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Emergency medicine: New missing blocks
EDITORIALS Emergency Medicine: New Missing Blocks he y e a r 1979 w a s a g r e a t one for e m e r g e n c y successes, c u l m i n a t i n g in formal specialty recognition, were well deserved a n d long overdue. The a l m o s t u n i f o r m l y positive r e a c t i o n in medical, g o v e r n m e n t a l , and public circles h a s been gratifying. The p a s t two y e a r s afforded the authors unprecedented opportunity for t r a v e l and observation of emergency medicine in action from coast to coast in this country, as well as in Canada, Mexico, and western Europe. In comparison with other countries, t h e r e is little doubt about t h e t r e m e n d o u s d e v e l o p m e n t an d advances a c h i e v e d in e m e r g e n c y c a r e in t h e U n i t e d States. But resting on our laurels, as p l e a s a n t as t h a t may be, is not the best medicine. To say t h a t e m e r gency medicine in the U n i t e d S t a t e s is all "peaches and cream" is s t r e t c h i n g the truth. Problems abound: while some are trivial, others are complex.
T medicine. Many
Research and Academia One g l a r i n g deficiency in emergency care today is the continuing lack of research in the field of emergency medicine. A l t h o u g h t h e r e are reasons for this, we hope t h a t specialty recognition and solidification of training programs in emergency medicine will propel research to fruition. Dr. A n w a r ' s recent publication in Annals, "Trends in Training: Focus on E m e r g e n c y Medicine" (9:60-71, 1980), h a s p o i n t e d o u t a n u m b e r of p r o b l e m s for academic emergency medicine. The p a u c i t y of publications by residency p r o g r a m directors in comparison to their counterparts in medicine and s u r g e r y is a reflection of lack of a t t e n t i o n paid to scholarly p u r s u i t s , perhaps as a response to an o v e r w h e l m i n g pressure to take care of the business of s t a r t i n g programs, running them, and providing p a t i e n t care. A l t h o u g h the "publish or perish" syndrome m a y be looked at as unnecessary academic pressure, the failure to p u b l i s h contributes to the lack of a r e s e a r c h base in emergency medicine. For emergency medicine to gain prestige and continuity, we m u s t develop two things. First, t h e r e m u s t be a cadre of teachers of emergency medicine, a cadre made up of e m e r g e n c y physicians who are respected as teachers a n d as r e s e a r c h e r s . A l t h o u g h e m e r g e n c y medicine will no doubt continue to r e l y to some e x t e n t on others for teaching, the core of the teaching m u s t be done by emergency physicians, w h e n a specialty must rely on others to teach its own content, it is diminished a n d t h e r e s u l t is d e t r i m e n t a l in t h e academic community. We must, as specialists and as representatives of an academic, scientific discipline, have our own teachers. A n d these teachers m u s t come from within; they m u s t be knowledgeable; and t h e y must be able to s t a n d on t h e i r own, especially in the academic community.
9:4 (April) 1980
The future of emergency medicine lies with today's medical students. We m u s t encourage t h e m by providing role models in the medical school. Dr. Anw a r ' s a r t i c l e has pointed out the positive influence which faculty m e m b e r s in s u r g e r y and medicine h a v e on students. We can exert this same kind of influence b y providing emergency medicine faculty. The second t h i n g which e m e r g e n c y medicine m u s t h a v e is a research base. A cadre of investigators who devote themselves to clinical or bench research m u s t be developed and fostered. This will add credibility to the specialty, improve academic prestige, nourish cont i n u e d development of the discipline, encourage initiation of academic d e p a r t m e n t s of emergency medicine and, best of all, improve p a t i e n t care. Despite the recent recognition of emergency medicine, t h e r e are still only three full academic d e p a r t m e n t s of e m e r g e n c y m e d i c i n e - - the U n i v e r s i t y of S o u t h e r n California, the U n i v e r s i t y of Louisville, and W r i g h t S t a t e University. Our colleague, P e t e r Rosen, MD, outlined nicely in the pages of J A C E P (8:280-283, 1979) the ~biology of emergency medicine" and the new frontiers of res e a r c h . B u t t h e p a u c i t y of r e s e a r c h in e m e r g e n c y medicine is still evident in most a r e a s of this new disciFline. A few i l l u s t r a t i o n s m a y be in order. Many of us continue to accept the existing methods for delivery of preh0spital and inhospital emergency care. A closer look will show t h a t very little solid proof exists to support this model. M a n y are approaching the p r e h o s p i t a l phase of emergency care as a "black box" phenomenon, concerned only with t h e u l t i m a t e p a t i e n t outcome, w i t h o u t c o n s i d e r i n g t h e m y r i a d of v a r i a b l e s which m a k