksPatient Acuity
      CriticalEmergentLower Acuity
      Prehospital care

      Emergency stabilization

      Performance of focused history and physical examination

      Modifying factors

      Professional issues

      Legal issues

      Diagnostic studies

      Diagnosis

      Therapeutic interventions

      Pharmacotherapy

      Observation and reassessment

      Consultation

      Transitions of care

      Prevention and education

      Documentation

      Task switching/Multiple patient care

      Team management

      Mass casualty/Disaster management

      Patient-centered communication skills

      Prognosis
      Table 2Patient Acuity Definitions
      CriticalEmergentLower Acuity
      Patient presents with symptoms of a life-threatening illness or injury with a high probability of mortality if immediate intervention is not begun to prevent further airway, respiratory, hemodynamic, and/or neurologic instability.Patient presents with symptoms of an illness or injury that may progress in severity or result in complications with a high probability for morbidity if treatment is not begun quickly.Patient presents with symptoms of an illness or injury that have a low probability of progression to more serious disease or development of complications.
      Table 3Physician Task Definitions
      Physician TaskDefinition
      Prehospital careParticipate actively in prehospital care; provide direct patient care or on-line or off-line medical direction or interact with prehospital medical providers; assimilate information from prehospital care into the assessment and management of the patient.
      Emergency stabilizationConduct primary assessment and take appropriate steps to stabilize and treat patients.
      Performance of focused history and physical examinationEffectively interpret and evaluate the patient's symptoms and history; identify pertinent risk factors in the patient's history; provide a focused evaluation; interpret the patient's appearance, vital signs and condition; recognize pertinent physical findings; perform techniques required for conducting the examination.
      Modifying factorsRecognize age, gender, ethnicity, barriers to communication, socioeconomic status, underlying disease, gender identity, sexual orientation, and other factors that may affect patient management.
      Professional issuesUnderstand and apply principles of professionalism and ethics pertinent to patient management.
      Legal issuesUnderstand and apply legal concepts pertinent to the practice of emergency medicine.
      Diagnostic studiesSelect and perform the most appropriate diagnostic studies and interpret the results, e.g., electrocardiogram, emergency ultrasound, and radiographic and laboratory tests.
      DiagnosisDevelop a differential diagnosis and establish the most likely diagnosis in light of the history, physical, interventions, and test results.
      Therapeutic interventionsPerform procedures and nonpharmacologic therapies, and counsel.
      PharmacotherapySelect, prescribe, and be aware of adverse effects of appropriate pharmaceutical agents based on relevant considerations such as intended effect, financial considerations, possible adverse effects, patient preferences, institutional policies, and clinical guidelines; monitor and intervene in the event of adverse effects in the emergency department.
      Observation and reassessmentEvaluate and re-evaluate the effectiveness of a patient's treatment or therapy, including addressing complications and potential errors; monitor, observe, manage, and maintain the stability of one or more patients who are at different stages in their workups.
      ConsultationCollaborate with physicians and other professionals to help guide optimal management of patients.
      Transitions of careArrange for patient admission, discharge (including follow-up plan), observation, or transfer and transitions of care as appropriate, and communicate these arrangements effectively with patients, family, and involved health care team members.
      Prevention and educationApply epidemiologic information to patients at risk; conduct patient education; select appropriate disease and injury prevention, and harm reduction techniques.
      DocumentationCommunicate patient care information in a concise and appropriate manner that facilitates quality care. This includes documentation and medical decision-making variables related to billing, coding, and reimbursement for patient care.
      Task switching/Multiple patient carePrioritize and implement the evaluation and management of multiple patients in the emergency department, including handling interruptions and task-switching, in order to provide optimal patient care.
      Team managementCoordinate, educate, or supervise members of the patient management team and utilize appropriate hospital resources.
      Mass casualty/Disaster managementUnderstand and apply the principles of disaster and mass casualty management including preparedness, triage, mitigation, response, and recovery.
      Patient-centered communication skillsEstablish rapport with and demonstrate empathy toward patients and their families; listen effectively to patients and their families. Identify situations that require individualized communication, such as goals of care, end of life care, and palliative options.
      PrognosisForecast the likely outcome of a medical disease or traumatic condition.
      Table 4Medical Knowledge, Patient Care, and Procedural Skills
      1.0SIGNS, SYMPTOMS, AND PRESENTATIONS
      CriticalEmergentLower Acuity
      1.1Abnormal Vital Signs
       1.1.1 HypothermiaXXX
       1.1.2 FeverXXX
       1.1.3 BradycardiaXXX
       1.1.4 TachycardiaXX
       1.1.5 Bradypnea/ApneaXX
       1.1.6 TachypneaXX
       1.1.7 HypoxiaXX
       1.1.8 HypotensionXX
       1.1.9 HypertensionXXX
      1.2Pain
       1.2.1 Pain (unspecified)XXX
       1.2.2 Headache (See 12.3)XXX
       1.2.3 Eye painXX
       1.2.4 Chest painXXX
       1.2.5 Abdominal painXXX
       1.2.6 Pelvic and genital painXXX
       1.2.7 Back painXXX
       1.2.8 Chronic painX
       1.2.9 Extremity painXXX
       1.2.10 Neck painXXX
      1.3General
       1.3.1 Altered mental statusXXX
       1.3.2 Anuria/OliguriaX
       1.3.3 AscitesXX
       1.3.4 AtaxiaXX
       1.3.5 Auditory disturbancesX
       1.3.6 BleedingXXX
       1.3.7 Congestion/RhinorrheaX
       1.3.8 Constipation/ObstipationXX
       1.3.9 CoughXX
       1.3.10 Crying/FussinessXX
       1.3.11 CyanosisX
       1.3.12 DehydrationXX
       1.3.13 DiarrheaXX
       1.3.14 DysmenorrheaX
       1.3.15 DysphagiaXX
       1.3.16 DysuriaX
       1.3.17 EdemaXX
       1.3.18 Failure to thriveXX
       1.3.19 Fatigue/MalaiseXX
       1.3.20 Feeding problemsX
       1.3.21 HematemesisXX
       1.3.22 HematuriaXX
       1.3.23 HemoptysisXX
       1.3.24 HiccupX
       1.3.25 JaundiceX
       1.3.26 Joint swellingXX
       1.3.27 LethargyXXX
       1.3.28 Lightheadedness/DizzinessXX
       1.3.29 LimpXX
       1.3.30 LymphadenopathyX
       1.3.31 Mechanical and indwelling devices, complicationsXXX
       1.3.32 Nausea/VomitingXX
       1.3.33 Occupational exposureXX
       1.3.34 PalpitationsXXX
       1.3.35 ParalysisXX
