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Ideas, promises and deadlines
EDITORIALS The "Pits" --- and the Pendulum m u l g a t e d and i n v e n t e d a new kind of practice limited to the study and m a n a g e m e n t of the flotsam and jetsam who needed emergency medical care. They practiced and t a u g h t this new set of skills and their n u m bers grew. As the p e n d u l u m swung, new organizations formed, i n v o l v i n g i n c r e a s i n g n u m b e r s of physicians c o m m i t t e d to t h i s u n i q u e p r a c t i c e , a n d m e d i c a l graduates began to seek t r a i n i n g in what w a s called ~%mergency Medicine." It was 1970. The p e n d u l u m continued its inexorable traverse. T e n t h o u s a n d p h y s i c i a n s devoted t h e i r skills a n d energies to this new, special practice. Prehospital care was m a r k e d l y improved. Sophisticated care became available on the roadside. New health care professionals, new methodologies, new t r a i n i n g programs were developed, and fewer patients rode outward bound in shiny jet black cars. It was 1975. Still the p e n d u l u m moved. The colleagues of these emergency physicians - - colleagues from the m a n y specialties - - began a dialogue which recognized the u n i q u e n e s s of emergency medicine and the need to educate medical s t u d e n t s and post-graduate physicians in this new discipline. The dialogue continued through a process in which the necessity was recogn i z e d to t r a i n b o n a fide s p e c i a l i s t s in e m e r g e n c y medicine and, t h r o u g h s t r i n g e n t examination, certify to the public t h a t these p h y s i c i a n s are specialists. W o r k i n g together, the dialogue c u l m i n a t e d in the A m e r i c a n Board of Emergency Medicine, dedicated to t h a t assurance of q u a l i t y specialty medical care t h a t is the h a l l m a r k and s i n e q u a n o n of all Boards. It was 10:30 am EDT, September 21, 1979. The pits are gone. The p e n d u l u m is rising.
hey were called ~pits." They were n a m e d after gory arenas i n which bulldogs ravaged other dogs or m a n g l e d rats, or where gamecocks fought to the death on blood- and offal-splattered floors. Even t h o u g h hospitals e u p h e m a t i z e d them ~'accident rooms," they were ~pits." In them, frightened i n t e r n s waited while low, sleek, s h i n y - b r i g h t red or jet black vehicles hauled in their cargoes of h u m a n misery. Not a few among those cargoes were carried - - well - elsewhere in those same jet black cars. The p e n d u l u m was not, even then, at the n a d i r of its swing: m a n y physicians were, at that time, caring for the severely medically ill by house calls, office visits, or on hospital wards. As specialization increased among physicians; as sophisticated diagnostic tests were added to a r m a m e n taria; as fewer and fewer physicians w e r e on constant call to t h e i r p a t i e n t s , t h e s e ~ p a t i e n t s - w i t h o u t portfolio" j o i n e d the r a n k s of the poor a n d of the gladiators of the u r b a n ghettoes in a n ever-increasing l e m m i n g trek into the "pits." There the frazzled i n t e r n waited. There the least sophisticated; the least trained; the least supervised doctor committed medical care on the p a t i e n t s at greatest risk: patients who presented by the twos a n d fours with the global potential for a n y disease or injury in a library of medical tomes. The p e n d u l u m was now at its outermost reach; at its true nadir. It was 1960. A m o m e n t of inertia, and the arc reversed with slow but ever-increasing m o m e n t u m . First, two physicians, t h e n five, well e s t a b l i s h e d in t h e i r practice skills b e g a n f u l l - t i m e careers in w h a t t h e y called emergency rooms. It was 1962. These p h y s i c i a n s met fortuitously in 1968 and shared their common interest. They organized, pro-
T the
C a r l J e l e n k o , III, M D JACEP Associate Editor
Ideas, P r o m i s e s and D e a d l i n e s Some research in emergency medicine has been going on quietly for three or more years, while concepts and results are repeatedly challenged or reproduced~ Other ideas are of fairly recent v i n t a g e and have been tested in relatively few experimental animals. Other reviews of clinical experience have resulted from m a n y hours of m i d n i g h t oil and chart analysis. The computer has c a l c u l a t e d s t a n d a r d d e v i a t i o n , s t a n d a r d e r r o r of thousands of samples, and when one applies the degrees of freedom, a ~'p" value has been obtained which, at times, is not as significant as one's i n i t i a l clinical impression. UA/EM has established its identity as the forum for reporting scientific emergency medicine research projects. The emergency medicine program director, the j u n i o r staff in emergency medicine and the new
p
r e s e n t a t i o n s at recent scientific m e e t i n g s have prompted m a n y of us to ask '~Why didn't I t h i n k of that?" D u r i n g the a n n u a l meeting of the U n i v e r s i t y Association for Emergency Medicine (UA/EM) earlier this y e a r m a n y e m e r g e n c y m e d i c i n e a c a d e m i c i a n s were heard to say, ~'I'm not sure I agree with t h a t concept. I'm going to research it and report my findings at next year's UA/EM meeting." The Biblical observation t h a t '~many are called b u t few are chosen" might be restated to apply to the p r o c r a s t i n a t i n g researcher: ~Many are the promises b u t few are the abstracts." Some of t h e u n m e t c h a l l e n g e s of e m e r g e n c y medicine have been tabulated. S t i m u l a t i o n for pursuing research projects arises from reading scientific reports, a t t e n d i n g n a t i o n a l meetings, c o m m u n i c a t i n g informally with colleagues, and individual introspection.
