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Opinions expressed in the Correspondence section are those of the authors, and not necessarily of the editors, ACER or SAEM. The editor reserves the right to edit and publish letters as space permits. Letters not meeting submission criteria will not be considered for publication. See "Instructions for Authors."
CORRESPONDENCE The Past & Future of Academic Emergency Medicine To the Editor: I feel compelled to respond to Dr Becker's editorial "Cellular Resuscitation, Basic Science, and the Future of Emergency Medicine" [August 1989;18:896-897], as I believe the basic premises on which his argument is based are incorrect. Dr Becket believes that emergency medicine has "lost sight of its origins"; he identifies these origins as the treatment of shock and hypotension and bemoans the fact that academic emergency medicine has failed to honor its origins by pursuing resuscitation research to the exclusion" of all 8ther research. Specifically, he seems to take issue with research that focuses on "clinical delivery and patient care services." As evidence for his thesis, he cites the 18th Annual University Association for Emergency Medicine meeting program. He believes that only by identifying and pursuing basic science research within a specialized clinical focus can e m e r g e n c y medicine emerge as a recognized and, therefore, legitimate specialty.
R o b e r t J Rothstein, MD, FACEP - - S e c t i o n E d i t o r Bethesda, Maryland
As a physician who trained in one of the older emergency medicine residency programs, under the direction of one of the founders of our specialty, my understanding of the origins of emergency medicine differs significantly from that of Dr Becker. I believe that emergency medicine originated from a perceived need to provide quality care to acutely ill and injured patients and out of recognition of the unique fund of knowledge that is required of those delivering emergency care. This fund of knowledge is distingnished not so much by its depth as by its breadth, and its recognition of the common pathophysiology of acute illness and injury. It is this common pathophysiology that Dr Becker correctly identifies as important and of significant concern to emergency medicine research, but to cite it as the origin and focus of our specialty ignores the true mission of emergency medicine - the provision of quality emergency care to patients and the teaching of these skills to physicians. Research is of value only insofar as it advances our scientific knowledge and improves our patient care and physician education. Basic science research accomplishes these goals, but no more or less effectively than does good quality clinical and health services research. That these efforts have gone unrewarded in academic medicine should serve as an indictment of the evaluation and promotion system, rather than as justification of the unique value of basic science research. Academic emergency medicine is ideally suited to significantly impact all of academic medicine in the 1990s and beyond. As the academic medical center learns to "function in a new world of cost containment, managed 19:5 May 1990
care delivery systems, utilization review, reduced lengths of stay, competition for market share, and external intervention, ''1 emergency physicians can become models for future academic medical practice. Cost control requires a shift from inpatient to ambulatory patient care and education.~ Emergency medicine is already meeting this need and furthering our ability to control costs with clinical and health services research. As academic emergency physicians, we are able to balance significantly greater clinical c o m m i t m e n t s (compared with other specialties) with teaching and administrative responsibilities and still conduct quality research, much of which addresses important clinical and practice management questions. Recognition of the value of this type of research has been slow, but there is evidence that the recognition is occurring. In the 1988 chairman's address to the Association of American Medical Colleges, John W Colloton spoke on "Academic Medicine's Changing Covenant with Society." In his address, he appealed for the establishment "within academic medicine [of] a national agenda that places a substantial priority on the scientific analysis of our entire health care system, analogous to that which presently supports the biomedical research dimension of our enterprise ... the time is past when such research could be dismissed as unscientific and unworthy of our attention ... the reward system, academic stature, financing, and other inducements essential to the alleviation of this shortage must be put in place so that faculty members appropriate in numbers and quality to address society's present concerns with our system of health care can be mobilized. ''2 Perhaps rather than attempting to adhere to the timehonored model of an academic specialty, emergency medicine should view itself as a model of the future academic specialty, effectively balancing the triad of patient care, teaching, and research while maintaining its focus on the delivery of cost-effective, quality care to patients. To the extent that we can accomplish this, we shall fulfill academic medicine's "covenant with society" and remain true to our origins as well. Robert A Schwab, MD Emergency Medical Services University of Virginia Health Sciences Center Charlottesville i. Ross RS, Johns ME: Changingenvironment and the academic medical center: The Johns Hopkins Schoolof Medicine. Acad Med 1989;64:1-6. 2. Colloton JW: Academicmedicine's changing covenant with society. Acad Med 1989;64:55-60.