e for a positive outcome. Others look at the i m m e d i a t e saves of CPR without considering the ultim a t e outcome. Consequently, we h a v e an expensive prehospital system which, perhaps, could be made less expensive if someone could determine, and focus on, only those factors which have the most influence on p a t i e n t outcome. While we believe t h a t we know a g r e a t deal about t h e efficiency of emergency care, we lack a complete u n d e r s t a n d i n g of its efficacy. The r e l a t i v e cost effectiveness of emergency care, a m b u l a t o r y care, a n d inp a t i e n t care also has y e t to be studied. In the more clinical realm, we t h i n k t h a t we know p r e t t y well the basic science and clinical aspects of c a r d i o p u l m o n a r y resuscitation. C u r r e n t r e s e a r c h has, however, raised questions r e g a r d i n g , for example, the u s e f u l n e s s of calcium in r e s u s c i t a t i o n . W h i t e et a l (8:298-303, 1979) h a v e helped elucidate its effect on mitochondria and ATP. Still to be identified is the location, at t h e cellular level, of calcium's effect. The usefulness of steroids in resuscitation has had increasing a t t e n t i o n (White et al, 8:188-193, 1979), b u t t h e i r cerebral and CNS effects remain controversial. F u r t h e r definitive work r e m a i n s to be done.
Ann Emerg Med
229/83
Solid research data concerning the proper use and u s e f u l n e s s of the MAST s u i t or the effects of the esophageal obturator airway on blood gases are lacki n g , a l t h o u g h M e i s l i n ' s work (9:54-59, 1980) h a s helped significantly. The available data on resuscitation of the b r a i n are f r a g m e n t a r y and should be developed to a much greater extent. Brain resuscitation, the newest frontier of resuscitation, requires a wide r a n g e of study. What use for steroids? Barbiturates? H y p o t h e r m i a ? E v e n i n such seemingly well-understood areas as sports injuries, definitive data are lacki n g i n regard to initial care, usefulness of hot and cold modalities, and use of enzymes.
Prehospital Care We are appalled by emergency p h y s i c i a n s ' freq u e n t a n d widespread lack of i n t e r e s t a n d commitm e n t to the prehospital phase of emergency medicine. One h a l f the foundation of emergency medicine is based on the recognition of the importance and relev a n c e of p r e h o s p i t a l care. The f o u n d i n g f a t h e r s of emergency medicine and of the A m e r i c a n College of Emergency Physicians were most definite and explicit in p o i n t i n g out the need for i n v o l v e m e n t of emergency medicine in prehospital care. Indeed, this has been listed and propagated as one of the u n i q u e aspects of the 23rd m e d i c a l specialty. P r e s e n t a t i o n s on t h i s t h e m e have been made to m a n y medical groups and o t h e r s as a p a r t of the effort to h a v e e m e r g e n c y medicine recognized as a separate specialty. While recounting its importance may be r e d u n d a n t , we cont i n u e to see in c o m m u n i t y after c o m m u n i t y the lack of i n t e r e s t a n d dedication to the prehospital phase of emergency care. It is almost painful for us to see a competent, intelligent, and efficient emergency physician limit his endeavors to the emergency d e p a r t m e n t phase of care.
If we, as emergency physicians, w a n t to occupy perm a n e n t and leading positions i n emergency care and set its standards, we m u s t get off dead center, agree locally on what should be done, and plunge into the activities of prehospital emergency care. Emergency physicians m u s t be i n the forefront of p l a n n i n g , training, and supervision of advanced life support, for every c o m m u n i t y deserves the benefits of a well:organized ALS program. We are disturbed by recent comments from citizens, providers of EMS, and physicians in other specialties concerning emergency physicians' a p p a r e n t lack of interest in EMS. Disaster p l a n n i n g , too, falls w i t h i n the domain of emergency medicine. Overall disaster planning, e v a l u a t i o n of disaster potential, and disaster response should be w i t h i n the p u r v i e w of emergency physicians. The n u m b e r of young, residency t r a i n e d emerg e n c y p h y s i c i a n s who are d e v o t i n g t h e m s e l v e s to academic pursuits is small. We encourage residents to seek out the academic e n v i r o n m e n t , to teach, to research, and to prepare themselves for the chairs in emergency medicine. We owe that to the profession, a n d to t h e s p e c i a l t y . The f o u n d e r s of e m e r g e n c y medicine owed to their progeny the formation of the specialty a n d its recognition; residents now owe to t h e i r p r o g e n y s o l i d i f i c a t i o n a n d d e f i n i t i o n of the academic discipline. They shall become the leaders; they are the future; and they are the continuity. If emergency medicine was the missing molecule i n the whole of medicine, then research and academic p u r s u i t s are the m i s s i n g atoms.