8"12 (December) 1979
JACEP
542/61
The P r o g r a m C o m m i t t e e has a n n o u n c e d J a n u a r y 31, 1980 as the deadline for receipt of a b s t r a c t s for the 1980 meeting. A limited n u m b e r of abstracts can be a c c e p t e d for p r e s e n t a t i o n . L a s t y e a r only h a l f t h e a b s t r a c t s s u b m i t t e d found a place on t h e final program. A l r e a d y this y e a r a n u m b e r of fine abstracts h a v e been received. You are encouraged to sttmmarize the results of your e m e r g e n c y medicine research and to construct your a b s t r a c t in a concise, m e a n i n g f u l way. You are encouraged to s u b m i t y o u r a b s t r a c t to t h e P r o g r a m Committee a t an e a r l y date. The future of academic emergency medicine is p r e d i c a t e d on the a b i l i t y of m e m b e r s of t h e s c i e n t i f i c e m e r g e n c y medicine c o m m u n i t y to develop a body of researchable knowledge which directly r e l a t e s to t h e discipline. It is with g r e a t a n t i c i p a t i o n t h a t I have a l r e a d y m a d e m y r e s e r v a t i o n s for the a n n u a l m e e t i n g o f the U n i v e r s i t y Association for E m e r g e n c y Medicine, and I encourage each of you to do the same.
breed of residents in e m e r g e n c y medicine ask ~How can I become accepted and recognized in this e l i t i s t organization, UA/EM?" A l t h o u g h in the p a s t UA/EM h a d i n n u m e r a b l e ad hoc committees, it h a s become c l e a r d u r i n g the p a s t t h r e e y e a r s t h a t the sole m e a n s of recognition in this h i g h l y selective organization is acceptance, on a scientific basis, of academic w o r k t h r o u g h research done in conceptual, logistic, applied clinical, or basic science research. The a n n u a l m e e t i n g of the U n i v e r s i t y Association for E m e r g e n c y M e d i c i n e w i l l be h e l d in T u c s o n , Arizona, A p r i l 13-17, 1980, and promises to be one of the most exciting, academically challenging m e e t i n g s in t h e history of emergency medicine. The r e s e a r c h projects which were r e p o r t e d at the 1979 O r l a n d o m e e t i n g h a d t h e g r e a t e s t n u m b e r of w o r t h w h i l e , well-researched p a p e r s in the history of the organization. F u r t h e r m o r e , t h e floor discussions r e v i e w i n g those articles were as professionally done and as scientifically pointed as those a t any academic m e e t i n g in the U n i t e d States. A continuation of this forum is expected at the Tucson meeting.
