Requirements

Minimum Requirements for Certification of Veterinary Emergency and Critical Care Facilities (effective 1/1/17)

The Veterinary Emergency and Critical Care Society (VECCS) advocates that the following building standards and infrastructure, staffing, equipment, supplies, and medical records, and references are the minimum requirements for all Levels (I-III) of Veterinary Emergency and Critical Care Facilities. These minimum requirements allow veterinary emergency and critical care facilities to identify themselves, using a certification process endorsed by VECCS.  The certification process is intended to raise the standard of care, in accordance with the Vision Statement of the Society, and increase public and professional awareness in the area of veterinary emergency and critical patient care.

PART 1: OPERATIONS OVERVIEW FOR A VETERINARY EMERGENCY FACILITY

Staffing

  1. A licensed DVM, VMD, or BVSc, dedicated exclusively to the practice of emergency and critical care medicine, must be on the premises during operating hours.
  2. A working relationship with a DACVR (onsite or via the Internet) for the review of diagnostic images when necessary.
  3. It is required (Level I), and recommended (Level II and III), that there be at least one licensed veterinarian on duty at all times with at least 2 years of practice experience, OR one year in a rotating internship and currently in a focused E/CC internship, or a first year resident, OR a first year intern after 5 months in a focused E/CC internship.
  4. A DACVECC employed full time (required for Level I certification).
  5. Effective January 1, 2017, it is required that there be at least one credentialed Veterinary Technician Specialist (Emergency and Critical Care) on the staff, or one credentialed technician eligible and in a documented training program for VTS-ECC certification on the staff (Level I).
  6. At least 2 certified technicians employed full time. (Levels I, II, and III, in states that offer technician licensing or certification).
  7. There must be sufficient other staff available and trained to provide expedient patient care and allow:
    • Processing of multiple patients concurrently
    • Performance of a wide range of life saving procedures to include, but not be limited to, cardiopulmonary resuscitation in accordance with current RECOVER guidelines, and emergency surgery. This requires a minimum of two people. One must be a veterinarian and the other may be a veterinary technician or trained assistant.
    • The ability to call in additional staff as needed.
    • Provision of timely and appropriate in-hospital care.
    • Timely and appropriate consultation with veterinary specialists via phone or Internet.

Medical Records

  1. A complete, accurate, and thorough medical record for each patient should be kept on file at the emergency and critical care facility. Because of the importance of legibility and availability of medical records, all summary medical records should be computer generated, digitally stored, and backed up. Additionally, the emergency and critical care facility must comply with State/Province/Country Veterinary Practice Act and other administrative codes for informed consent, patient record keeping, and the release of patient records. Terminology and abbreviations should be generally recognizable and acceptable across the profession.
  2. The Medical Record must include, but not be limited to:
    • Client information
      • Name
      • Address
      • Phone number
    • Referring Veterinarian/Clinic
    • Patient identification or signalment
      • Name
      • Species
      • Breed
      • Age
      • Sex, including reproductive status
      • Color (or photograph of the patient embedded into the template, which clearly identifies the patient)
      • Patient vaccination status, emphasis on Rabies vaccination status
      • Patient body weight
    • Chief Complaint
    • Patient History
    • Vital signs (8)
      • Temperature
      • Heart Rate
      • Pulse Quality
      • Respiratory Rate
      • Respiratory Effort
      • Mucus Membrane Color
      • Mental Status
      • Level of pain, expressed numerically, any scale
    • Physical Exam Findings
    • Clinical pathology tests performed, and all abnormal results definitively listed.
    • Diagnostic imaging performed, and their interpretation(s)
    • Assessment, diagnosis, or differential diagnosis
    • Procedures performed (include all anesthetic and surgical release forms, anesthesia logs, and surgery reports)
    • All drugs administered, admixed, prescribed, and dispensed, to include:
      • Name of drug
      • Dose, by weight; frequency, and length of treatment
      • Route of administration
    • Progress notes, such as SOAPs at shift changes.
    • Additional treatment and nursing notes, including ICU flow sheets
    • Client discharge instructions, including follow up instructions
    • All entries in the medical records should identify the individuals who administered the care, and entered data, with the date and time included.