       1.3.36 Paresthesia/DysesthesiaXX
       1.3.37 PoisoningXXX
       1.3.38 PruritusXX
       1.3.39 RashXXX
       1.3.40 Rectal bleedingXXX
       1.3.41 ShockX
       1.3.42 Shortness of breathXX
       1.3.43 Sore throatXX
       1.3.44 StridorXX
       1.3.45 Syncope/Near syncopeXXX
       1.3.46 TinnitusX
       1.3.47 TremorXX
       1.3.48 Urinary incontinenceX
       1.3.49 Urinary retentionX
       1.3.50 Vaginal bleedingXXX
       1.3.51 Vaginal dischargeX
       1.3.52 Visual disturbancesXX
       1.3.53 WeaknessXX
       1.3.54 WheezingXX
       1.3.55 ToxidromesXXX
       1.3.56 Sudden unexpected infant death (SUID)X
       1.3.57 Suicidal ideationXXX
       1.3.58 Brief resolved unexplained events (BRUE)XXX
       1.3.59 Intoxication syndromesXXX
       1.3.60 Postsurgical complicationsXXX
      2.0ABDOMINAL AND GASTROINTESTINAL DISORDERS
      CriticalEmergentLower Acuity
      2.1Abdominal Wall
       2.1.1 HerniasXX
       2.1.2 HematomaX
      2.2Esophagus
       2.2.1 Infectious disorders
      2.2.1.1 Candida (See 4.4.2.1, 7.4.6)XX
      2.2.1.2 Viral esophagitisXX
       2.2.2 Inflammatory disorders
      2.2.2.1 EsophagitisXX
      2.2.2.2 Gastroesophageal reflux (GERD)X
      2.2.2.3 Toxic effects of caustic agents (See 17.1.16.1)
      2.2.2.3.1 AcidXX
      2.2.2.3.2 AlkaliXX
       2.2.3 Motor abnormalities
       2.2.4 Structural disorders
      2.2.4.1 Boerhaave's syndromeXX
      2.2.4.2 DiverticulaXX
      2.2.4.3 Foreign bodyX
      2.2.4.4 HerniasXX
      2.2.4.5 Mallory-Weiss syndromeXX
      2.2.4.6 Stricture and stenosisXX
      2.2.4.7 Tracheoesophageal fistulaXX
      2.2.4.8 VaricesXX
       2.2.5 TumorsXX
      2.3Liver
       2.3.1 Noninfectious hepatitis/CirrhosisXX
      2.3.1.1 AlcoholicXX
      2.3.1.2 Biliary obstructiveX
      2.3.1.3 Drug-inducedXX
      2.3.1.4 Nonalcoholic steatohepatitis (NASH)X
       2.3.2 Hepatorenal failureXX
       2.3.3 Infectious disordersXX
      2.3.3.1 AbscessX
      2.3.3.2 HepatitisX
      2.3.3.3 PerihepatitisX
       2.3.4 TumorsXX
       2.3.5 Hepatic encephalopathyXX
      2.4Gallbladder and Biliary Tract
       2.4.1 CholangitisXX
       2.4.2 CholecystitisXX
       2.4.3 Cholelithiasis/CholedocholithiasisXX
       2.4.4 TumorsXX
      2.5Pancreas
       2.5.1 PancreatitisXX
       2.5.2 TumorsXX
       2.5.3 PseudocystX
      2.6Peritoneum
       2.6.1 Spontaneous bacterial peritonitisXX
       2.6.2 Abdominal compartment syndromeXX
      2.7Stomach
       2.7.1 Infectious disordersX
       2.7.2 Inflammatory disorders
      2.7.2.1 GastritisXX
       2.7.3 Peptic ulcer diseaseXX
      2.7.3.1 HemorrhageXX
      2.7.3.2 PerforationXX
       2.7.4 Structural disorders
      2.7.4.1 Congenital hypertrophic pyloric stenosisX
      2.7.4.2 Foreign bodyXX
       2.7.5 TumorsXX
       2.7.6 GastroparesisXX
       2.7.7 Cyclic vomiting syndrome (See 17.1.24.1.1)XX
      2.8Small Bowel
       2.8.1 Infectious disordersXX
       2.8.2 Inflammatory disorders
      2.8.1.1 Regional enteritis/Crohn's diseaseXX
      2.8.1.2 Gluten enteropathy/Celiac diseaseX
       2.8.3 Motor abnormalities
      2.8.3.1 ObstructionXX
      2.8.3.2 Paralytic ileusX
       2.8.4 Structural disorders
      2.8.4.1 Aortoenteric fistulaX
      2.8.4.2 Congenital anomaliesXX
      2.8.4.3 Intestinal malabsorptionXX
      2.8.4.4 Meckel's diverticulumXX
       2.8.5 TumorsXX
       2.8.6 Vascular insufficiencyXX
      2.9Large Bowel
       2.9.1 Infectious disorders
      2.9.1.1 Antibiotic-associatedX
      2.9.1.2 BacterialXX
      2.9.1.3 ParasiticXX
      2.9.1.4 ViralXX
       2.9.2 Inflammatory disorders
      2.9.2.1 AppendicitisX
      2.9.2.2 Necrotizing enterocolitis (NEC)XX
      2.9.2.3 Radiation colitisX
      2.9.2.4 Ulcerative colitisXX
      2.9.2.5 Neutropenic enterocolitis/TyphlitisXX
       2.9.3 Motor abnormalities
      2.9.3.1 Hirschsprung's diseaseXX
      2.9.3.2 Irritable bowelX
      2.9.3.3 ObstructionXX
       2.9.4 Structural disorders
      2.9.4.1 Congenital anomaliesXX
      2.9.4.2 DiverticulaXX
      2.9.4.3 IntussusceptionXX
      2.9.4.4 VolvulusXX
       2.9.5 TumorsXX
      2.10Rectum and Anus
       2.10.1 Infectious disorders
      2.10.1.1 Perianal/Anal abscessXX
      2.10.1.2 Perirectal abscessX
      2.10.1.3 Pilonidal cyst and abscessXX
       2.10.2 Inflammatory disorders
      2.10.2.1 ProctitisX
       2.10.3 Structural disorders
      2.10.3.1 Anal fissureX
      2.10.3.2 Anal fistulaXX
      2.10.3.3 Congenital anomaliesX
      2.10.3.4 Foreign bodyXX
      2.10.3.5 HemorrhoidsX
      2.10.3.6 Rectal prolapseX
       2.10.4 TumorsXX
      2.11Spleen
       2.11.1 AsplenismXX
       2.11.2 SplenomegalyX
       2.11.3 Vascular insufficiency/InfarctionXXX
      2.12Specific Post-surgical Populations
       2.12.1 Bariatric surgeryXXX
       2.12.2 OstomyXX
      3.0CARDIOVASCULAR DISORDERS
      CriticalEmergentLower Acuity
      3.1Cardiopulmonary ArrestX
      3.2Congenital Abnormalities of the Cardiovascular SystemXXX
       3.2.1 Tetralogy of Fallot spellsXX
       3.2.2 Patent ductus arteriosus-dependent congenital heart anomaliesXX
      3.3Disorders of Circulation
       3.3.1 Arterial
      3.3.1.1 AneurysmXXX
      3.3.1.2 DissectionX
      3.3.1.2.1 AorticXXX
      3.3.1.2.2 Non-aorticXXX
      3.3.1.3 ThromboembolismXX
       3.3.2 Venous
      3.3.2.1 Thromboembolism (See 16.6.2)XX
      3.4Disturbances of Cardiac Rhythm
       3.4.1 Cardiac dysrhythmiasXXX
      3.4.1.1 VentricularXX
      3.4.1.2 SupraventricularXXX
      3.4.1.3 Pulseless electrical activityX
       3.4.2 Conduction disordersXXX
      3.5Diseases of the Myocardium, Acquired
       3.5.1 Cardiac failureXX
      3.5.1.1 Cor pulmonaleXX
      3.5.1.2 High outputXX
      3.5.1.3 Low outputXX
       3.5.2 CardiomyopathyXXX
      3.5.2.1 HypertrophicXXX
      3.5.2.2 DilatedXXX
       3.5.3 Congestive heart failureXX
       3.5.4 Coronary syndromesXX
       3.5.5 Ischemic heart diseaseXX
       3.5.6 Myocardial infarctionXX
       3.5.7 MyocarditisXXX
       3.5.8 Ventricular aneurysmXXX
      3.6Diseases of the Pericardium
       3.6.1 Pericardial tamponade (See 18.1.2.6)XX
       3.6.2 PericarditisXX
      3.7HypertensionXXX
       3.7.1 Asymptomatic hypertensionX
       3.7.2 Hypertensive emergencyXX
      3.8TumorsXX
      3.9Valvular DisordersXXX
       3.9.1 EndocarditisXX
      3.10Cardiovascular Devices
       3.10.1 Pacemaker/Automatic implantable cardioverter-defibrillator (AICD)XXX
       3.10.2 Left ventricular assist device (LVAD)XXX
      4.0CUTANEOUS DISORDERS
      CriticalEmergentLower Acuity
      4.1Cancers of the Skin
       4.1.1 Basal cellX
       4.1.2 Kaposi's sarcomaX
       4.1.3 MelanomaX
       4.1.4 Squamous cellX
      4.2Ulcerative Lesions
       4.2.1 DecubitusXX
       4.2.2 Venous stasisX
       4.2.3 Diabetic foot ulcersXX
      4.3Dermatitis
       4.3.1 Atopic/EczemaX
       4.3.2 ContactX
       4.3.3 PsoriasisX
       4.3.4 SeborrheaX
      4.4Infections
       4.4.1 Bacterial
      4.4.1.1 AbscessXX
      4.4.1.2 CellulitisXX
      4.4.1.3 ErysipelasX
      4.4.1.4 ImpetigoX
      4.4.1.5 Necrotizing infectionXX
       4.4.2 Fungal
      4.4.2.1 Candida (See 2.2.1.1, 7.4.6)X
      4.4.2.2 DermatophytesX
       4.4.3 EctoparasitesX