Kenneth L. Mattox, MD President, UA/EM
Annals of Emergency Medicine emergency medicine. As the n u m b e r of m a n u s c r i p t s s u b m i t t e d has increased we have become more selective of those to be printed. A p p r o x i m a t e l y 40% of all m a n u s c r i p t s reviewed by the E d i t o r i a l Board are rejected as we seek t o publish only the best work in the field. We have m a d e every effort to expedite the review and modification process so t h a t a u t h o r s are informed of t h e disposition of t h e i r m a n u s c r i p t s . Since J u l y 1979 we have tried to p u b l i s h an a v e r a g e of 10 scientific articles in each issue. Even so, t h e r e are occasionally delays of m a n y months before an accepted m a n u s c r i p t appears in the J o u r n a l . We are constantly s t r i v i n g to reduce t h e a m o u n t of t i m e between receipt and publication. The J o u r n a l owes much to the o r g a n i z a t i o n a l involvement and support provided by ACEP.and UA/EM. By r e q u i r i n g t h a t p r e s e n t e r s of original work at the organizations' a n n u a l m e e t i n g s s u b m i t t h e i r m a n u s c r i p t s for consideration by t h e J o u r n a l , we have b e n e f i t e d from t h e a v a i l a b i l i t y of m a n y e x c e l l e n t manuscripts. We look f o r w a r d to t h e c o n t i n u e d suloport of A C E P and UA/EM and to the continued involvement of emergency medicine's r e s e a r c h e r s and clinicians. A c o m m i t m e n t to excellence by all of us will ensure the continued growth of Annals of Emergency Medicine.
new era will begin with t h e J a n u a r y 1980 i~ssue of the J o u r n a l . A t t h a t time, this joint p u b l i s h i n g v e n t u r e of the A m e r i c a n College of E m e r g e n c y Physicians and the U n i v e r s i t y Association for E m e r g e n c y Medicine will be r e n a m e d Annals of Emergency Medicine. The new title is designed to reflect a b r o a d e r emp h a s i s on all aspects of t h e field of emergency medicine. The editorial content of the J o u r n a l Will continue its h i g h l y successful orientation. This c h a n g e c u l m i n a t e s a process b e g u n origin a l l y w i t h a n a n n o u n c e m e n t in t h e S e p t e m b e r / October 1974 issue and given impetus by George Podgorny, MD, in his recent s u m m a r y s t a t e m e n t as outgo-ing P r e s i d e n t of the College. A l t h o u g h t h e E d i t o r i a l Board, the A C E P Board of Directors, and the U A / E M Executive Council agreed to the n a m e change y e a r s ago, a delay was b r o u g h t about by legal actions t a k e n by t h e p u b l i s h e r of Emergency Medicine m a g a z i n e . But as the generic t e r m ~'emergency medicine" has become accepted as denoting an officially recognized a n d defined medical specialty, the three governing bodies h a v e agreed to proceed with the change a s originally scheduled. The n u m b e r a n d q u a l i t y of s u b m i s s i o n s to t h e J o u r n a l has risen r e m a r k a b l y in recent years. W h i l e m a n y of t h e kudos for this enhanced q u a l i t y have b e e n directed to the editors, t h e r e is little d o u b t t h a t t h e r e a l reason for this i m p r o v e m e n t is the c o m m i t m e n t by e m e r g e n c y p h y s i c i a n s to develop and m a i n t a i n a p u b l i c a t i o n of, by, and for professionals in the field of
A
62/543
Ronald L. Krome, MD Editor
JACEP
8"12 (December) 1979
hey were called ~pits." They were n a m e d after gory arenas i n which bulldogs ravaged other dogs or m a n g l e d rats, or where gamecocks fought to the death on blood- and offal-splattered floors. Even t h o u g h hospitals e u p h e m a t i z e d them ~'accident rooms," they were ~pits." In them, frightened i n t e r n s waited while low, sleek, s h i n y - b r i g h t red or jet black vehicles hauled in their cargoes of h u m a n misery. Not a few among those cargoes were carried - - well - elsewhere in those same jet black cars. The p e n d u l u m was not, even then, at the n a d i r of its swing: m a n y physicians were, at that time, caring for the severely medically ill by house calls, office visits, or on hospital wards. As specialization increased among physicians; as sophisticated diagnostic tests