Communications

  1. Effective communications must be maintained to allow efficient transfer of patient information between the emergency and critical care facility and the primary care veterinarians in a timely manner. It is highly recommended that the emergency and critical care facility maintain an updated list of primary care veterinarians that includes an after-hours contact number, and indicates whether or not they are willing to be contacted after-hours. A copy of the case summary including discharge instructions should be given to the clients at the time of patient discharge and a faxed or electronic medical record/report should be sent to the primary care veterinarian within 12 hours of patient discharge in order to ensure immediate continuity of care and for inclusion in the patient’s permanent record.

Continuing Education

  1. Continuing education (CE) must be provided for professional and technical staff and must allow:
    • Veterinarians and veterinary technicians to comply with CE requirements for state licensure.
    • Veterinary specialists to meet specialty board CE requirements to maintain certification.
    • Veterinary technician specialists to meet CE requirements of their respective specialty academy to maintain certification.
  2. All emergency staff veterinarians should obtain a minimum of 28 hours of CE every two years in the field of emergency medicine, surgery, and/or critical care medicine. A maximum of 6 CE hours per two year period may be obtained via online CE courses.
  3. ACVECC residents are exempt from the 28 hours/2 years CE requirement, but must be in compliance with the requirements of their training program.
  4. First year interns, and new graduates for the first calendar year after graduation are excluded from this requirement.
  5. An in-house training program should be provided for all technical staff to assure teamwork and familiarity with the facility’s current procedures, protocols, practices and guidelines.
  6. Credentialed technical staff, and non-credentialed technical staff (veterinary assistants), having completed the in house training program, should obtain a minimum of ten (10) hours of CE every 2 years, in the field of emergency and critical care medicine. This CE can be obtained through several routes:
    • Enrollment in a local community college/technical program
    • Attendance at local, state, regional, national, or international veterinary meetings.
    • In-house CE classes, given by credentialed staff or doctors. Dates, topics and hours of CE obtained must be documented.
    • Online options: Credentialed technicians and non-credentialed veterinary assistants can use RACE approved, online CE for 5 out of the 10 hours of required continuing education.
  7. A comprehensive, written, in house training and continuing education program to include as a minimum, the following components: journal club, morbidity and mortality rounds, and wet labs (Level I).

Resources

  1. The emergency and critical care facility must have current references appropriate for the emergency and critical care mission available to the staff at all times. A list of required textbook and journal references may be found in Part 2 of this document.
  2. Internet access to online emergency and critical care resource information must be available.

Emergency Capabilities

  1. The level of care and maintenance provided in areas of laboratory, pharmacy, medicine, surgery, anesthesiology, diagnostic imaging, infectious disease control, and housekeeping should be consistent with currently accepted practice standards, and comply with state, federal, and provincial directives. Instrumentation, pharmaceuticals, and supplies should be sufficient for the practice of veterinary medicine and surgery at a level of care equal to or higher than the standard of care dictated by the individual country, state, or provincial practice acts.
  2. All emergency and critical care facilities must have the capacity to:
    • Diagnose and manage life threatening emergencies, including cardiovascular, respiratory, metabolic, gastrointestinal, urogenital, neurologic, environmental, hematologic, hemorrhagic, toxicologic, and coagulopathic problems.
    • Perform procedures to address life-threatening problems including but not limited to:
      • Cardiopulmonary resuscitation, consistent with RECOVER guidelines
      • Placement and maintenance of thoracostomy tubes
      • Emergency tracheostomy and tracheostomy tube care
      • Blood product administration
      • Oxygen supplementation
      • Assisted ventilation
    • Perform emergency surgery including, but not limited to:
      • Surgical hemostasis, wound debridement, and application of wound dressings
      • Stabilization of musculoskeletal injuries
      • Aseptic thoracic and abdominal surgery
    • Treat circulatory shock using:
      • Crystalloid fluids
      • Colloid fluids
      • Blood products
      • Vasoactive drugs
    • Allow accurate delivery of fluids using calibrated burettes, mechanical infusion pumps, and syringe pumps.
    • Administer natural and/or artificial blood products, as well as type and cross match donor and recipient blood.
    • Administer analgesic therapy and anesthetic agents including, but not limited to,
      • Pure opioid agonist analgesics
      • Non-steroidal anti-inflammatory analgesic medications
      • Alpha-2 agonists
      • Partial mu opioid agonist analgesics
      • Injectable and inhalant anesthetics
      • Reversal agents for opiates and alpha-2 agonists
      • Sedative medication
    • Provide intra-operative monitoring to include, but not be limited to:
      • Body temperature
      • Electrocardiography
      • Blood pressure
      • Capnography
      • Pulse oximetry
    • Maintain an anesthetic log for all anesthetized patients, documenting duration of anesthesia, monitoring parameters, and medications administered, expressed in weight measures, where appropriate (milligrams, etc).
    • Decontaminate and administer antidotes, when indicated for toxin exposure.
    • Perform, in a timely manner, the onsite laboratory procedures listed in Part 3 of this document. Additionally, the emergency and critical care facility must have the necessary laboratory supplies to collect, prepare, preserve, and ship samples for analysis at an offsite (reference) laboratory.
    • Perform diagnostic imaging to include, but not limited to:
      • Digital radiography
      • Ultrasonography, with the associated minimum requirement that all staff veterinarians have proficiency in the detection of life threatening clinical problems to include (but not limited to) fluid in the thoracic, pericardial, and abdominal cavities.
      • Diagnostic abdominal ultrasound, and echocardiography, or a documented relationship with a DACVR, DACVIM, or DACVECC (Level I).
    • The ability to perform intravenous renal replacement therapy (Level I), or to refer to a regional facility for this procedure. (Level II).
    • Perform long term, volume- or pressure-cycled mechanical ventilation, in the ICU setting, using a critical care ventilator (Level I).
    • Perform invasive blood pressure monitoring (Level I)
    • Perform endoscopic removal of esophageal foreign bodies (Level I and Level II), and bronchoscopy (Level I).