       4.4.4 Viral
      4.4.4.1 Aphthous ulcersX
      4.4.4.2 Childhood exanthems (See 10.6.8, 10.6.9)X
      4.4.4.3 Herpetic infections (See 10.6.4, 10.6.5, 13.1.3.1)XX
      4.4.4.4 Human papillomavirus (HPV) (See 13.1.3.2)X
      4.4.4.5 Molluscum contagiosumX
      4.5Maculopapular Lesions
       4.5.1 Erythema multiformeXX
       4.5.2 Pityriasis roseaX
       4.5.3 UrticariaXX
       4.5.4 Drug eruptionsXX
      4.6Papular/Nodular Lesions
       4.6.1 Hemangioma/LymphangiomaX
       4.6.2 LipomaX
       4.6.3 Sebaceous cystX
       4.6.4 Erythema nodosumX
      4.7Vesicular/Bullous Lesions
       4.7.1 PemphigusX
       4.7.2 Staphylococcal scalded skin syndromeXX
       4.7.3 Stevens-Johnson syndromeXX
       4.7.4 Toxic epidermal necrolysisXX
       4.7.5 Bullous pemphigoidXX
      4.8Purpuric RashXXX
       4.8.1 Henoch-Schӧnlein purpura (HSP)X
      5.0ENDOCRINE, METABOLIC, AND NUTRITIONAL DISORDERS
      CriticalEmergentLower Acuity
      5.1Acid–base Disturbances
       5.1.1 Metabolic or respiratory
      5.1.1.1 AcidosisXX
      5.1.1.2 AlkalosisXXX
       5.1.2 Mixed acid–base balance disorderXX
      5.2Adrenal Disease
       5.2.1 Corticoadrenal insufficiencyXX
       5.2.2 Cushing's syndromeXX
      5.3Fluid and Electrolyte Disturbances
       5.3.1 Calcium metabolismXXX
       5.3.2 Hypervolemia/HypovolemiaXXX
       5.3.3 Potassium metabolismXXX
       5.3.4 Sodium metabolismXXX
       5.3.5 Magnesium metabolismXX
       5.3.6 Phosphorus metabolismXX
      5.4Glucose Metabolism
       5.4.1 Diabetes mellitusXXX
      5.4.1.1 Complications in glucose metabolism
      5.4.1.1.1 HyperglycemiaXX
      5.4.1.1.2 Diabetic ketoacidosis (DKA)XXX
      5.4.1.1.3 Hyperosmolar hyperglycemic stateXX
      5.4.1.1.4 HypoglycemiaXX
      5.5Nutritional Disorders
       5.5.1 Vitamin deficienciesX
       5.5.2 Wernicke-Korsakoff syndromeX
       5.5.3 MalabsorptionXX
       5.5.4 MalnutritionXX
      5.6Parathyroid DiseaseXX
      5.7Pituitary DisordersXX
       5.7.1 PanhypopituitarismX
      5.8Thyroid Disorders
       5.8.1 HyperthyroidismXXX
       5.8.2 HypothyroidismXXX
       5.8.3 ThyroiditisXX
       5.8.4 Thyroid stormXX
      5.9Tumors of Endocrine Glands
       5.9.1 AdrenalXX
      5.9.1.1 PheochromocytomaXX
       5.9.2 PituitaryXX
       5.9.3 ThyroidXX
      6.0ENVIRONMENTAL DISORDERS
      CriticalEmergentLower Acuity
      6.1Bites and Envenomation (See 18.1.3.2)
       6.1.1 ArthropodsXX
      6.1.1.1 InsectsX
      6.1.1.2 ArachnidsXX
       6.1.2 MammalsXX
       6.1.3 Marine organisms (See 17.1.20)XXX
       6.1.4 ReptilesXXX
      6.2Dysbarism
       6.2.1 Air embolismXX
       6.2.2 BarotraumaXXX
       6.2.3 Decompression syndromeXX
      6.3Electrical Injury (See 18.1.3.3.1)XXX
       6.3.1 LightningXX
      6.4High-altitude Illness
       6.4.1 Acute mountain sicknessXX
       6.4.2 High-altitude cerebral edemaXX
       6.4.3 High-altitude pulmonary edemaXX
      6.5Submersion IncidentsXXX
      6.6Temperature-related Illness
       6.6.1 HeatXXX
       6.6.2 ColdXXX
      6.6.2.1 FrostbiteXX
      6.6.2.2 HypothermiaXX
      6.7Radiation EmergenciesXXX
      7.0HEAD, EAR, EYE, NOSE, THROAT DISORDERS
      CriticalEmergentLower Acuity
      7.1Ear
       7.1.1 Foreign bodyXX
      7.1.1.1 Impacted cerumenX
       7.1.2 LabyrinthitisX
       7.1.3 MastoiditisX
       7.1.4 Ménière's diseaseX
       7.1.5 Otitis externaX
      7.1.5.1 InfectiveX
      7.1.5.1.1 MalignantX
       7.1.6 Otitis mediaXX
       7.1.7 Perforated tympanic membrane (See 18.1.11.2)X
       7.1.8 PerichondritisXX
      7.2Eye
       7.2.1 External eye
      7.2.1.1 Burn confined to eye (See 18.1.10.2)X
      7.2.1.2 ConjunctivitisX
      7.2.1.3 Corneal abrasions (See 18.1.10.1)XX
      7.2.1.4 Disorders of lacrimal systemXX
      7.2.1.5 Foreign bodyXX
      7.2.1.6 Disorders of the eyelidsX
      7.2.1.7 KeratitisXX
       7.2.2 Anterior pole
      7.2.2.1 GlaucomaXX
      7.2.2.2 Hyphema (See 18.1.10.5)XX
      7.2.2.3 Iritis (See 18.1.10.8)XX
      7.2.2.4 HypopyonX
       7.2.3 Posterior pole
      7.2.3.1 Choroiditis/ChorioretinitisX
      7.2.3.2 Optic neuritisX
      7.2.3.3 PapilledemaXX
      7.2.3.4 Retinal detachments and defects (See 18.1.10.7)X
      7.2.3.5 Retinal vascular occlusionX
       7.2.4 Orbit
      7.2.4.1 Cellulitis
      7.2.4.1.1 PreseptalX
      7.2.4.1.2 Septal/OrbitalX
      7.2.4.2 EndophthalmitisX
      7.3Nose
       7.3.1 EpistaxisXXX
       7.3.2 Foreign bodyXX
       7.3.3 RhinitisX
       7.3.4 SinusitisX
      7.4Oropharynx/Throat
       7.4.1 DentalgiaX
       7.4.2 Diseases of the oral soft tissue
      7.4.2.1 Ludwig's anginaXX
      7.4.2.2 StomatitisX
      7.4.2.3 Gingival and periodontal disordersXX
      7.4.2.4 Odontogenic infections/AbscessesXX
       7.4.3 Diseases of the salivary glands
      7.4.3.1 SialolithiasisXX
      7.4.3.2 Suppurative parotitisX
       7.4.4 Foreign bodyXX
       7.4.5 Larynx/Trachea
      7.4.5.1 Epiglottitis (See 16.1.1.2)XX
      7.4.5.2 LaryngitisX
      7.4.5.3 TracheitisXX
      7.4.5.4 Tracheostomy complicationsXXX
       7.4.6 Oral candidiasis (See 2.2.1.1, 4.4.2.1)X
       7.4.7 Peritonsillar abscessX
       7.4.8 Pharyngitis/TonsillitisX
       7.4.9 Retropharyngeal abscessXX
       7.4.10 Temporomandibular joint disordersX
      7.5TumorsXXX
      8.0HEMATOLOGIC AND ONCOLOGIC DISORDERS
      CriticalEmergentLower Acuity
      8.1Blood Transfusion
       8.1.1 ComplicationsXX
      8.2Hemostatic Disorders
       8.2.1 Coagulation defectsXXX
      8.2.1.1 AcquiredXXX
      8.2.1.2 HemophiliasXXX
      8.2.1.3 Anticoagulation agentsXXX
       8.2.2 Disseminated intravascular coagulationX
       8.2.3 Platelet disordersXXX
      8.2.3.1 ThrombocytopeniaXX
      8.2.3.2 Idiopathic thrombocytopenic purpuraXXX
      8.2.3.3 Thrombotic thrombocytopenic purpuraXX
      8.3LymphomasXX
      8.4PancytopeniaXX
      8.5Red Blood Cell Disorders
       8.5.1 Anemias
      8.5.1.1 AplasticXX
      8.5.1.2 HemoglobinopathiesXX
      8.5.1.2.1 Sickle cell anemiaXXX
      8.5.1.2.2 ThalassemiaXX
      8.5.1.3 HemolyticX
      8.5.1.4 Hypochromic
      8.5.1.4.1 Iron deficiencyXX
      8.5.1.5 MegaloblasticXX
       8.5.2 PolycythemiaXX
       8.5.3 Methemoglobinemia (See 17.1.21)XX
      8.6White Blood Cell Disorders
       8.6.1 LeukemiaXX
       8.6.2 Multiple myelomaXX
       8.6.3 LeukopeniaXX
      8.7Oncologic EmergenciesXXX
       8.7.1 Febrile neutropeniaXXX
       8.7.2 Hypercalcemia of malignancyXXX
       8.7.3 Hyperviscosity syndromeXXX
       8.7.4 Malignant pericardial effusionXXX
       8.7.5 Spinal cord compression (See 12.10)XX
       8.7.6 Superior vena cava syndromeXX
       8.7.7 Tumor hemorrhageXXX
       8.7.8 Tumor lysis syndromeXX
      9.0IMMUNE SYSTEM DISORDERS
      CriticalEmergentLower Acuity
      9.1Collagen Vascular Disease
       9.1.1 Raynaud's diseaseX
       9.1.2 Reactive arthritis (See 11.3.1.6)XX
       9.1.3 Rheumatoid arthritis (See 11.3.1.3)XX
       9.1.4 SclerodermaXX
       9.1.5 Systemic lupus erythematosusXX
       9.1.6 VasculitisXX
      9.2Hypersensitivity
       9.2.1 Allergic reactionXX
       9.2.2 AnaphylaxisX
       9.2.3 AngioedemaXX
       9.2.4 Drug allergiesXXX
      9.3Transplant-related ProblemsXXX
       9.3.1 ImmunosuppressionXX