were added to a r m a m e n taria; as fewer and fewer physicians w e r e on constant call to t h e i r p a t i e n t s , t h e s e ~ p a t i e n t s - w i t h o u t portfolio" j o i n e d the r a n k s of the poor a n d of the gladiators of the u r b a n ghettoes in a n ever-increasing l e m m i n g trek into the "pits." There the frazzled i n t e r n waited. There the least sophisticated; the least trained; the least supervised doctor committed medical care on the p a t i e n t s at greatest risk: patients who presented by the twos a n d fours with the global potential for a n y disease or injury in a library of medical tomes. The p e n d u l u m was now at its outermost reach; at its true nadir. It was 1960. A m o m e n t of inertia, and the arc reversed with slow but ever-increasing m o m e n t u m . First, two physicians, t h e n five, well e s t a b l i s h e d in t h e i r practice skills b e g a n f u l l - t i m e careers in w h a t t h e y called emergency rooms. It was 1962. These p h y s i c i a n s met fortuitously in 1968 and shared their common interest. They organized, pro-
T the
C a r l J e l e n k o , III, M D JACEP Associate Editor
Ideas, P r o m i s e s and D e a d l i n e s Some research in emergency medicine has been going on quietly for three or more years, while concepts and results are repeatedly challenged or reproduced~ Other ideas are of fairly recent v i n t a g e and have been tested in relatively few experimental animals. Other reviews of clinical experience have resulted from m a n y hours of m i d n i g h t oil and chart analysis. The computer has c a l c u l a t e d s t a n d a r d d e v i a t i o n , s t a n d a r d e r r o r of thousands of samples, and when one applies the degrees of freedom, a ~'p" value has been obtained which, at times, is not as significant as one's i n i t i a l clinical impression. UA/EM has established its identity as the forum for reporting scientific emergency medicine research projects. The emergency medicine program director, the j u n i o r staff in emergency medicine and the new
p
r e s e n t a t i o n s at recent scientific m e e t i n g s have prompted m a n y of us to ask '~Why didn't I t h i n k of that?" D u r i n g the a n n u a l meeting of the U n i v e r s i t y Association for Emergency Medicine (UA/EM) earlier this y e a r m a n y e m e r g e n c y m e d i c i n e a c a d e m i c i a n s were heard to say, ~'I'm not sure I agree with t h a t concept. I'm going to research it and report my findings at next year's UA/EM meeting." The Biblical observation t h a t '~many are called b u t few are chosen" might be restated to apply to the p r o c r a s t i n a t i n g researcher: ~Many are the promises b u t few are the abstracts." Some of t h e u n m e t c h a l l e n g e s of e m e r g e n c y medicine have been tabulated. S t i m u l a t i o n for pursuing research projects arises from reading scientific reports, a t t e n d i n g n a t i o n a l meetings, c o m m u n i c a t i n g informally with colleagues, and individual introspection.
8"12 (December) 1979
JACEP
542/61
The P r o g r a m C o m m i t t e e has a n n o u n c e d J a n u a r y 31, 1980 as the deadline for receipt of a b s t r a c t s for the 1980 meeting. A limited n u m b e r of abstracts can be a c c e p t e d for p r e s e n t a t i o n . L a s t y e a r only h a l f t h e a b s t r a c t s s u b m i t t e d found a place on t h e final program. A l r e a d y this y e a r a n u m b e r of fine abstracts h a v e been received. You are encouraged to sttmmarize the results of your e m e r g e n c y medicine research and to construct your a b s t r a c t in a concise, m e a n i n g f u l way. You are encouraged to s u b m i t y o u r a b s t r a c t to t h e P r o g r a m Committee a t an e a r l y date. The future of academic emergency medicine is p r e d i c a t e d on the a b i l i t y of m e m b e r s of t h e s c i e n t i f i c e m e r g e n c y medicine c o m m u n i t y to develop a body of researchable knowledge which directly r e l a t e s to t h e discipline. It is with g r e a t a n t i c i p a t i o n t h a t I have a l r e a d y m a d e m y r e s e r v a t i o n s for the a n n u a l m e e t i n g o f the U n i v e r s i t y Association for E m e r g e n c y Medicine, and I encourage each of you to do the same.