In Reply: I appreciate Dr Schwab's interest in my editorial. While he and I disagree on several points, we share a recognition of current problems and a deep concern for the future growth and development of emergency medicine.
Annals of Emergency Medicine
612/171
CORRESPONDENCE
Much like the fable of three blind men with completely different descriptions of the same elephant, each viewpoint may be completely accurate, while the larger truth involves the merger of multiple descriptions. I described a basic science foundation in resuscitation as a unifying p a t h o p h y s i o l o g i c focus for emergency medicine. Dr Schwab prefers to focus on cost-effective, high-quality health care delivery for patients. Others have alternatively suggested that we should focus on the subtlety and variety of disease presentation or on the range of required diagnostic skills. My view of the genesis of emergency medicine in the treatment of shock and acute hypotension is shared by others. Dr B Ken Gray, past president of the American College of Emergency Physicians, writes, "We are all familiar with the origins of emergency medicine. The battlefield medical systems of Korea and Vietnam taught us more about the practice than any system prior to that time. Triage systems, quick stabilization methods, and emergency surgery procedures were employed to save the lives of soldiers injured in battle. 'q The message of my editorial, however, was not that resuscitation should become the single focus of emergency medicine but that we now need to emphasize and develop basic science research in order to augment existing patient care, teaching, and clinical research. Obviously, research in resuscitation should not exclude all other research, nor should clinical research be seen as less important or valuable for our future than basic science research. But let us be clear: there is currently almost no basic science research within emergency medicine. This is to be expected in an emerging specialty, but to assure our growth and maturation it is now crucial for us to establish the link between clinical resuscitation and the basic science of resuscitation. Research in cellular resuscitation, mitochondrial function, membrane permeability, ischemia, and reversal of cell death provides a unifying patho-
physiologic focus and opens up possibilities for extensive basic science exploration. Such research will be directly applicable to the emergency department and prehospital care and at the same time foster new opportunities for emergency physicians. We can complete more successfully for large research grants when basic science research is part of our general research effort. We can offer a basic science research track to interested and capable emergency physicians. We can offer a basic science research exposure to residents and fellows. Stressing the need for faculty development, Dr Glenn Hamilton writes, "We will always be in 'second-class citizen' mindset in relation to our peers in academic medicine until there are deans of medical schools with emergency medicine backgrounds; until there are endowed professorships/chairs and research institutes in emergency medicine...,,2 Clearly, the development of basic science research to augment our overall research program can help us to strengthen areas where we now lag behind other specialties. Again, I thank Dr Schwab for his response and welcome the comments of others. It is only through the exchange of diverse opinions and differing viewpoints that we will stimulate the development and maturation of our specialty. As we seek a fuller definition of the field and a vision for the future, we are just beginning to explore the elephant. Lance B Becket, MD Division of Emergency Medicine, Department of Medicine University of Chicago 1. GrayBK: The rise of emergencymedicine. EmergencyMedical Services 1982;11:39-41. 2. Hamilton GC: Faculty development in emergency medicine. Am 1 Emerg Med 1988;6:540-544.
Benefits of Early Defibrillation To the Editor." Olson and his associates are to be commended for sharing with us their experience with EMT-defibrillation in Wisconsin in their article, "EMT-Defibrillation: The Wisconsin Experience" [August 1989;18:806-811]. It is only through publication of such continued experience that we will be able to define clearly the objective benefits of early defibrillation in a variety of prehospital environments. There are several points in this paper that we believe need to be underscored and understood in an attempt to determine the benefit of early defibrillation from this experience in Wisconsin. The limitations imposed by using a historical control group and a two-year retrospective review of that patient population must be understood. Although survival from ventricular fibrillation (VF) in communities of less than 6,000 people was 9% (six of 67), survival from all communities of less than 15,000 was 7% 172/613
(11 of 157). This was less than half the survival rate from VF in communities of more than 15,000 people. It is important to emphasize that most truly "rural" communities should not realistically expect survival figures to compare favorably with those from larger communities. There were 33 survivors among the 304 patients with VF, but ten of these 33 survivors failed to respond to prehospital defibrillatory shocks and were only resuscitated in the emergency department. It cannot be assumed that these ten patients benefitted in any way from prehospital defibrillation. One must then conclude that early defibrillation appeared to contribute to survival in 23 of 304 patients with VF (7.5%). Eleven of the survivors of prehospital VF had experienced an EMT-witnessed arrest. Obviously this quite high incidence of EMT-witnessed arrest (26 of 304 patients with VF) with immediate availability of defibrillation,
Annals of Emergency Medicine
19:5 May 1990
CORRESPONDENCE The Past & Future of Academic Emergency Medicine To the Editor: I feel compelled to respond to Dr Becker's editorial "Cellular Resuscitation, Basic Science, and the Future of Emergency Medicine" [August 1989;18:896-897], as I believe the basic premises on which his argument is based are incorrect. Dr Becket believes that emergency medicine has "lost sight of its origins"; he identifies these origins as the treatment of shock and hypotension and bemoans the fact that academic emergency medicine has failed to honor its origins by pursuing resuscitation research to the exclusion" of all 8ther research. Specifically, he seems to take issue with research that focuses on "clinical delivery and patient care services." As evidence for his thesis, he cites the 18th Annual University Association for Emergency Medicine meeting program. He believes that only by identifying and pursuing basic science research within a specialized clinical focus can e m e r g e n c y medicine emerge as a recognized and, therefore, legitimate specialty.