Ronald L. Krome, MD Annals Editor George Podgorny, MD Annals Contributing Editor
JCAH Emergency Service Standards: The Sisyphean Struggle Continues ot long ago, the College received the most recent in a series of requests from the J o i n t Commission on Accreditation of Hospitals to review and c o m m e n t on the Emergency Services Standards for their Accreditation Manual. I m u s t a d m i t t h a t when I was asked to add my personal comments to those prepared by the Hospital C o m m i t t e e a n d staff, I felt a c e r t a i n k i n s h i p to Sisyphus. It seems as though we are c o n t i n u a l l y rolling the "stone" of our objections up the J C A H mount a i n only to have it come t u m b l i n g back down before we reach the summit. Time and a g a i n our comments a n d recommendations have gone unheeded. But, with Sisyphean d e t e r m i n a t i o n , we have once a g a i n reviewed the Standards and our comments have been dutifully forwarded to JCAH. You should be interested i n our comments because the Standards are a fact of professional life for you. Some of the concerns we conveyed are major; others a m o u n t to little more t h a n semantical housekeeping tasks. First of all, we reacted n e g a t i v e l y - - again - - to the inappropriateness of the categorical scheme t h a t
N
84/230
Ann
J C A H has developed. P h i l o s o p h i c a l l y we disagree with the concept of J C A H involving itself in categorization at all, but a s s u m i n g t h a t t h e i r interest is valid, there are serious inadequacies in their categorization scheme. Briefly, JCAH has designed a four level categorization program. The levels r a n g e from "comprehensive" to "life-saving first aid" service. It is our contention t h a t while it m a y be appropriate to classify the total hospital's capabilities by "levels," the emergency d e p a r t m e n t - - as a d e p a r t m e n t - - either exists or it doesn't. Our definition of a n emergency d e p a r t m e n t is one i n which a n e x p e r i e n c e d e m e r g e n c y p h y s i c i a n (or physicians) is on duty 24 hours a day. A hospital service that does not meet this basic criterion is not an emergency d e p a r t m e n t and should not be so titled. This emergency %ervice" - - whether covered by rotati n g a t t e n d i n g staff members, house staff, physicians on call, nurses or physician-extenders - - should have a multi-disciplinary committee to oversee its functions a n d should have a physician in charge, probably the
Emerg M e d
9:4 (April) 1980!
T medicine. Many
Research and Academia One g l a r i n g deficiency in emergency care today is the continuing lack of research in the field of emergency medicine. A l t h o u g h t h e r e are reasons for this, we hope t h a t specialty recognition and solidification of training programs in emergency medicine will propel research to fruition. Dr. A n w a r ' s recent publication in Annals, "Trends in Training: Focus on E m e r g e n c y Medicine" (9:60-71, 1980), h a s p o i n t e d o u t a n u m b e r of p r o b l e m s for academic emergency medicine. The p a u c i t y of publications by residency p r o g r a m directors in comparison to their counterparts in medicine and s u r g e r y is a reflection of lack of a t t e n t i o n paid to scholarly p u r s u i t s , perhaps as a response to an o v e r w h e l m i n g pressure to take care of the business of s t a r t i n g programs, running them, and providing p a t i e n t care. A l t h o u g h the "publish or perish" syndrome m a y be looked at as unnecessary academic pressure, the failure to p u b l i s h contributes to the lack of a r e s e a r c h base in emergency medicine. For emergency medicine to gain prestige and continuity, we m u s t develop two things. First, t h e r e m u s t be a cadre of teachers of emergency medicine, a cadre made up of e m e r g e n c y physicians who are respected as teachers a n d as r e s e a r c h e r s . A l t h o u g h e m e r g e n c y medicine will no doubt continue to r e l y to some e x t e n t on others for teaching, the core of the teaching m u s t be done by emergency physicians, w h e n a specialty must rely on others to teach its own content, it is diminished a n d t h e r e s u l t is d e t r i m e n t a l in t h e academic community. We must, as specialists and as representatives of an academic, scientific discipline, have our own teachers. A n d these teachers m u s t come from within; they m u s t be knowledgeable; and t h e y must be able to s t a n d on t h e i r own, especially in the academic community.