       9.3.2 RejectionXX
      9.4Immune Complex DisordersX
       9.4.1 Mucocutaneous lymph node syndrome (Kawasaki syndrome)XX
       9.4.2 Rheumatic feverXX
       9.4.3 SarcoidosisXX
       9.4.4 Post-streptococcal glomerulonephritis (See 15.3.1)X
      9.5Medication-induced ImmunosuppressionXX
       9.5.1 Chemotherapeutic agentsXX
       9.5.2 SteroidsXX
       9.5.3 Targeted immune modulatorsXX
      10.0SYSTEMIC INFECTIOUS DISORDERS
      CriticalEmergentLower Acuity
      10.1Bacterial
       10.1.1 Bacterial food poisoningXX
      10.1.1.1 BotulismXX
       10.1.2 ChlamydiaXX
       10.1.3 GonococcusXX
       10.1.4 MeningococcusXX
       10.1.5 Mycobacterium
      10.1.5.1 Atypical mycobacteriaXX
      10.1.5.2 TuberculosisXX
       10.1.6 Other bacterial diseasesXX
      10.1.6.1 Gas gangrene (See 11.6.3)XX
       10.1.7 Sepsis/BacteremiaXX
      10.1.7.1 ShockX
      10.1.7.2 Toxic shock syndromeXX
       10.1.8 Spirochetes
      10.1.8.1 SyphilisXX
       10.1.9 TetanusXX
      10.2Biological Warfare AgentsXX
      10.3Fungal InfectionsXX
      10.4Protozoan/Parasites
       10.4.1 MalariaX
       10.4.2 ToxoplasmosisXX
      10.5Tick-borne
       10.5.1 Anaplasmosis (Ehrlichiosis)X
       10.5.2 Lyme diseaseX
       10.5.3 Rocky Mountain spotted feverX
       10.5.4 BabesiosisX
      10.6ViralXX
       10.6.1 Infectious mononucleosisXX
       10.6.2 Influenza/ParainfluenzaXX
       10.6.3 ArbovirusXXX
       10.6.4 Herpes simplex (See 4.4.4.3, 13.1.3.1)XX
       10.6.5 Herpes zoster/Varicella (See 4.4.4.3)XX
       10.6.6 HIV/AIDSXXX
       10.6.7 RabiesX
       10.6.8 Roseola (See 4.4.4.2)X
       10.6.9 Rubella (See 4.4.4.2)X
       10.6.10 MeaslesXXX
       10.6.11 Mumps (Paramyxovirus)XX
      10.7Emerging Infections/PandemicsXXX
      10.8Drug ResistanceXXX
      11.0MUSCULOSKELETAL DISORDERS (NONTRAUMATIC)
      CriticalEmergentLower Acuity
      11.1Bony Abnormalities
       11.1.1 Aseptic/Avascular necrosisXX
       11.1.2 OsteomyelitisX
       11.1.3 TumorsXX
       11.1.4 Atypical fracturesXX
      11.1.4.1 OsteoporoticXX
      11.1.4.2 Tumor-relatedXX
      11.1.4.3 Congenital disordersXX
      11.2Disorders of the Spine
       11.2.1 Disc disordersXX
       11.2.2 Inflammatory/Infectious spondylopathiesXX
       11.2.3 Radiculopathy (See 12.7.3)XX
       11.2.4 Spinal stenosisXX
       11.2.5 Cervical painXXX
       11.2.6 Thoracic painXXX
       11.2.7 Lumbosacral painXXX
      11.2.7.1 Cauda equina syndrome (See 18.1.15.1)XX
      11.2.7.2 SacroiliitisX
      11.2.7.3 SciaticaXX
       11.2.8 DiscitisXX
      11.3Joint Abnormalities
       11.3.1 Arthritis
      11.3.1.1 SepticX
      11.3.1.2 Crystal arthropathiesXX
      11.3.1.3 Rheumatoid (See 9.1.3)X
      11.3.1.4 JuvenileX
      11.3.1.5 OsteoarthrosisX
      11.3.1.6 Reactive arthritis (See 9.1.2)XX
       11.3.2 Developmental dysplasia of the hipXX
       11.3.3 Slipped capital femoral epiphysisX
       11.3.4 SynovitisXX
      11.4Muscle Abnormalities
       11.4.1 MyositisX
       11.4.2 RhabdomyolysisXX
      11.5Overuse Syndromes
       11.5.1 BursitisX
       11.5.2 Muscle strainsX
       11.5.3 Peripheral nerve syndromeX
      11.5.3.1 Carpal tunnel syndromeX
       11.5.4 TendinopathyX
       11.5.5 Stress reaction fractureXX
      11.6Soft Tissue Infections
       11.6.1 FasciitisXXX
       11.6.2 FelonX
       11.6.3 Gangrene (See 10.1.6.1)XX
       11.6.4 ParonychiaXX
       11.6.5 TenosynovitisXX
      12.0NERVOUS SYSTEM DISORDERS
      CriticalEmergentLower Acuity
      12.1Cranial Nerve DisordersX
       12.1.1 Idiopathic facial nerve paralysis (Bell's palsy)X
       12.1.2 Trigeminal neuralgiaX
      12.2Demyelinating DisordersXX
       12.2.1 Multiple sclerosisXX
      12.3Headache (See 1.2.2)XXX
       12.3.1 TensionX
       12.3.2 VascularXX
       12.3.3 ClusterXX
      12.4HydrocephalusXX
       12.4.1 Normal pressureXX
       12.4.2 Shunt complicationsX
      12.5Infections/Inflammatory Disorders
       12.5.1 EncephalitisXX
       12.5.2 Intracranial and intraspinal abscessXX
       12.5.3 Meningitis
      12.5.3.1 BacterialXX
      12.5.3.2 ViralXXX
      12.5.3.3 FungalXXX
       12.5.4 MyelitisX
      12.5.4.1 Acute flaccid myelitisX
       12.5.5 NeuritisX
      12.6Movement DisordersXX
       12.6.1 Dystonic reactionXX
       12.6.2 Chorea/ChoreiformX
       12.6.3 Tardive dyskinesiaX
      12.7Neuromuscular Disorders
       12.7.1 Guillain-Barré syndromeXX
       12.7.2 Myasthenia gravisXXX
       12.7.3 Peripheral neuropathy (See 11.2.3)X
      12.8Other Conditions of the Brain
       12.8.1 Dementia (See 14.5.2)X
       12.8.2 Parkinson's diseaseX
       12.8.3 Idiopathic intracranial hypertensionXX
       12.8.4 Cerebral venous sinus thrombosisXXX
       12.8.5 Posterior reversible encephalopathy syndrome (PRES)XX
       12.8.6 Transient global amnesiaX
      12.9Seizure Disorders
       12.9.1 EpileptiformXXX
      12.9.1.1 NeonatalXX
      12.9.1.2 FebrileXXX
      12.9.1.3 Status epilepticusX
      12.9.1.4 NonconvulsiveacXX
      12.9.1.5 Drug-inducedXX
       12.9.2 NonepileptiformX
      12.10Spinal Cord Compression (See 8.7.5)XX
      12.11Stroke
       12.11.1 Hemorrhagic
      12.11.1.1 IntracerebralXX
      12.11.1.2 SubarachnoidXX
       12.11.2 Ischemic
      12.11.2.1 EmbolicXX
      12.11.2.2 ThromboticXX
      12.12Transient Cerebral IschemiaXX
      12.13TumorsXXX
      12.14DeliriumXXX
       12.14.1 Excited delirium syndromeXX
      13.0OBSTETRICS AND GYNECOLOGY
      CriticalEmergentLower Acuity
      13.1Female Genital Tract
       13.1.1 Cervix
      13.1.1.1 Cervicitis and endocervicitisXX
      13.1.1.2 TumorsX
       13.1.2 Infectious disorders
      13.1.2.1 Pelvic inflammatory diseaseX
      13.1.2.1.1 Fitz-Hugh-Curtis syndromeX
      13.1.2.1.2 Tuboovarian abscessX
      13.1.2.2 UrethritisX
      13.1.2.3 Gangrene of perineumXX
       13.1.3 Lesions
      13.1.3.1 Herpes simplex (See 4.4.4.3, 10.6.4)X
      13.1.3.2 Human papillomavirus (HPV) (See 4.4.4.4)X
       13.1.4 Ovary
      13.1.4.1 CystX
      13.1.4.2 TorsionX
      13.1.4.3 TumorsXX
       13.1.5 Uterus
      13.1.5.1 Abnormal bleedingXX
      13.1.5.2 EndometriosisX
      13.1.5.3 ProlapseX
      13.1.5.4 TumorsXX
      13.1.5.4.1 Gestational trophoblastic diseaseX
      13.1.5.4.2 LeiomyomaX
       13.1.6 Vagina and vulva
      13.1.6.1 Bartholin's cystXX
      13.1.6.2 Foreign bodyXX
      13.1.6.3 Vaginitis/VulvovaginitisX
      13.2Normal PregnancyX
      13.3Complications of Pregnancy
       13.3.1 AbortionX
       13.3.2 Ectopic pregnancyXX
       13.3.3 Hemolysis, elevated liver enzymes, low platelets (HELLP) syndromeXX
       13.3.4 Hemorrhage, antepartum
      13.3.4.1 Abruptio placentae (See 18.2.1)XX
      13.3.4.2 Placenta previaXX
       13.3.5 Hyperemesis gravidarumXX
       13.3.6 Gestational hypertensionXX
      13.3.6.1 EclampsiaXX
      13.3.6.2 PreeclampsiaX
       13.3.7 InfectionsX
       13.3.8 Rh isoimmunizationX
       13.3.9 First trimester bleedingXXX
       13.3.10 Gestational diabetesXX
      13.4High-risk PregnancyXX
       13.4.1 Assisted reproductive therapiesXXX
       13.4.2 Pre-existing medical problemsXXX
      13.5Normal Labor and DeliveryXX
      13.6Complications of Labor
       13.6.1 Fetal distressX