breed of residents in e m e r g e n c y medicine ask ~How can I become accepted and recognized in this e l i t i s t organization, UA/EM?" A l t h o u g h in the p a s t UA/EM h a d i n n u m e r a b l e ad hoc committees, it h a s become c l e a r d u r i n g the p a s t t h r e e y e a r s t h a t the sole m e a n s of recognition in this h i g h l y selective organization is acceptance, on a scientific basis, of academic w o r k t h r o u g h research done in conceptual, logistic, applied clinical, or basic science research. The a n n u a l m e e t i n g of the U n i v e r s i t y Association for E m e r g e n c y M e d i c i n e w i l l be h e l d in T u c s o n , Arizona, A p r i l 13-17, 1980, and promises to be one of the most exciting, academically challenging m e e t i n g s in t h e history of emergency medicine. The r e s e a r c h projects which were r e p o r t e d at the 1979 O r l a n d o m e e t i n g h a d t h e g r e a t e s t n u m b e r of w o r t h w h i l e , well-researched p a p e r s in the history of the organization. F u r t h e r m o r e , t h e floor discussions r e v i e w i n g those articles were as professionally done and as scientifically pointed as those a t any academic m e e t i n g in the U n i t e d States. A continuation of this forum is expected at the Tucson meeting.
Kenneth L. Mattox, MD President, UA/EM
Annals of Emergency Medicine emergency medicine. As the n u m b e r of m a n u s c r i p t s s u b m i t t e d has increased we have become more selective of those to be printed. A p p r o x i m a t e l y 40% of all m a n u s c r i p t s reviewed by the E d i t o r i a l Board are rejected as we seek t o publish only the best work in the field. We have m a d e every effort to expedite the review and modification process so t h a t a u t h o r s are informed of t h e disposition of t h e i r m a n u s c r i p t s . Since J u l y 1979 we have tried to p u b l i s h an a v e r a g e of 10 scientific articles in each issue. Even so, t h e r e are occasionally delays of m a n y months before an accepted m a n u s c r i p t appears in the J o u r n a l . We are constantly s t r i v i n g to reduce t h e a m o u n t of t i m e between receipt and publication. The J o u r n a l owes much to the o r g a n i z a t i o n a l involvement and support provided by ACEP.and UA/EM. By r e q u i r i n g t h a t p r e s e n t e r s of original work at the organizations' a n n u a l m e e t i n g s s u b m i t t h e i r m a n u s c r i p t s for consideration by t h e J o u r n a l , we have b e n e f i t e d from t h e a v a i l a b i l i t y of m a n y e x c e l l e n t manuscripts. We look f o r w a r d to t h e c o n t i n u e d suloport of A C E P and UA/EM and to the continued involvement of emergency medicine's r e s e a r c h e r s and clinicians. A c o m m i t m e n t to excellence by all of us will ensure the continued growth of Annals of Emergency Medicine.
new era will begin with t h e J a n u a r y 1980 i~ssue of the J o u r n a l . A t t h a t time, this joint p u b l i s h i n g v e n t u r e of the A m e r i c a n College of E m e r g e n c y Physicians and the U n i v e r s i t y Association for E m e r g e n c y Medicine will be r e n a m e d Annals of Emergency Medicine. The new title is designed to reflect a b r o a d e r emp h a s i s on all aspects of t h e field of emergency medicine. The editorial content of the J o u r n a l Will continue its h i g h l y successful orientation. This c h a n g e c u l m i n a t e s a process b e g u n origin a l l y w i t h a n a n n o u n c e m e n t in t h e S e p t e m b e r / October 1974 issue and given impetus by George Podgorny, MD, in his recent s u m m a r y s t a t e m e n t as outgo-ing P r e s i d e n t of the College. A l t h o u g h t h e E d i t o r i a l Board, the A C E P Board of Directors, and the U A / E M Executive Council agreed to the n a m e change y e a r s ago, a delay was b r o u g h t about by legal actions t a k e n by t h e p u b l i s h e r of Emergency Medicine m a g a z i n e . But as the generic t e r m ~'emergency medicine" has become accepted as denoting an officially recognized a n d defined medical specialty, the three governing bodies h a v e agreed to proceed with the change a s originally scheduled. The n u m b e r a n d q u a l i t y of s u b m i s s i o n s to t h e J o u r n a l has risen r e m a r k a b l y in recent years. W h i l e m a n y of t h e kudos for this enhanced q u a l i t y have b e e n directed to the editors, t h e r e is little d o u b t t h a t t h e r e a l reason for this i m p r o v e m e n t is the c o m m i t m e n t by e m e r g e n c y p h y s i c i a n s to develop and m a i n t a i n a p u b l i c a t i o n of, by, and for professionals in the field of
A
62/543
Ronald L. Krome, MD Editor
JACEP
8"12 (December) 1979