R o b e r t J Rothstein, MD, FACEP - - S e c t i o n E d i t o r Bethesda, Maryland
As a physician who trained in one of the older emergency medicine residency programs, under the direction of one of the founders of our specialty, my understanding of the origins of emergency medicine differs significantly from that of Dr Becker. I believe that emergency medicine originated from a perceived need to provide quality care to acutely ill and injured patients and out of recognition of the unique fund of knowledge that is required of those delivering emergency care. This fund of knowledge is distingnished not so much by its depth as by its breadth, and its recognition of the common pathophysiology of acute illness and injury. It is this common pathophysiology that Dr Becker correctly identifies as important and of significant concern to emergency medicine research, but to cite it as the origin and focus of our specialty ignores the true mission of emergency medicine - the provision of quality emergency care to patients and the teaching of these skills to physicians. Research is of value only insofar as it advances our scientific knowledge and improves our patient care and physician education. Basic science research accomplishes these goals, but no more or less effectively than does good quality clinical and health services research. That these efforts have gone unrewarded in academic medicine should serve as an indictment of the evaluation and promotion system, rather than as justification of the unique value of basic science research. Academic emergency medicine is ideally suited to significantly impact all of academic medicine in the 1990s and beyond. As the academic medical center learns to "function in a new world of cost containment, managed 19:5 May 1990
care delivery systems, utilization review, reduced lengths of stay, competition for market share, and external intervention, ''1 emergency physicians can become models for future academic medical practice. Cost control requires a shift from inpatient to ambulatory patient care and education.~ Emergency medicine is already meeting this need and furthering our ability to control costs with clinical and health services research. As academic emergency physicians, we are able to balance significantly greater clinical c o m m i t m e n t s (compared with other specialties) with teaching and administrative responsibilities and still conduct quality research, much of which addresses important clinical and practice management questions. Recognition of the value of this type of research has been slow, but there is evidence that the recognition is occurring. In the 1988 chairman's address to the Association of American Medical Colleges, John W Colloton spoke on "Academic Medicine's Changing Covenant with Society." In his address, he appealed for the establishment "within academic medicine [of] a national agenda that places a substantial priority on the scientific analysis of our entire health care system, analogous to that which presently supports the biomedical research dimension of our enterprise ... the time is past when such research could be dismissed as unscientific and unworthy of our attention ... the reward system, academic stature, financing, and other inducements essential to the alleviation of this shortage must be put in place so that faculty members appropriate in numbers and quality to address society's present concerns with our system of health care can be mobilized. ''2 Perhaps rather than attempting to adhere to the timehonored model of an academic specialty, emergency medicine should view itself as a model of the future academic specialty, effectively balancing the triad of patient care, teaching, and research while maintaining its focus on the delivery of cost-effective, quality care to patients. To the extent that we can accomplish this, we shall fulfill academic medicine's "covenant with society" and remain true to our origins as well. Robert A Schwab, MD Emergency Medical Services University of Virginia Health Sciences Center Charlottesville i. Ross RS, Johns ME: Changingenvironment and the academic medical center: The Johns Hopkins Schoolof Medicine. Acad Med 1989;64:1-6. 2. Colloton JW: Academicmedicine's changing covenant with society. Acad Med 1989;64:55-60.
In Reply: I appreciate Dr Schwab's interest in my editorial. While he and I disagree on several points, we share a recognition of current problems and a deep concern for the future growth and development of emergency medicine.