9:4 (April) 1980
The future of emergency medicine lies with today's medical students. We m u s t encourage t h e m by providing role models in the medical school. Dr. Anw a r ' s a r t i c l e has pointed out the positive influence which faculty m e m b e r s in s u r g e r y and medicine h a v e on students. We can exert this same kind of influence b y providing emergency medicine faculty. The second t h i n g which e m e r g e n c y medicine m u s t h a v e is a research base. A cadre of investigators who devote themselves to clinical or bench research m u s t be developed and fostered. This will add credibility to the specialty, improve academic prestige, nourish cont i n u e d development of the discipline, encourage initiation of academic d e p a r t m e n t s of emergency medicine and, best of all, improve p a t i e n t care. Despite the recent recognition of emergency medicine, t h e r e are still only three full academic d e p a r t m e n t s of e m e r g e n c y m e d i c i n e - - the U n i v e r s i t y of S o u t h e r n California, the U n i v e r s i t y of Louisville, and W r i g h t S t a t e University. Our colleague, P e t e r Rosen, MD, outlined nicely in the pages of J A C E P (8:280-283, 1979) the ~biology of emergency medicine" and the new frontiers of res e a r c h . B u t t h e p a u c i t y of r e s e a r c h in e m e r g e n c y medicine is still evident in most a r e a s of this new disciFline. A few i l l u s t r a t i o n s m a y be in order. Many of us continue to accept the existing methods for delivery of preh0spital and inhospital emergency care. A closer look will show t h a t very little solid proof exists to support this model. M a n y are approaching the p r e h o s p i t a l phase of emergency care as a "black box" phenomenon, concerned only with t h e u l t i m a t e p a t i e n t outcome, w i t h o u t c o n s i d e r i n g t h e m y r i a d of v a r i a b l e s which m a k e for a positive outcome. Others look at the i m m e d i a t e saves of CPR without considering the ultim a t e outcome. Consequently, we h a v e an expensive prehospital system which, perhaps, could be made less expensive if someone could determine, and focus on, only those factors which have the most influence on p a t i e n t outcome. While we believe t h a t we know a g r e a t deal about t h e efficiency of emergency care, we lack a complete u n d e r s t a n d i n g of its efficacy. The r e l a t i v e cost effectiveness of emergency care, a m b u l a t o r y care, a n d inp a t i e n t care also has y e t to be studied. In the more clinical realm, we t h i n k t h a t we know p r e t t y well the basic science and clinical aspects of c a r d i o p u l m o n a r y resuscitation. C u r r e n t r e s e a r c h has, however, raised questions r e g a r d i n g , for example, the u s e f u l n e s s of calcium in r e s u s c i t a t i o n . W h i t e et a l (8:298-303, 1979) h a v e helped elucidate its effect on mitochondria and ATP. Still to be identified is the location, at t h e cellular level, of calcium's effect. The usefulness of steroids in resuscitation has had increasing a t t e n t i o n (White et al, 8:188-193, 1979), b u t t h e i r cerebral and CNS effects remain controversial. F u r t h e r definitive work r e m a i n s to be done.
Ann Emerg Med
229/83
Solid research data concerning the proper use and u s e f u l n e s s of the MAST s u i t or the effects of the esophageal obturator airway on blood gases are lacki n g , a l t h o u g h M e i s l i n ' s work (9:54-59, 1980) h a s helped significantly. The available data on resuscitation of the b r a i n are f r a g m e n t a r y and should be developed to a much greater extent. Brain resuscitation, the newest frontier of resuscitation, requires a wide r a n g e of study. What use for steroids? Barbiturates? H y p o t h e r m i a ? E v e n i n such seemingly well-understood areas as sports injuries, definitive data are lacki n g i n regard to initial care, usefulness of hot and cold modalities, and use of enzymes.