Avian and Exotic Companion Animal Capabilities

  1. All emergency and critical care facilities must have the capacity to receive, evaluate, stabilize, and provide limited, emergency medical support for any small (pet) mammal, avian, or reptilian species which is commonly found in the pet trade, until such time that the patient can be referred to another facility which can provide specific, expert, diagnostic procedures and care for these so called ‘exotic’ species, ie, species other than felines and canines.
  2. There are definitions, exceptions, inclusions, and limitations associated with this requirement, as follows:
    • Primates, dangerous mammals or reptiles, zoological specimens, and species commonly regarded as livestock, are not considered pets.
    • Wild animals are not considered pets. However, VECCS certified facilities should accept critically ill or injured wildlife, using appropriate personal safety precautions, but only for the purposes of providing temporary shelter and relief from pain, until they can be redirected to a licensed rehabilitator, within the constraints of local, state, federal, or provincial statues for that species. This requirement does not preclude the facility from providing timely relief from pain and suffering for any wild animal through properly administered humane euthanasia, as recommended by the AVMA Guidelines for Humane Euthanasia.
    • Koi and aquarium fish are considered pets, but are excluded from this requirement.
    • For the purposes of this requirement, ‘receive’ means to not turn away a ‘walk-up’ emergency patient at your door, if that patient is an ‘exotic’ species. If a phone call is received, that pet owner can be referred to another emergency facility that routinely deals with ‘exotics’, if one is available. If there is no other facility available, the VECCS Certified Facility should be capable of accepting the emergent exotic patient.
    • For the purposes of this requirement, ‘evaluate’ means to look at the patient, obtain a history, and do, at a minimum, a visual exam. A ‘hands-on’ exam can be done within the limits of the patient’s and the examiner’s safety and comfort level, understanding that some exotic species may not be able to tolerate handling. The use of species-specific references, such as those listed in Part 2 of this document, the Minimum Required Reference List, would be expected, and encouraged.
    • For the purposes of this requirement, ‘stabilize’ means to have available in the facility equipment and supplies necessary to provide basic support, such as species specific housing, warmth, oxygen, if needed, possibly fluid therapy, and some form of pain relief, to include humane euthanasia if no other options are available.
    • The capability to do species specific diagnostic testing, or surgical procedures, on exotic pet species is not a minimum requirement for emergency and critical care facilities.