       13.6.2 Premature labor (See 18.2.3)X
       13.6.3 Premature rupture of membranesX
       13.6.4 Rupture of uterus (See 18.2.4)X
      13.7Complications of Delivery
       13.7.1 Malposition of fetusXX
       13.7.2 Nuchal cordX
       13.7.3 Prolapse of cordX
       13.7.4 Amniotic fluid embolismXX
      13.8Postpartum Complications
       13.8.1 EndometritisX
       13.8.2 HemorrhageXX
       13.8.3 MastitisXX
       13.8.4 Pituitary infarctionXX
      13.9ContraceptionXX
      14.0PSYCHOBEHAVIORAL DISORDERS
      CriticalEmergentLower Acuity
      14.1Substance Use Disorders
       14.1.1 Alcohol use disorder (See 17.1.1)XXX
       14.1.2 Illicit drug useXXX
       14.1.3 Prescription drug useXXX
      14.1.3.1 Drug diversionX
       14.1.4 Tobacco use disorderX
       14.1.5 Withdrawal syndromesXXX
       14.1.6 Opioid use disorder (17.1.2.3)XXX
       14.1.7 Stimulant use disorderXXX
       14.1.8 Medication-assisted treatment (MAT)XX
      14.2Mood Disorders and Thought Disorders
       14.2.1 Acute psychosisXX
       14.2.2 Bipolar disorderXX
       14.2.3 DepressionXX
      14.2.3.1 Suicidal riskXX
       14.2.4 Grief reactionX
       14.2.5 SchizophreniaXX
      14.3Factitious DisordersXX
      14.4Neurotic Disorders
       14.4.1 Anxiety/PanicX
       14.4.2 Obsessive compulsiveX
       14.4.3 PhobicX
       14.4.4 Post-traumatic stressX
      14.5Organic Psychoses
       14.5.1 Chronic organic psychotic conditionsX
      14.5.1.1 Alcoholic psychosesXX
      14.5.1.2 Drug psychosesXX
       14.5.2 Dementia (See 12.8.1)X
      14.6Patterns of Violence/Abuse/Neglect
       14.6.1 Interpersonal violence
      14.6.1.1 ChildXXX
      14.6.1.2 Intimate partnerXXX
      14.6.1.3 ElderXXX
       14.6.2 Homicidal RiskXX
       14.6.3 Sexual assaultX
       14.6.4 Staff/Patient safetyX
       14.6.5 Human traffickingXX
      14.7Personality DisordersX
      14.8Psychosomatic Disorders
       14.8.1 HypochondriasisX
       14.8.2 Hysteria/ConversionX
      14.9Feeding and Eating DisordersXXX
      15.0RENAL AND UROGENITAL DISORDERS
      CriticalEmergentLower Acuity
      15.1Acute and Chronic Renal FailureXXX
      15.2Complications of DialysisXX
       15.2.1 VascularXXX
       15.2.2 PeritonealXXX
      15.3Glomerular Disorders
       15.3.1 Glomerulonephritis (See 9.4.4)XX
       15.3.2 Nephrotic syndromeXX
      15.4Infection
       15.4.1 CystitisX
       15.4.2 PyelonephritisX
       15.4.3 Asymptomatic bacteriuriaX
      15.5Male Genital Tract
       15.5.1 Genital lesionsX
       15.5.2 HerniasXX
       15.5.3 Inflammation/Infection
      15.5.3.1 Balanitis/BalanoposthitisXX
      15.5.3.2 Epididymitis/OrchitisXX
      15.5.3.3 Gangrene of the perineum (Fournier's gangrene)XX
      15.5.3.4 ProstatitisXX
      15.5.3.5 UrethritisX
       15.5.4 Structural
      15.5.4.1 Paraphimosis/PhimosisX
      15.5.4.2 PriapismX
      15.5.4.2.1 Medication inducedXX
      15.5.4.3 Prostatic hypertrophy (BPH)X
      15.5.4.4 TorsionX
       15.5.5 Testicular massesX
      15.6NephritisXX
       15.6.1 Hemolytic uremic syndromeX
      15.7Structural Disorders
       15.7.1 Calculus of urinary tractXX
       15.7.2 Obstructive uropathyXX
       15.7.3 Polycystic kidney diseaseX
      15.8TumorsX
      16.0THORACIC-RESPIRATORY DISORDERS
      CriticalEmergentLower Acuity
      16.1Acute Upper Airway Disorders
       16.1.1 Infections
      16.1.1.1 CroupX
      16.1.1.2 Epiglottitis (See 7.4.5.1)XX
       16.1.2 Obstruction/Foreign body (See 16.4.7)X
      16.2Disorders of Pleura, Mediastinum, and Chest Wall
       16.2.1 CostochondritisX
       16.2.2 MediastinitisXX
       16.2.3 Pleural effusionXX
       16.2.4 PleuritisX
       16.2.5 PneumomediastinumX
       16.2.6 Pneumothorax (See 18.1.2.7)
      16.2.6.1 SimpleX
      16.2.6.2 TensionX
      16.2.6.3 OpenX
       16.2.7 EmpyemaXX
      16.3Acute Respiratory Distress SyndromeXX
      16.4Obstructive/Restrictive Lung Disease
       16.4.1 Asthma/Reactive airway diseaseXX
       16.4.2 Bronchitis and bronchiolitisXX
       16.4.3 Bronchopulmonary dysplasiaXX
       16.4.4 Chronic obstructive pulmonary diseaseXXX
       16.4.5 Cystic fibrosisXXX
       16.4.6 Environmental/Industrial exposureXXX
       16.4.7 Foreign body (See 16.1.2)XX
      16.5Physical and Chemical Irritants/Insults
       16.5.1 PneumoconiosisXX
       16.5.2 Toxic effects of gases, fumes, vapors (See 18.1.3.3.2)XXX
      16.6Pulmonary Embolism/Infarct
       16.6.1 Septic emboliXX
       16.6.2 Venous thromboembolism (See 3.3.2.1)XXX
      16.6.2.1 Massive and submassive embolismXX
       16.6.3 Fat emboliXX
      16.7Pulmonary Infections
       16.7.1 Lung abscessX
       16.7.2 Pneumonia
      16.7.2.1 AspirationXX
      16.7.2.2 Community-acquiredXXX
      16.7.2.3 Hospital-acquired pneumoniaXXX
      16.7.2.4 PneumocystisXXX
       16.7.3 Pulmonary tuberculosisX
       16.7.4 Respiratory syncytial virus (RSV)XXX
       16.7.5 PertussisXXX
      16.8Tumors
       16.8.1 BreastX
       16.8.2 PulmonaryXX
      16.9Pulmonary HypertensionXXX
      17.0TOXICOLOGIC DISORDERS
      CriticalEmergentLower Acuity
      17.1Drug and Chemical Classes
       17.1.1 Alcohol (See 14.1.1)
      17.1.1.1 EthanolXXX
      17.1.1.2 Ethylene glycolXX
      17.1.1.3 IsopropylXXX
      17.1.1.4 MethanolXX
       17.1.2 Analgesics
      17.1.2.1 AcetaminophenXX
      17.1.2.2 Nonsteroidal anti-inflammatories (NSAIDS)XX
      17.1.2.3 Opioids (See 14.1.6)XX
      17.1.2.4 SalicylatesXX
       17.1.3 AnticholinergicsXX
      17.1.3.1 AntihistaminesX
       17.1.4 Anticoagulants/Antithrombotics/AntiplateletsXX
      17.1.4.1 Direct thrombin inhibitorsX
      17.1.4.2 Factor Xa inhibitorsX
      17.1.4.3 HeparinsXX
      17.1.4.4 Vitamin K antagonistsXX
       17.1.5 AnticonvulsantsXX
       17.1.6 AntidepressantsXX
      17.1.6.1 BupropionX
      17.1.6.2 Selective serotonin reuptake inhibitorsXX
      17.1.6.3 Tricyclic antidepressantsXX
       17.1.7 AntiemeticsX
       17.1.8 Antimicrobials
      17.1.8.1 AntibioticsXX
      17.1.8.1.1 IsoniazidXX
      17.1.8.2 AntimalarialsXXX
      17.1.8.3 AntiretroviralsXXX
       17.1.9 AntipsychoticsXX
       17.1.10 Carbon monoxideXX
       17.1.11 Cardiovascular drugs
      17.1.11.1 AntidysrhythmicsXX
      17.1.11.1.1 DigoxinXX
      17.1.11.2 AntihypertensivesXX
      17.1.11.2.1 Central actingXX
      17.1.11.2.2 Peripheral ActingXX
      17.1.11.3 Beta blockersXX
      17.1.11.4 Calcium channel blockersXX
       17.1.12 CholinergicsXX
      17.1.12.1 Nerve agentsXX
      17.1.12.2 OrganophosphatesXX
       17.1.13 Cyanides, hydrogen sulfideXX
       17.1.14 Heavy metalsXX
       17.1.15 Herbicides, insecticides, and rodenticidesXX
       17.1.16 Household/Industrial chemicalsXXX
      17.1.16.1 Caustic agents (See 2.2.2.3)XX
      17.1.16.2 HydrocarbonsXX
      17.1.16.3 Inhaled irritantsXX
       17.1.17 Hypoglycemics/InsulinXX
       17.1.18 LithiumXXX
       17.1.19 Local anestheticsXX
       17.1.20 Marine toxins (See 6.1.3)XXX
       17.1.21 Methemoglobinemia (See 8.5.3)XX
       17.1.22 Mushrooms/Poisonous plantsXX
       17.1.23 Nutritional supplementsXX
      17.1.23.1 IronXX
      17.1.23.2 Performance enhancing and weight-loss drugsXXX
       17.1.24 Recreational drugsXXX