Prehospital Care We are appalled by emergency p h y s i c i a n s ' freq u e n t a n d widespread lack of i n t e r e s t a n d commitm e n t to the prehospital phase of emergency medicine. One h a l f the foundation of emergency medicine is based on the recognition of the importance and relev a n c e of p r e h o s p i t a l care. The f o u n d i n g f a t h e r s of emergency medicine and of the A m e r i c a n College of Emergency Physicians were most definite and explicit in p o i n t i n g out the need for i n v o l v e m e n t of emergency medicine in prehospital care. Indeed, this has been listed and propagated as one of the u n i q u e aspects of the 23rd m e d i c a l specialty. P r e s e n t a t i o n s on t h i s t h e m e have been made to m a n y medical groups and o t h e r s as a p a r t of the effort to h a v e e m e r g e n c y medicine recognized as a separate specialty. While recounting its importance may be r e d u n d a n t , we cont i n u e to see in c o m m u n i t y after c o m m u n i t y the lack of i n t e r e s t a n d dedication to the prehospital phase of emergency care. It is almost painful for us to see a competent, intelligent, and efficient emergency physician limit his endeavors to the emergency d e p a r t m e n t phase of care.
If we, as emergency physicians, w a n t to occupy perm a n e n t and leading positions i n emergency care and set its standards, we m u s t get off dead center, agree locally on what should be done, and plunge into the activities of prehospital emergency care. Emergency physicians m u s t be i n the forefront of p l a n n i n g , training, and supervision of advanced life support, for every c o m m u n i t y deserves the benefits of a well:organized ALS program. We are disturbed by recent comments from citizens, providers of EMS, and physicians in other specialties concerning emergency physicians' a p p a r e n t lack of interest in EMS. Disaster p l a n n i n g , too, falls w i t h i n the domain of emergency medicine. Overall disaster planning, e v a l u a t i o n of disaster potential, and disaster response should be w i t h i n the p u r v i e w of emergency physicians. The n u m b e r of young, residency t r a i n e d emerg e n c y p h y s i c i a n s who are d e v o t i n g t h e m s e l v e s to academic pursuits is small. We encourage residents to seek out the academic e n v i r o n m e n t , to teach, to research, and to prepare themselves for the chairs in emergency medicine. We owe that to the profession, a n d to t h e s p e c i a l t y . The f o u n d e r s of e m e r g e n c y medicine owed to their progeny the formation of the specialty a n d its recognition; residents now owe to t h e i r p r o g e n y s o l i d i f i c a t i o n a n d d e f i n i t i o n of the academic discipline. They shall become the leaders; they are the future; and they are the continuity. If emergency medicine was the missing molecule i n the whole of medicine, then research and academic p u r s u i t s are the m i s s i n g atoms.
Ronald L. Krome, MD Annals Editor George Podgorny, MD Annals Contributing Editor
JCAH Emergency Service Standards: The Sisyphean Struggle Continues ot long ago, the College received the most recent in a series of requests from the J o i n t Commission on Accreditation of Hospitals to review and c o m m e n t on the Emergency Services Standards for their Accreditation Manual. I m u s t a d m i t t h a t when I was asked to add my personal comments to those prepared by the Hospital C o m m i t t e e a n d staff, I felt a c e r t a i n k i n s h i p to Sisyphus. It seems as though we are c o n t i n u a l l y rolling the "stone" of our objections up the J C A H mount a i n only to have it come t u m b l i n g back down before we reach the summit. Time and a g a i n our comments a n d recommendations have gone unheeded. But, with Sisyphean d e t e r m i n a t i o n , we have once a g a i n reviewed the Standards and our comments have been dutifully forwarded to JCAH. You should be interested i n our comments because the Standards are a fact of professional life for you. Some of the concerns we conveyed are major; others a m o u n t to little more t h a n semantical housekeeping tasks. First of all, we reacted n e g a t i v e l y - - again - - to the inappropriateness of the categorical scheme t h a t
N
84/230
Ann
J C A H has developed. P h i l o s o p h i c a l l y we disagree with the concept of J C A H involving itself in categorization at all, but a s s u m i n g t h a t t h e i r interest is valid, there are serious inadequacies in their categorization scheme. Briefly, JCAH has designed a four level categorization program. The levels r a n g e from "comprehensive" to "life-saving first aid" service. It is our contention t h a t while it m a y be appropriate to classify the total hospital's capabilities by "levels," the emergency d e p a r t m e n t - - as a d e p a r t m e n t - - either exists or it doesn't. Our definition of a n emergency d e p a r t m e n t is one i n which a n e x p e r i e n c e d e m e r g e n c y p h y s i c i a n (or physicians) is on duty 24 hours a day. A hospital service that does not meet this basic criterion is not an emergency d e p a r t m e n t and should not be so titled. This emergency %ervice" - - whether covered by rotati n g a t t e n d i n g staff members, house staff, physicians on call, nurses or physician-extenders - - should have a multi-disciplinary committee to oversee its functions a n d should have a physician in charge, probably the
Emerg M e d
9:4 (April) 1980!