PART 2: MINIMUM REQUIRED REFERENCE LIST

Textbooks

  1. General physiology-an edition of ONE of the following textbooks published within the past 15 years
    • Textbook of Medical Physiology, by Boron and Boulpaep
    • Review of Medical Physiology, by Ganong
    • Textbook of Medical Physiology, by Guyton and Hall
    • Berne and Levy Physiology, by Koeppen and Stanton, et al
    • Textbook of Veterinary Physiology, by Cunningham
  2. Veterinary Emergency and Critical Care-an edition of EACH of the following, published within the previous 10 years
    • Small Animal Critical Care Medicine, by Silverstein and Hopper
    • Manual of Trauma Management in the dog and Cat, by Drobatz, Beal, and Syring.
  3. Veterinary ECC Technician Manuals-an edition of ONE of the following, published within the previous 15 years
    • Veterinary Emergency and Critical Care Manual, by Mathews, 2nd edition
    • Veterinary Emergency and Critical Care Procedures, by Hackett and Mazzaferro
    • Manual of SA Emergency and Critical Care Medicine, Macintire, et al
    • Advanced Monitoring and Procedures for Small Animal Emergency and Critical Care, Burkitt-Creedon, and Davis
  4. Fluid Therapy/Acid-Base/Electrolyte Disorders-an edition of the following text published within the previous 10 years
    • Fluid, Electrolyte, and Acid-Base Disorders in Small Animal Practice, by DiBartola
  5. General Veterinary Internal Medicine-an edition of ONE of the following, published within the previous 10 years
    • Textbook of Veterinary Internal Medicine, by Ettinger and Feldman
    • Small Animal Internal Medicine, by Nelson and Couto
  6. Veterinary Surgery-an edition of ONE of the following, published within the previous 15 years
    • Small Animal Surgery, by Fossum
    • Textbook of Veterinary Small Animal Surgery, by Slatter
    • Veterinary Surgery: Small Animal, by Tobias and Johnston
  7. Veterinary Anesthesia-an edition of ONE of the following published within the previous 15 years
    • Veterinary Anesthesia & Analgesia, by McKelvey and Hollingshead
    • Veterinary Anesthesia and Analgesia, Tranquilli, et al
  8. Veterinary Ophthalmology – an edition of ONE of the following, published within the previous 15 years
    • Essentials of Veterinary Ophthalmology, by Gelatt
    • Slatter’s Fundamentals of Veterinary Ophthalmology, by Maggs, et al
  9. Veterinary Pharmacology-an edition of ONE of the following, published within the previous 10 years
    • Small Animal Clinical Pharmacology and Therapeutics, by Boothe
    • Small Animal Clinical Pharmacology, Maddison et al
  10. Veterinary Toxicology-an edition of ONE of the following, published within the previous 15 years
    • Veterinary Toxicology: Basic and Clinical Principles, by Gupta
    • Clinical Veterinary Toxicology, by Plumlee
    • Small Animal Toxicology, by Peterson and Talcott
  11. Veterinary Clinical Pathology-an edition of ONE of the following published within the previous 15 years
    • Fundamentals of Veterinary Clinical Pathology, by Stockham and Scott
    • Duncan and Prasse’s Veterinary Laboratory Medicine: Clinical Pathology, by Latimer et al
    • Small Animal Clinical Diagnosis by Laboratory Methods, by Willard and Tvedten
    • Veterinary Hematology and Clinical Chemistry, by Thrall
  12. Veterinary Pediatrics-an edition of ONE of the following, published within the previous 15 years
    • Veterinary Pediatrics, by Hoskins
    • Small Animal Pediatrics, by Peterson & Kutzler
  13. Specific Topic Areas of Veterinary Medicine, published within the previous 15 years
    • Canine and Feline Endocrinology, by Feldman & Nelson (or Canine and Feline Endocrinology and Reproduction, same authors)
    • Infectious Diseases of the Dog and Cat, by Greene
    • Ferrets, Rabbits, and Rodents, by Quesenberry and Carpenter
    • Reptile Medicine and Surgery, by Mader
    • Exotic Animal Formulary, by Carpenter
    • Clinical Veterinary Advisor-Birds and Exotic Pets, by Mayer and Donnelly
  14. Veterinary Neurology-an edition of ONE of the following, published within the previous 15 years
    • Fundamentals of Veterinary Clinic Neurology, by Bagley
    • Handbook of Veterinary Neurology, by Lorenz and Kornegay
    • BSAVA Manual of Canine and Feline Neurology, by Platt and Olby
    • Veterinary Neuroanatomy and Clinical Neurology, de Lahunta and Glass
    • Small Animal Neurology, Andre Jaggy
    • Practical Guide to Canine and Feline Neurology, by Dewey
  15. Veterinary Oncology-an edition published within the previous 15 years
    • Small Animal Clinical Oncology, Withrow and MacEwan
  16. Veterinary Cardiology-an edition of ONE of the following, published within the previous 15 years
    • Textbook of Canine and Feline Cardiology, by Fox, et al
    • Small Animal Cardiovascular Medicine, Kittleson and Keinle
    • Cardiovascular Disease in Small Animal Medicine, Ware
  17. Veterinary Avian Medicine and Surgery-an edition of ONE of the following, published within the previous 15 years
    • Avian Medicine and Surgery, by Altman
    • Avian Medicine and Surgery in Practice, by Donely
    • Essentials in Avian Medicine and Surgery, by Coles
  18. Veterinary Journals
    • Journal of Veterinary Emergency and Critical Care
    • Journal of the American Veterinary Medical Association
    • NAVTA Journal

