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The biology of emergency medicine
FORUM
The Biology of Emergency Medicine Peter Rosen, MD Denver, Colorado
Rosen P: The biology of emergency medicine. JACEP 8:280-283, July, 1979.
emergency medicine, specialty
INTRODUCTION Aristotle has often been misquoted as stating that all things must have a beginning, middle, and end. What he actually said 1 was, "A whole is that which has a beginning, middle, and end." I think it might be instructive to analyze emergency medicine as a whole to present my vision of the specialness of emergency medicine.
THE WHOLE The BEGINNING - - "that which is not itself necessarily after anything else, and which has naturally something else after i t . . . , u The history of emergency medicine is not yet written. But less important than who were the first physicians to restrict their practice to emergency medicine are the reasons for the appearance of the specialty. It is hard to comprehend why it took so long for attention to be paid to the demands of the specialty. Certainly, since man took his first steps, there have been accidents and ailments that struck him down unawares. Doubtless, it takes a certain technology and willingness to intervene in natural disasters by an emergency response. Nevertheless, it is still an unaccountably late development in modern medicine. The beginning cannot, therefore, be the onset of those medical conditions that would mandate a professional emergency response. In fact, when one analyzes emergency medicine in terms of its case load, one is quickly struck b y the fact that true emergencies, ie, the life or limb threat, are .not what has produced the beginning of the field. Even the urgent cases (nonlife or limb threat but requiring a response to prevent deterioration into true emergency) probably would not have produced the field. In fact, I believe that two events coincided to produce the beginning: first was increasing numbers of nonemergency patients in the emergency department; second, the initial financial support for these cases in the emergency department. The cause of the increased workloads is multifactorial: the disappearance of primary physicians; the demise of the housecall, the growth of urban populations, the increased expectations of the public ("If you can put a man on the moon, why can't you cure my cold?"); the initial willingness of third party carriers to pay for emergency department visits but not office calls, and last, but not least, the captive presence of a physician in a predictable geographic area From Emergency Medical Services, Denver General:Hospital, Denver, Colorado. Presented at the Fifth Annual Rocky Mountain Regional Conference on Emergency Medicine in Keystone, Colorado, January 1979. Address for reprints: Peter Rosen, MD, Director, Emergency Medical Services, Denver General Hospital, West Eighth Avenue and Cherokee Street, Denver, Colorado 80204.
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~hen t h e p a t i e n t w a n t e d to be seen: the interface w i t h the medical d e l i v e r y system. I,m sure t h a t m a n y o t h e r factors can be offered to e x p l a i n this onset, b u t whatever the conglomeration of sociologic, technologic and sedical events, in the late 1960s the crisis became ~biquitous, a n d t h e r e s p o n s e p r o d u c e d e m e r g e n c y ~edicine. The MIDDLE - - " t h a t which is b y n a t u r e after one thing, a n d has also a n o t h e r after it. ''1 I It is h a r d l y a r g u a b l e t h a t e m e r g e n c y m e d i c i n e evolved along the only possible p a t h or even t h a t w h a t we recognize as emergency medicine t o d a y is the form that it will a s s u m e over the n e x t s e v e r a l decades. B u t as we a l l s t r u g g l e to define o u r roles a n d responsibilities, it is worthwhile to pause and ask: Is t h e r e anything u n i q u e a b o u t e m e r g e n c y medicine t h a t we can see in our struggle to define it as a special entity? That this was not done before the specialty h a d its beginning is not unique. While one can clearly distinguish b e t w e e n the allergist a n d t h e v a s c u l a r surgeon, and r e a d i l y u n d e r s t a n d the i n t e l l e c t u a l a n d t e c h n i c a l concerns t h a t s e p a r a t e them, the epistomological waters b e c o m e v e r y m u r k y w h e n t r y i n g to d e c i d e to whom to refer the facial fracture - - oral, plastic surgeon, or otolaryngologist.
