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A career in emergency medicine
  1. Dan Chan

Abstract

Despite unsociable hours, an unpredictable workload, coping with stressful situations and having to face difficult ethical dilemmas, working in emergency care is nevertheless gratifying, explains Dan Chan, who has worked in this field for 14 years

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IT is difficult to say exactly why a career in emergency medicine appealed to me, but an interest became a passion relatively early in my training – probably in my second year at veterinary school. Perhaps it was the buzz of the television show ‘ER’, but when I discovered that there was a specialty in veterinary emergency and critical care, I decided then that this was the right path for me. I found a student chapter of the Veterinary Emergency and Critical Care Society at college (Cornell University) and began my quest to pursue this specialty. As a final-year veterinary student, I did extra emergency shifts on clinical rotations, but knew that I needed to go elsewhere to truly experience what veterinary emergency medicine had to offer. So I arranged externships at other renowned emergency centres, namely the Animal Medical Center in New York City, the Uni-versity of Pennsylvania, Tufts University and Colorado State University. During those 12 weeks, I saw an incredible variety of cases and met amazing people. I knew then that there was no other path for me. Dan Chan is senior lecturer in emergency and critical care and clinical nutritionist at the Royal Veterinary College, London

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Following graduation, I embarked on a one-year rotating internship at the Animal Medical Center. The ‘AMC’ – one of the largest and busiest small animal hospitals in the world, with a caseload of over 65,000 cases per year – showed me that it wasn't advanced equipment that made emergency medicine possible, it was the team. Despite the pace, the long hours and the endless cases, one couldn't help but to flow with the energy of the place. It was with this enthusiasm and thirst for more that I then began a residency in emergency and critical care the following year at Tufts University's Small Animal Veterinary Teaching Hospital in 1999.

The semi-rural setting of Tufts was a bit misleading as there were over 8000 small animal emergencies seen per year. This (normally) three-year advanced specialist training programme led to my certification as a diplomate of the American College of Veterinary Emergency and Critical Care (ACVECC). I stayed on as a faculty member for two years before moving to the Royal Veterinary College (RVC) as a lecturer in emergency and critical care in 2005.

Appeal of emergency and critical care

From the outset, I knew that focusing on emergency medicine would be challenging, demanding, stressful and, yet at the same time, exciting and gratifying. The sense that I am saving lives and ‘making a difference’ may sound a bit clichéd, but to this day, it is what I find most gratifying about doing emergency and critical care work.

Some people like to refer to emergency vets as ‘adrenaline junkies’. I have never seen myself this way, but I am known to run across our campus to attend to an arresting patient from time to time. It's not really the stress or intensity of situations that appeals to me; rather, it's about being part of an efficient team that works together to diffuse stressful situations. The satisfaction comes in the aftermath of dealing with very critical patients. Emergency work requires you to think on your feet; it forces you to continually reassess the situation and makes you focus on the patient, not the disease.

Many will be surprised to hear that critical care medicine is actually quite distinct from emergency medicine in many respects. Although there are stressful situations, it generally requires a bit more patience, as recovery of very critically ill patients can take a long time. Because the nature of critical care revolves around constant monitoring and frequent interventions, it does rely more on special equipment, facilities and personnel (such as a team of great veterinary nurses). While emergency medicine frequently involves responding to changes in the patient, critical care is about anticipating and preventing complications. The commonalities between the two specialties centre on the emphasis on serial physical examinations and responding rapidly to the patient's needs. The satisfaction that comes from doing emergency and critical care work is very much linked with the knowledge that our interventions help a great many patients. And even in those patients that we cannot save, satisfaction comes from knowing that we have tried our best.

Another exciting aspect of emergency and critical care is that it is a dynamic and rapidly advancing field. Innovation and medical advancements are core aspects of this specialty, and veterinary surgeons wanting to work in this field must constantly refine and acquire new skills and knowledge. We also look very closely at advances in human medicine, particularly as it pertains to our patients, and consider whether there are any possible applications to what we could offer.

Challenges

The immediate challenges for veterinary surgeons wanting to pursue emergency and critical care medicine as a career involve the unsociable hours required for this line of work, the unpredictable workload, the high exposure to stressful situations and frequently facing difficult ethical dilemmas. The latter can be very taxing, as in many cases there are no clear guidelines to help veterinary surgeons make difficult ethical decisions. Because of the severe degree of illness in many of our patients, veterinary surgeons devoted to this line of work often spend a lot of time worrying and agonising over their unstable patients, and continue to worry after completing their shift. There is a real risk of burn-out for vets who work exclusively in this area, and steps must to be taken to ensure that individuals are well supported and prepared to continue in this line of work.

Training opportunities

The good news is that there are now many opportunities and options for vets who are keen to work in this area. Additional training qualifications range from certificates (for example, the RCVS certificate in advanced clinical practice with emphasis on emergency and critical care), to diploma-level qualifications following a residency or senior clinical training scholarship.

Additionally, exclusive emergency medicine service providers, such as Vets Now, offer intensive on-the-job training (Vets Now's ‘Cutting Edge’ programme), which may be undertaken before joining as an associate vet. Individuals who are interested in diploma or specialist qualifications can enrol in senior clinical training scholarships in this field. The RVC is the largest emergency and critical care specialist training centre in Europe, and one of the largest in the world. Currently, the training programme has five scholars (residents) and four diplomates of the ACVECC. This three-year intensive clinical programme includes a Master's degree (MVetMed), provides scholars with advanced clinical training, exposes them to clinical research training and prepares them for the certification process. The RVC has produced 10 ACVECC diplomates since the programme was introduced in 2002.

The future

It is an exciting time for veterinary emergency and critical care in the UK. There has been significant growth in interest in these areas of veterinary medicine, with the development of training programmes and additional referral centres with emergency and critical care specialists.

Critical care centres, such as the RVC, already lead the way in offering advanced and innovative therapies such as mechanical ventilation, peritoneal dialysis and plasmapheresis, and soon it will also offer continuous renal replacement therapy. Development of the European College of Veterinary Emergency and Critical Care in the next few years may provide further opportunities for those interested in joining this dynamic area of veterinary medicine.

Further information

▪ RCVS modular certificate in advanced veterinary practice: www.rcvs.org.uk/education/postgraduate-education-for-veterinary-surgeons/modular-certificates/

▪ ACVECC: www.acvecc.org

▪ European Veterinary Emergency and Critical Care Society: www.eveccs.org

▪ Senior clinical training scholarship in emergency and critical care, Royal Veterinary College: www.rvc.ac.uk/Postgraduate/CTS/emergency.cfm

▪ Vets Now Cutting Edge Programme: www.vets-now.com/vets/career-opportunities/cutting-edge/

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