The use of e-books for reference texts is acceptable provided the following information is supplied:

  1. The e-books must be legally purchased or obtained
  2. Proof of purchase, including the hospital’s address, must be submitted
  3. Everyone in the hospital’s E/CC department must have access to the books at all times

 

PART 3: MINIMUM REQUIREMENTS FOR A CERTIFIED VETERINARY EMERGENCY FACILITY

Facilities

  1. ER receiving and triage area, or ‘STAT’ area
  2. ICU area, or dedicated room; avian and small mammal patients may share the ICU with canines and felines, but some spatial segregation should be provided.
  3. Dedicated isolation room.
    • Comprehensive Biosecurity Plan, including infectious disease control, handwashing and sanitation protocols, and zoonotic disease control.
  4. Dedicated surgical preparation area, for patient prep, not to be in the surgery room. (Levels I and II).
  5. Dedicated surgery room (s).
  6. Radiology room that is compliant with federal, state, or provincial radiation safety requirements.
  7. Oxygen available in the triage area, ICU, isolation, surgery rooms, and radiology.
  8. Anesthesia scavenging available in the ICU, surgery rooms, and radiology.
  9. Suction; dedicated suction capability in the surgery rooms; suction capability should also be available in the triage area, and ICU; may be portable unit or central.
  10. Equipment sterilization capability with quality control.
  11. Emergency preparedness plan, or on site backup power supply, in case of power loss to the facility.
  12. System in place to ensure continuous, ongoing electric power in case of power outage (Level I )