vene in t h a t d e a t h t h r e a t , in fact, sets the limits of our field. L e t us e x a m i n e t h e d y i n g p a t i e n t . Despite t h e etiology, t h e r e a r e o n l y a s m a l l , finite n u m b e r of p a t h w a y s to death: f a i l u r e of r e s p i r a t i o n , f a i l u r e of circulation - - e i t h e r v i a t h e p u m p or via the volume of t h e s y s t e m , f a i l u r e o f t h e b r a i n , or f a i l u r e of metabolism. A l t h o u g h specific i n t e r v e n t i o n s m u s t be made for specific causes - - t h e response to the care coronary is different t h a n to the r e s p i r a t o r y failure from drug overdose -- our specialty establishes a d e q u a t e oxygenation, a n d does not teach b e t t e r t a b l e m a n n e r s to t h e former or p e r s o n a l i t y control to the l a t t e r . F u r t h e r m o r e , t h e p r o c e s s of d y i n g c a n be looked at grossly or microscopically. Not every p a t i e n t with low blood p r e s s u r e and r a p i d pulse has inadequate tissue perfusion. Correct a s s e s s m e n t h a s to be the most i m p o r t a n t r e s p o n s i b i l i t y of our specialty. Nor is our s p e c i a l t y confined to medical p a r a m e ters alone. E m e r g e n c y medicine h a s extended the a r m of t h e p h y s i c i a n to the field. In m a n y a r e a s we have been r e m i s s in a s s u m i n g t h e obligations of p r e h o s p i t a l care. But as one reviews t h e l i t e r a t u r e , it is s t r i k i n g how i n a d e q u a t e a n d i n a p p r o p r i a t e is the field medical control of the i n t e r n or of the coronary care unit. The education, function a n d q u a l i t y control of p r e h o s p i t a l c a r e m u s t , a n d w i l l , b e a s s u m e d by e m e r g e n c y medicine. In addition, t h e r e a r e the sociologic aspects of t h e acutely d y i n g to be d e a l t with. Much of the w o r k on d e a t h and d y i n g h a s b e e n in the context of chronic disease. All preconceived lessons m u s t be u n l e a r n e d w h e n calling out-of-state p a r e n t s to inform t h e m of t h e i r child's sudden death. To m y m i n d , t h e h a r d e s t t a s k in e m e r g e n c y medicine is the decision to send home a p o t e n t i a l l y life-threatened p a t i e n t . The p a t i e n t who is d i a p h o r e t i c w i t h clenched fist a n d an e l e c t r o c a r d i o g r a m (ECG) w i t h ST elevations p r e s e n t s no p r o b l e m in m a k i n g a decision. Not so the p a t i e n t who has had some chest pain, which is now gone, a n d no other clues to assist in the decision. Our awesome responsibility is deciding w h e t h e r to i n t e r v e n e in this p a t i e n t ' s life t h r e a t or to send h i m home. I w i s h I could say I have a l w a y s e r r e d on t h e side of safety for the p a t i e n t .
DEFINING THE SPECIALTY
Webster's Dictionary d e f i n e s a s p e c i a l t y as: " A branch of knowledge, science, a r t or business to which one devotes o n e s e l f w h e t h e r as a n avocation or a profession, and u s u a l l y to the p a r t i a l or t o t a l exclusion of related matters~. '' W h a t is there to e m e r g e n c y medicine to j u s t i f y this definition? First, t h e r e is the workload in and of itself. Not only did it produce the economic incentive for people to "exclude t o t a l l y or p a r t i a l l y r e l a t e d m a t t e r s , " b u t its l o g i s t i c s b e g a n to s h a p e t h e s p e c i a l n e s s o f emergency medicine. One of the specialty's responsibilities is not only to s e p a r a t e t h e sicker from the less sick b u t to j u g g l e several patients simultaneously. The emergency physician does not have the l u x u r y of devoting all of his energy to a single case at a time. To r e t u r n to the s e p a r a t i o n of emergency, u r g e n t , a n d n o n e m e r g e n c y , c l e a r l y m a n y of us c h o o s e emergency medicine because of t h e life or limb t h r e a t . The "cowboy case" m a k e s our a d r e n a l i n flow a n d combatting d e a t h is t h e i n t e l l e c t u a l and e m o t i o n a l challenge we sought in becoming physicians. But, in fact, as we e x a m i n e our response to t h e emergency, o u r res p o n s i b i l i t i e s a r e d e f i n e d less b y t h e d e f i n i t i o n of the disease s t a t e t h a n by the level of life threat. As an analogy, the role of e m e r g e n c y medicine is to catch the climber who is falling from a precipice and r e t u r n h i m to as much safety, as can be r e a d i l y achieved, b u t not necessarily to get h i m all t h e w a y b a c k down to the valley. Nor does it m a t t e r how he fell. The life t h r e a t of the fall m u s t be overcome before d e t e r m i n i n g t h a t his rope broke or t h a t he Was p u s h e d by a j i l t e d lover. A t times, t h a t i n t e r v e n t i o n can be lifesaving; a t times, m e r e l y stabilizing as in volume r e p l a c e m e n t in the h e m o r r h a g i n g patient. A n d as we define o u r r e s p o n s i b i l i t i e s , we g e t c a u g h t up i n t h e u n i q u e n e s s of o u r s p e c i a l t y . T h e dying o r g a n i s m b e h a v e s differently. W h e r e we inter8:7 (July) !979