      17.1.24.1 CannabisX
      17.1.24.1.1 Cannabinoid hyperemesis syndrome/Cyclic vomiting (See 2.7.7)X
      17.1.24.2 Synthetic cannabinoidsXXX
      17.1.24.3 HallucinogensXXX
      17.1.24.4 GHBXXX
       17.1.25 Sedatives/HypnoticsXX
       17.1.26 Stimulants/SympathomimeticsXX
      17.1.26.1 AmphetaminesXX
      17.1.26.2 CocaineXXX
      18.0TRAUMATIC DISORDERS
      CriticalEmergentLower Acuity
      18.1Trauma
       18.1.1 Abdominal trauma
      18.1.1.1 DiaphragmXX
      18.1.1.2 Hollow viscusXX
      18.1.1.3 PenetratingXX
      18.1.1.4 RetroperitoneumXX
      18.1.1.5 Solid organXX
      18.1.1.6 VascularXX
      18.1.1.7 Abdominal wallXX
       18.1.2 Thoracic trauma
      18.1.2.1 Aortic dissection/DisruptionX
      18.1.2.2 Contusion
      18.1.2.2.1 CardiacXXX
      18.1.2.2.2 PulmonaryXX
      18.1.2.3 Fracture
      18.1.2.3.1 ClavicleXX
      18.1.2.3.2 Ribs/Flail chestXXX
      18.1.2.3.3 SternumXX
      18.1.2.3.4 ScapulaXX
      18.1.2.4 HemothoraxXX
      18.1.2.5 Penetrating chest traumaXX
      18.1.2.6 Pericardial tamponade (See 3.6.1)X
      18.1.2.7 Pneumothorax (See 16.2.6)
      18.1.2.7.1 SimpleX
      18.1.2.7.2 TensionX
      18.1.2.7.3 OpenX
       18.1.3 Cutaneous trauma
      18.1.3.1 AvulsionsXX
      18.1.3.2 Bite wounds (See 6.1)XX
      18.1.3.3 Burns
      18.1.3.3.1 Electrical (See 6.3)XXX
      18.1.3.3.2 Chemical (See 16.5.2)XXX
      18.1.3.3.3 ThermalXXX
      18.1.3.4 LacerationsXX
      18.1.3.5 Puncture woundsXX
      18.1.3.6 Nail injuriesX
       18.1.4 Facial traumaX
      18.1.4.1 DentalXX
      18.1.4.2 Le FortXXX
      18.1.4.3 MandibularXX
      18.1.4.4 OrbitalXX
      18.1.4.5 NasalX
      18.1.4.5.1 Septal hematomaX
      18.1.4.6 Zygomaticomaxillary complexX
       18.1.5 Genitourinary trauma
      18.1.5.1 BladderX
      18.1.5.2 External genitaliaX
      18.1.5.3 RenalXX
      18.1.5.4 UreteralX
      18.1.5.5 UrethralXX
       18.1.6 Head trauma
      18.1.6.1 Intracranial injuryXX
      18.1.6.1.1 ConcussionXX
      18.1.6.1.2 Intracranial hemorrhageXX
      18.1.6.2 Scalp lacerations/AvulsionsXX
      18.1.6.3 Skull fracturesXX
       18.1.7 Spine trauma
      18.1.7.1 Dislocations/SubluxationsXX
      18.1.7.2 FracturesXXX
      18.1.7.3 Sprains/StrainsX
       18.1.8 Extremity bony trauma
      18.1.8.1 Dislocations/SubluxationsX
      18.1.8.2 Fractures (open and closed)XX
       18.1.9 Neck trauma
      18.1.9.1 Laryngotracheal injuriesXX
      18.1.9.2 Penetrating neck traumaXX
      18.1.9.3 Vascular injuriesXX
      18.1.9.4 StrangulationXXX
       18.1.10 Ophthalmologic trauma
      18.1.10.1 Corneal abrasions/Lacerations (See 7.2.1.3)XX
      18.1.10.2 Corneal burns (See 7.2.1.1)
      18.1.10.2.1 AcidX
      18.1.10.2.2 AlkaliX
      18.1.10.2.3 UltravioletXX
      18.1.10.3 Periorbital lacerationsX
      18.1.10.3.1 EyelidX
      18.1.10.3.2 Lacrimal ductX
      18.1.10.4 Foreign body (See 19.4.4.8)X
      18.1.10.5 Hyphema (See 7.2.2.2)X
      18.1.10.6 Penetrating globe injuriesX
      18.1.10.7 Retinal detachments (See 7.2.3.4)X
      18.1.10.8 Traumatic iritis (See 7.2.2.3)XX
      18.1.10.9 Retrobulbar hematomaX
       18.1.11 Otologic trauma
      18.1.11.1 HematomaXX
      18.1.11.2 Perforated tympanic membrane (See 7.1.7)X
       18.1.12 Pediatric fractures
      18.1.12.1 EpiphysealXX
      18.1.12.1.1 Salter-Harris classificationXX
      18.1.12.2 GreenstickX
      18.1.12.3 TorusX
      18.1.12.4 Apophyseal avulsionX
       18.1.13 Pelvic fractureXX
       18.1.14 Soft-tissue extremity injuries
      18.1.14.1 Amputations/ReplantationX
      18.1.14.2 Compartment syndromesX
      18.1.14.3 High-pressure injectionX
      18.1.14.4 Injuries to jointsXX
      18.1.14.5 Penetrating traumaXX
      18.1.14.6 PeriarticularX
      18.1.14.7 Sprains/StrainsX
      18.1.14.8 Tendon injuries
      18.1.14.8.1 Lacerations/TransectionsX
      18.1.14.8.2 RupturesXX
      18.1.14.9 Vascular injuriesXX
       18.1.15 Spinal cord and nervous system trauma
      18.1.15.1 Cauda equina syndrome (See 11.2.7.1)XX
      18.1.15.2 Injury to nerve rootsXX
      18.1.15.3 Peripheral nerve injuryXX
      18.1.15.4 Spinal cord injuryXXX
      18.1.15.4.1 Spinal cord injury without radiologic abnormality (SCIWORA)X
      18.2Trauma in Pregnancy
       18.2.1 Abruptio placentae (See 13.3.4.1)XX
       18.2.2 Resuscitative hysterotomy (See 19.4.8.2)X
       18.2.3 Premature labor (See 13.6.2)X
       18.2.4 Rupture of uterus (See 13.6.4)X
      18.3Multi-system TraumaXX
       18.3.1 Blast injuryXX
       18.3.2 FallsXXX
       18.3.3 Motor vehicle collisionXXX
       18.3.4 AssaultXXX
      19.0PROCEDURES AND SKILLS INTEGRAL TO THE PRACTICE OF EMERGENCY MEDICINE
      19.1Airway Techniques
       19.1.1 Intubation
       19.1.2 Airway adjuncts
       19.1.3 Surgical airway
       19.1.4 Mechanical ventilation
       19.1.5 Noninvasive ventilatory management
       19.1.6 Ventilatory monitoring
      19.2Resuscitation
       19.2.1 Cardiopulmonary resuscitation
       19.2.2 Neonatal resuscitation
       19.2.3 Pediatric resuscitation
       19.2.4 Post-resuscitative care
      19.2.4.1 Therapeutic hypothermia (or targeted temperature management)
       19.2.5 Blood, fluid, and component therapy
       19.2.6 Arterial catheter insertion
       19.2.7 Central venous access
       19.2.8 Intraosseous line placement
       19.2.9 Defibrillation
       19.2.10 Thoracotomy
       19.2.11 Extracorporeal membrane oxygenation (ECMO)
       19.2.12 Thermoregulation procedures
      19.3Anesthesia and Acute Pain Management
       19.3.1 Regional anesthesia
       19.3.2 Procedural sedation
       19.3.3 Analgesia
      19.4Diagnostic and Therapeutic Procedures
       19.4.1 Abdominal and gastrointestinal
      19.4.1.1 Anoscopy
      19.4.1.2 Excision of thrombosed hemorrhoid
      19.4.1.3 Gastrostomy tube replacement
      19.4.1.4 Nasogastric tube
      19.4.1.5 Paracentesis
      19.4.1.6 Mechanical control of upper gastrointestinal bleeding
       19.4.2 Cardiovascular and Thoracic
      19.4.2.1 Cardiac pacing
      19.4.2.2 Cardioversion
      19.4.2.3 ECG interpretation
      19.4.2.4 Pericardiocentesis
      19.4.2.5 Thoracentesis
      19.4.2.6 Thoracostomy
       19.4.3 Cutaneous
      19.4.3.1 Escharotomy
      19.4.3.2 Incision and drainage
      19.4.3.3 Trephination, nails
      19.4.3.4 Wound closure techniques
      19.4.3.5 Wound management
       19.4.4 Head, ear, eye, nose, and throat
      19.4.4.1 Control of epistaxis
      19.4.4.2 Drainage of peritonsillar abscess
      19.4.4.3 Laryngoscopy
      19.4.4.4 Lateral canthotomy
      19.4.4.5 Slit lamp examination
      19.4.4.6 Tonometry
      19.4.4.7 Tooth stabilization
      19.4.4.8 Corneal foreign body removal (See 18.1.10.4)
      19.4.4.9 Drainage of hematoma
       19.4.5 Systemic infectious
      19.4.5.1 Personal protection (equipment and techniques)
      19.4.5.2 Universal precautions and exposure management
       19.4.6 Musculoskeletal
      19.4.6.1 Arthrocentesis
      19.4.6.2 Compartment pressure measurement
      19.4.6.3 Fracture/Dislocation immobilization techniques
      19.4.6.4 Fracture/Dislocation reduction techniques
      19.4.6.5 Spine immobilization techniques
      19.4.6.6 Fasciotomy