In-Patient Support

  1. Species appropriate housing (e.g., avian/small mammal/reptile ICU unit for exotics; bird cage; aquarium with heat source and full spectrum UV lighting)
  2. Species appropriate, commercially available, critical care diets for herbivores, carnivores and omnivores.
  3. Anesthesia
    • Warming support  (e.g., forced air, circulating warm water blanket, or Hot Dog thermal unit)
    • Logs/records
  4. Small animal blood products
    • Blood typing capability for canines and felines
    • Fresh frozen plasma
      • Canine
      • Feline (Levels I and II)
    • Packed red blood cells (Level I and II)
      • Canine
      • Feline, Type A
      • Feline Type B, or readily available donor (recommended)
    • Readily available, screened canine and feline donors, either onsite, or a local blood bank with 24 hour service, in lieu of canine and feline packed red cells (Level III)
    • Red blood cell substitute, if available
  5. Fluid therapy
    • Crystalloids
      • Hypertonic saline
      • Replacement fluids-isotonic, buffered (e.g., LRS, Plasmalyte, Normosol-R)
      • 0.9% NaCl
      • Maintenance fluids (Plasmalyte 56, 0.45% saline w 5% dextrose, Normosol-M) (Levels I and II)
      • Carrier fluid, traditionally 5% dextrose in water
      • Synthetic colloids
  6. Fluid pumps
  7. Syringe pumps
  8. Calibrated burettes
  9. Intravenous catheters
    • Peripheral
    • Central (Levels I and II)
    • Intra-osseous fluid administration supplies, e.g., spinal needles
  10. Nutritional support
    • Naso-esophageal or naso-gastric tube feeding
    • Esophagostomy tube feeding (Level I and Level II)
    • Gavage tube feeding of small mammals, birds and reptiles
    • Partial parenteral nutrition capability (Level I and Level II)
    • Total parenteral nutrition capability (Level I)
  11. Pharmacy
    • Activated charcoal
    • Analgesia
      • Injectable agonist and partial agonists/antagonists opioids
      • Non-steroidal anti-inflammatory agents
      • Alpha-2 agonists and reversal agent
      • Local anesthetics, short acting and intermediate or long acting
      • NMDA receptor antagonists
      • Oral analgesic medications
    • Antibiotics
      • Injectables (Minimum: beta-lactam, fluoroquinolone, aminoglycoside, metronidazole)
      • Oral (same spectrum; add potentiated sulfonamide and tetracyclines for small mammals and birds)
    • Antihistamine (injectable)
    • Anti-seizure medications
      • Injectable
      • Oral
    • Corticosteroid
      • Injectable
      • Oral
    • Dextrose injection
    • Drugs for CPR
      • Epinephrine
      • Atropine
      • Glycopyrrolate
      • Vasopressin (recommended)
    • Electrolyte admixtures
      • Calcium gluconate
      • Potassium chloride
      • Magnesium sulfate or magnesium chloride (Levels I and II)
      • Sodium phosphate or potassium phosphate (Levels I and II)
      • Sodium bicarbonate
    • Insulin-Regular
    • 20% lipid solution
    • Sedative medications
      • Injectable
      • Oral
    • Vasoactive/anti-arrhythmic drugs
      • Dopamine
      • Dobutamine
      • Lidocaine
      • Propanolol or esmolol
      • Norepinephrine (Level I and Level II)
      • Diltiazem (Level I and Level II)
      • Sodium nitroprusside, or hydralazine (Level I and Level II)
  12. Renal Support
    • Intravenous renal replacement therapy
  13. Respiratory support
    • Oxygenation therapy, by nasal O2 cannula, or oxygen cage(s)
    • Tracheostomy tubes
  14. Defibrillator (Level I and Level II)
  15. Ventilation support
    • Ambu bag/ anesthetic machine (minimum of 2 in the facility)
    • Anesthetic ventilator
    • ICU ventilator (Level I required)
  16. Monitoring
    • Blood pressure
      • Non-invasive
      • Invasive (Level I)
    • Body Temperature
    • Capnometry/Capnography
    • Electrocardiography
    • Pulse oximetry
    • Tonometry
  17. Urinary catheters and closed collection systems
  18. Diagnostics
    • Radiography
      • 300 Ma radiography machine (standard or digital)
      • Automatic processor, with standard radiography
    • Ultrasonography
      • Minimum capability by E/CC staff to do AFAST, TFAST and tri-cavity fluid checks
  19. Endoscopy (Level I)
  20. Bronchoscopy (Level I)
  21. Laboratory Equipment, and in-house test capabilities
    • Packed cell volume
    • Refractometric total solids
    • CBC with manual differential reading
    • Glucose
    • Lactate
    • Dry chemistry analyzer
    • Electrolytes
    • Blood gases
    • Coagulation
      • Prothrombin Time
      • Activated Partial Thromboplastin Time
    • FIV/FELV antigen testing
    • Cytology
    • Urinalysis
    • Fecal flotation
    • Parvoviral antigen testing

 

APPENDIX: Abbreviations

A-FAST       Abdomen Focused Assessment with Sonography for Trauma

APTT           Activated Partial Thromboplastin Time

CBC             Complete Blood Count

CPR              Cardiopulmonary Cerebral Resuscitation

D5W             5% Dextrose in Water

DACVECC   Diplomate of the American College of Veterinary Emergency and Critical Care

DACVIM      Diplomate of the American College of Veterinary Internal Medicine

DACVR         Diplomate of the American College of Veterinary Radiology

ER                  Emergency Room

FIV                 Feline Immunodeficiency Virus

FELV              Feline Leukemia Virus

ICU                 Intensive care unit

ISO                  Isolation ward

NMDA            N-methyl d-aspartate

NAVTA          North American Veterinary Technicians Association

PT                    Prothrombin Time

RECOVER     Reassessment Campaign on Veterinary Resuscitation

SOAP             Subjective/Objective/Assessment/Plan method of medical record keeping

SX                   Surgery (room)

TFAST            Thoracic Focused Assessment with Sonography for Trauma

VTS/(ECC)     Veterinary Technician Specialist (Emergency and Critical Care)

UPDATED 1/1/17