EMERGENCY MEDICINE'S UNIQUE BIOLOGY To r e t u r n to the classic acute m y o c a r d i a l infarction, the biology of e m e r g e n c y medicine does not dem a n d proof of t h i s d i a g n o s i s in the e m e r g e n c y dep a r t m e n t ; it does d e m a n d stabilization. U n t i l this lesson is learned, lives will be lost while ECGs a r e being r u n prior to p l a c e m e n t of IV lines and a d m i n i s t r a t i o n of prophylactic lidocaine. For a n u m b e r of years, I have been s a y i n g t h a t the e m e r g e n c y p h y s i c i a n m u s t be as good as the cardiologist in r u n n i n g a n a r r e s t . After s e v e r a l r e c e n t experiences w a t c h i n g cardiologists in charge of a n arrest, I say they m u s t become as good as the e m e r g e n c y physician. It is t i m e t h a t we accept o u r role in m e d i c i n e without apology a n d w i t h the confidence t h a t we can do the job well w i t h o u t c a l l i n g for help u n t i l t h e n e x t phase of care by the a p p r o p r i a t e specialty. The d a y s w h e n the e m e r g e n c y p h y s i c i a n functioned as a referr i n g s e c r e t a r y a n d a s k e d p e r m i s s i o n before i n t e r v e n -
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ing in a p a t i e n t ' s life t h r e a t , must, should, a n d shall come to an end. P a t i e n t s do not '~belong" to p h y s i c i a n s or services. P a t i e n t s have p r o b l e m s t h a t r e q u i r e c a r e on m a n y levels. The quality, appropriateness and t i m e l i n e s s of the i n i t i a l care is the biology and r e s p o n s i b i l i t y of our specialty. No one who h a s n ' t t r a i n e d for it, or practiced it o t h e r t h a n full-time, is capable of r e n d e r i n g it. Merely because someone passed through an emergency medicine service as a student, intern, or medical r e s i d e n t does not give t h e m the expertise of our specialty. It t a k e s y e a r s of diligence, experience, and c o m m i t m e n t to gain t h a t expertise. The limit of our specialty is, therefore, set by its u n i q u e biology, and t h a t t i m e c o n t i n u u m w h e n other i n t e r v e n t i o n s b e c o m e a p p r o p r i a t e . These will v a r y w i t h the degree of life t h r e a t , the need for future care, or the need for i n p a t i e n t or follow-up care. But to a degree, to r e t u r n to our analogy, the type of intervention r e l a t e s to the distance to the valley. C e r t a i n life t h r e a t s c a n be s t a b i l i z e d d e f i n i t i v e l y w i t h i n t h e e m e r g e n c y d e p a r t m e n t . Others require special interventions, frequently dictated by how critical is time. F o r example, an extensive facial l a c e r a t i o n m u s t at t i m e s be referred to a surgeon because t h e r e are 20 o t h e r p a t i e n t s a w a i t i n g care.
of p a t i e n t s is not j u s t w h a t is h a p p e n i n g on the cellu. lar level b u t the interface b e t w e e n h e a l t h and disease, between p a t i e n t and system, and between emergency system and the i n p a t i e n t service. No e m e r g e n c y patient, w h a t e v e r the m a g n i t u d e of his problem, is free from fear. '~An emergency is a~ acute problem I have which I fear will t u r n into some. t h i n g worse," said a s t u d e n t to m e once. The sore t h r o a t t h a t seemed a mild a n n o y a n c e d u r i n g the day, becomes d i p h t h e r i t i c choking (to the patient) in the middle of the night. The blood p r e s s u r e check at 3 a~ is fear of i m p e n d i n g stroke. Moreover, the fear of the r e l a t i v e s m u s t be part of the interface. Who can forget the panic of a carihg person facing the awesome r e a l i t y of an acutely in. j u r e d and life t h r e a t e n e d relative? We all live on the b r i n k of d i s a s t e r and helping people on the wrong side L of t h a t b r i n k is one of e m e r g e n c y medicine's biologies. Even w h e n d e a l i n g with a nonemergency, it is s t i l l i n c u m b e n t u p o n t h e e m e r g e n c y p h y s i c i a n to e l i m i n a t e all possible life t h r e a t s a n d to t r y to discover w h a t m o t i v a t e d t h i s visit. Often, it is Something other t h a n the s t a t e d complaint. S o m e t i m e s the motive is never clear and the e m e r g e n c y d e p a r t m e n t has to ad. j u s t to p a t i e n t s who will not seek medical attention a n y w h e r e else. We h a v e f r e q u e n t l y s e e n t h e phe. nomenon of p a t i e n t s who relate to an institution, and specifically the e m e r g e n c y d e p a r t m e n t , r a t h e r than, and in preference to, a n i n d i v i d u a l physician. This is becoming true not j u s t for i n d i g e n t s who have been n u r t u r e d in a s y s t e m of r o t a t i n g h o u s e s t a f f but also in a d e q u a t e l y funded p a t i e n t s who s i m p l y possess what we call the s u p e r m a r k e t m e n t a l i t y of medical care. As one reviews the t o t a l c o m m i t m e n t of the field, a new responsibility emerges t h a t indeed requires special skills a n d knowledge - - the a b i l i t y to prioritize and a p p r o p r i a t e l y t r e a t each of t h e s e t h r e e categories. We are poorly t a u g h t in medical school and residencies to d i s t i n g u i s h sick from well. There are two g r e a t shocks for every e m e r g e n c y medicine resident: one, not every p a t i e n t is sick, and two, m a n y patients are much sicker t h a n t h e y first appear. Not only m u s t we l e a r n the specialized skill of sorting and t r e a t i n g these categories b u t we m u s t research the q u a l i t y and q u a n t i t y of care appropriate to each.