       19.4.7 Nervous system
      19.4.7.1 Lumbar puncture
       19.4.8 Obstetrics and gynecology
      19.4.8.1 Delivery of newborn
      19.4.8.2 Resuscitative hysterotomy (See 18.2.2)
      19.4.8.3 Sexual assault examination
       19.4.9 Psychobehavioral
      19.4.9.1 Psychiatric screening examination
      19.4.9.2 Violent patient management/Restraint
       19.4.10 Renal and urogenital
      19.4.10.1 Bladder catheterization
      19.4.10.1.1 Urethral catheter
      19.4.10.1.2 Suprapubic catheter
      19.4.10.2 Cystourethrogram
      19.4.10.3 Testicular detorsion
       19.4.11 Toxicologic
      19.4.11.1 Decontamination
      19.4.11.2 Antidote administration
      19.5Ultrasound
       19.5.1 Diagnostic ultrasound
       19.5.2 Procedural ultrasound
      19.6Other Diagnostic and Therapeutic Procedures
       19.6.1 Foreign body removal
       19.6.2 Collection and handling of forensic material
      20.0OTHER CORE COMPETENCIES OF THE PRACTICE OF EMERGENCY MEDICINE
      20.1Interpersonal and Communication Skills
       20.1.1 Interpersonal skills
      20.1.1.1 Inter-departmental and medical staff relations
      20.1.1.2 Intra-departmental relations, teamwork, and collaboration skills
      20.1.1.3 Patient and family experience of care
       20.1.2 Communication skills
      20.1.2.1 Complaint management and service recovery
      20.1.2.2 Conflict management
      20.1.2.3 Crisis resource management
      20.1.2.4 Delivering bad news/Death notifications
      20.1.2.5 Cultural competency
      20.1.2.6 Negotiation skills
      20.1.2.7 Management of patient expectations
      20.2Practice-based Learning and Improvement
       20.2.1 Performance improvement and lifelong learning
      20.2.1.1 Evidence-based medicine
      20.2.1.2 Interpretation of medical literature
      20.2.1.3 Knowledge translation
      20.2.1.4 Patient safety and medical errors
      20.2.1.5 Performance evaluation and feedback
      20.2.1.6 Research
       20.2.2 Practice guidelines
       20.2.3 Education
      20.2.3.1 Patient and family
      20.2.3.2 Provider
       20.2.4 Principles of quality improvement
      20.3Professionalism
       20.3.1 Advocacy
      20.3.1.1 Patient
      20.3.1.2 Professional
      20.3.1.3 Healthcare disparities
       20.3.2 Ethical principles
      20.3.2.1 Conflicts of interest
      20.3.2.2 Diversity and inclusion awareness
      20.3.2.3 Electronic communications/Social media
      20.3.2.4 Medical ethics
      20.3.2.5 Stewardship of resources
      20.3.2.6 Care of vulnerable populations
       20.3.3 Leadership and management principles
       20.3.4 Well-being and resilience
      20.3.4.1 Fatigue and impairment
      20.3.4.1.1 Sleep hygiene
      20.3.4.2 Time management/Organizational skills
      20.3.4.3 Work/Life balance
      20.3.4.4 Work dysphoria (burn-out)
      20.3.4.5 Job and contract evaluation
      20.3.4.6 Care for the caregiver
      20.4Systems-based Practice
       20.4.1 Clinical informatics
      20.4.1.1 Computerized order entry
      20.4.1.2 Clinical decision support
      20.4.1.3 Electronic health record
      20.4.1.4 Health information exchange and interoperability
       20.4.2 ED Administration
      20.4.2.1 Contracts and practice models
      20.4.2.2 Patient flow and throughput
      20.4.2.2.1 Patient triage and classification
      20.4.2.2.2 Hospital crowding and diversion
      20.4.2.2.3 Observation and rapid treatment units
      20.4.2.3 Financial principles
      20.4.2.3.1 Billing and coding
      20.4.2.3.2 Cost-effective care and resource utilization
      20.4.2.3.3 Reimbursement issues
      20.4.2.4 Human resource management
      20.4.2.4.1 Allied health professionals
      20.4.2.4.2 Recruitment, credentialing, and orientation
      20.4.2.4.3 Staffing/Scheduling
      20.4.2.5 Emergency preparedness
       20.4.3 ED operations
      20.4.3.1 Policies and procedures
      20.4.3.2 ED data acquisition and operational metrics
      20.4.3.3 Safety, security, and violence in the ED
      20.4.3.4 Patient satisfaction
       20.4.4 Health care coordination
      20.4.4.1 Advance directives
      20.4.4.2 Palliative care
      20.4.4.2.1 Patient identification for palliative care
      20.4.4.2.2 Withdrawal of support
      20.4.4.2.3 Hospice referral
      20.4.4.3 Placement options
      20.4.4.3.1 Activities of daily living/Functional assessment
      20.4.4.4 Outpatient services
      20.4.4.5 Organ donation
       20.4.5 Regulatory/Legal
      20.4.5.1 Accreditation
      20.4.5.2 Compliance and reporting requirements
      20.4.5.3 Confidentiality and privacy
      20.4.5.4 Consent, capacity, and refusal of care
      20.4.5.5 Emergency Medical Treatment and Active Labor Act (EMTALA)
      20.4.5.6 External quality metrics
      20.4.5.7 Good Samaritan emergency care
       20.4.6 Risk management
      20.4.6.1 Liability and litigation
      20.4.6.2 Professional liability insurance
      20.4.6.3 Risk mitigation
      20.4.6.4 Error disclosure
      20.4.6.5 Root cause analysis
       20.4.7 Evolving trends in health care delivery
      20.4.7.1 Public policy
      20.4.7.2 Gender identity and sexual orientation
      20.4.7.2.1 Transgender care
      20.4.7.3 Social determinants of health
      20.4.7.4 Firearm injury prevention
       20.4.8 Regionalization of emergency care
      ED = emergency department.
      The Accreditation Council for Graduate Medical Education (ACGME) requires each specialty to develop outcomes-based milestones for resident performance within the six general (core) competencies (i.e., patient care, medical knowledge, practice-based learning and improvement, interpersonal skills, professionalism, and system-based practice). The six general competencies are an integral part of the practice of emergency medicine and are embedded in the EM Model (
      • Chapman D.M.
      • Hayden S.
      • Sanders A.B.
      • et al.
      Integrating the Accreditation Council for Graduate Medical Education Core Competencies into the Model of the Clinical Practice of Emergency Medicine.
      ,
      • Chapman D.M.
      • Hayden S.
      • Sanders A.B.
      • et al.
      Integrating the Accreditation Council for Graduate Medical Education Core Competencies into the Model of the Clinical Practice of Emergency Medicine.
      ). The EM Model is closely aligned with the general competencies, using section headings with similar terminology.
      The EM Model is designed for use as the core document for the specialty. It provides the foundation for developing medical school and residency curricula; certification examination specifications; continuing education objectives; research agendas; residency program review requirements; and other documents necessary for the definition, skills acquisition, assessment, and practice of the specialty. In conjunction with the EM Model, these six general competencies construct a framework for evaluation of physician performance and curriculum design to further refine and improve the education and training of competent emergency physicians. The six competencies and the EM Model also form the core of ABEM's continuing certification process. For further information on this process see ABEM's website (www.abem.org/).