Annals of Emergency Medicine
612/171
CORRESPONDENCE
Much like the fable of three blind men with completely different descriptions of the same elephant, each viewpoint may be completely accurate, while the larger truth involves the merger of multiple descriptions. I described a basic science foundation in resuscitation as a unifying p a t h o p h y s i o l o g i c focus for emergency medicine. Dr Schwab prefers to focus on cost-effective, high-quality health care delivery for patients. Others have alternatively suggested that we should focus on the subtlety and variety of disease presentation or on the range of required diagnostic skills. My view of the genesis of emergency medicine in the treatment of shock and acute hypotension is shared by others. Dr B Ken Gray, past president of the American College of Emergency Physicians, writes, "We are all familiar with the origins of emergency medicine. The battlefield medical systems of Korea and Vietnam taught us more about the practice than any system prior to that time. Triage systems, quick stabilization methods, and emergency surgery procedures were employed to save the lives of soldiers injured in battle. 'q The message of my editorial, however, was not that resuscitation should become the single focus of emergency medicine but that we now need to emphasize and develop basic science research in order to augment existing patient care, teaching, and clinical research. Obviously, research in resuscitation should not exclude all other research, nor should clinical research be seen as less important or valuable for our future than basic science research. But let us be clear: there is currently almost no basic science research within emergency medicine. This is to be expected in an emerging specialty, but to assure our growth and maturation it is now crucial for us to establish the link between clinical resuscitation and the basic science of resuscitation. Research in cellular resuscitation, mitochondrial function, membrane permeability, ischemia, and reversal of cell death provides a unifying patho-
physiologic focus and opens up possibilities for extensive basic science exploration. Such research will be directly applicable to the emergency department and prehospital care and at the same time foster new opportunities for emergency physicians. We can complete more successfully for large research grants when basic science research is part of our general research effort. We can offer a basic science research track to interested and capable emergency physicians. We can offer a basic science research exposure to residents and fellows. Stressing the need for faculty development, Dr Glenn Hamilton writes, "We will always be in 'second-class citizen' mindset in relation to our peers in academic medicine until there are deans of medical schools with emergency medicine backgrounds; until there are endowed professorships/chairs and research institutes in emergency medicine...,,2 Clearly, the development of basic science research to augment our overall research program can help us to strengthen areas where we now lag behind other specialties. Again, I thank Dr Schwab for his response and welcome the comments of others. It is only through the exchange of diverse opinions and differing viewpoints that we will stimulate the development and maturation of our specialty. As we seek a fuller definition of the field and a vision for the future, we are just beginning to explore the elephant. Lance B Becket, MD Division of Emergency Medicine, Department of Medicine University of Chicago 1. GrayBK: The rise of emergencymedicine. EmergencyMedical Services 1982;11:39-41. 2. Hamilton GC: Faculty development in emergency medicine. Am 1 Emerg Med 1988;6:540-544.
Benefits of Early Defibrillation To the Editor." Olson and his associates are to be commended for sharing with us their experience with EMT-defibrillation in Wisconsin in their article, "EMT-Defibrillation: The Wisconsin Experience" [August 1989;18:806-811]. It is only through publication of such continued experience that we will be able to define clearly the objective benefits of early defibrillation in a variety of prehospital environments. There are several points in this paper that we believe need to be underscored and understood in an attempt to determine the benefit of early defibrillation from this experience in Wisconsin. The limitations imposed by using a historical control group and a two-year retrospective review of that patient population must be understood. Although survival from ventricular fibrillation (VF) in communities of less than 6,000 people was 9% (six of 67), survival from all communities of less than 15,000 was 7% 172/613
(11 of 157). This was less than half the survival rate from VF in communities of more than 15,000 people. It is important to emphasize that most truly "rural" communities should not realistically expect survival figures to compare favorably with those from larger communities. There were 33 survivors among the 304 patients with VF, but ten of these 33 survivors failed to respond to prehospital defibrillatory shocks and were only resuscitated in the emergency department. It cannot be assumed that these ten patients benefitted in any way from prehospital defibrillation. One must then conclude that early defibrillation appeared to contribute to survival in 23 of 304 patients with VF (7.5%). Eleven of the survivors of prehospital VF had experienced an EMT-witnessed arrest. Obviously this quite high incidence of EMT-witnessed arrest (26 of 304 patients with VF) with immediate availability of defibrillation,
Annals of Emergency Medicine
19:5 May 1990