      Changes in the EM Model

      The 2019 EM Model Review Task Force met to consider changes based on input received from the seven collaborating organizations. Each organization was asked to comment on how it uses the EM Model, identify changes in practice or updated evidence, and recommend changes in the document that would address any deficiencies. The changes recommended by the 2019 EM Model Review Task Force and accepted by the seven organizations can be found in the Appendix.

      Current Uses of the EM Model

      AAEM

      AAEM uses the EM Model as a reference document to identify topics for annual conference programming.

      ABEM

      ABEM uses the EM Model to define its examination specifications. Each question or structured case used in any ABEM examination is referenced to the EM Model. Every test and examination that ABEM develops is based on a blueprint derived directly from the EM Model.

      ACEP

      ACEP uses the EM Model primarily as the basis for its educational activities. In addition, the ACEP Academic Affairs Committee uses the EM Model to align programming with academic educational needs. This information is used to develop a comprehensive list of web-based educational resources that can be incorporated into residency curricula.

      CORD and the RRC-EM

      The integration of the competencies into the EM Model meets the program requirements of the RRC-EM that the six core competencies are included in residency training. The EM Model is a major tool for CORD and Emergency Medicine program faculty to use when integrating the competencies into the training, residency curricula, and evaluation of residents.

      EMRA

      EMRA uses the EM Model as a reference document to identify content at risk for testing on the in-training and certification examinations.

      SAEM

      SAEM uses the EM Model as a reference document to identify topics and plan programming.
      In summary, the EM Model is accomplishing the intended purposes for which it was developed. The 2019 review of the EM Model resulted in significant changes and clarifications, including the addition of an oncology section within Category 8, Hematologic and Oncologic Disorders. Several emergency medicine organizations are using the EM Model to support the ongoing development of the specialty of emergency medicine. The complete updated 2019 EM Model can be found on the websites of each of the eight collaborating organizations.

      Acknowledgments

      The 2019 Model of the Clinical Practice of Emergency Medicine is used with permission of the American Academy of Emergency Medicine, the American Board of Emergency Medicine, the American College of Emergency Physicians, the Council of Emergency Medicine Residency Directors, the Emergency Medicine Residents' Association, the Residency Review Committee for Emergency Medicine, and the Society for Academic Emergency Medicine, copyright 2020.

      Supplementary Data

      References

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