EMERGENCY MEDICINE IN THE FUTURE But is it enough to be involved in only one phase of life threat? The a n s w e r to t h a t question is the shape of emergency medicine in the future. The degree of satisfaction or dissatisfaction in a n y field is the price t a g or r e w a r d upon w h i c h c o n t i n u e d p a r t i c i p a t i o n hangs. I t h i n k e m e r g e n c y medicine "burn out" is more dependent on t h e psychic tension and stress of d e a l i n g w i t h d e a t h as a s t e a d y diet t h a n a lack of being able to "play in the valley." A second component o f our specialty is the u r g e n t patient. Here, too, is a special pathophysiology t h a t r e q u i r e s knowledge, technique and c o m m i t m e n t s - the pathophysiology in acute exacerbation of a chronic disease or l i m i t e d n o n l i f e - t h r e a t e n i n g disease. E v e n if t h e p a t i e n t is n o t s e r i o u s l y d e c o m p e n s a t i n g , t h a t t h r e a t m u s t be r u l e d out. The h a r d e s t m e n t a l change to create in new r e s i d e n t s is to ~'assume the worst e v e n if s t a t i s t i c a l l y i m p r o b a b l e . " N o w h e r e in i n p a t i e n t medicine does one l e a r n t h a t in early disease states, the t h r e a t to life, or well-being, hides itself. The responsibility is to describe or to deny t h a t life t h r e a t r a t h e r t h a n to place a specific label on a patient. M a n y p a t i e n t s c a n be t o t a l l y c a r e d for w i t h i n e m e r g e n c y medicine; m a n y will require some followup. Again, the degree of service will depend on f u t u r e definitions and m a y h a v e much less to do w i t h s t a t e d t u r f t h a n how care is p a i d t0r. For example, at the city h o s p i t a l or u n d e r n a t i o n a l h e a l t h i n s u r a n c e m a n y cases are, or will be, seen in the e m e r g e n c y departm e n t which had been m a n d a t o r y referrals to private offices. F i n a l l y , t h e r e is t h e price t a g of our specialty: the n o n e m e r g e n c y p a t i e n t . He, of course, t r i e s o u r patience, s t u l t i f i e s o u r d r e a m s of professional importance, produces voluminous letters of complaint, a n d of course, p a y s our e x t r a v a g a n t salaries. But t h e r e is still s o m e t h i n g unique about the p a t i e n t who d e m a n d s a blood p r e s s u r e check a t 3 am. But w h a t is unique t o the field in all t h r e e classes
RESEARCH E m e r g e n c y medicine h a s y e t to define to anyone's satisfaction its r e s e a r c h goals. T h a t is h a r d l y unique to emergency medicine in its p r e s e n t infancy. IS there a biochemical definition of d e a t h a n d dying? We still live w i t h the legacy of t h e 1950s which insisted all medicine fit into the Kreb's cycle. It will b e v e r y hard to produce t h i s k i n d of research, not only because we l a c k the t a l e n t (at p r e s e n t at any rate), b u t also because the big a n d e a s y basic r e s e a r c h dollar is now much h a r d e r to come by. Nevertheless, I do believe t h e r e is much basic l a b o r a t o r y r e s e a r c h p e r t i n e n t to our field, and given t i m e and support, we will have a m u c h e a s i e r t i m e d e m o n s t r a t i n g o u r own unique biology. For example, let someone discover a solution that will c a r r y and r e l e a s e oxygen a n d carbon dioxide and a t r i p to Stockholm awaits. U n q u e s t i o n a b l y , t h e r e is g r e a t room for viable clinical r e s e a r c h and inroads have been made. t personally believe t h a t m a n y of our most respectable clin-
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ical notions, doctrines and fads will be overturned in the next t e n years as appropriate emergency medical clinical t r e a t m e n t schedules are devised. S y s t e m s r e s e a r c h is p r e s e n t l y f a s h i o n a b l e in ~Vashington b u t hopefully will produce something of a little higher q u a l i t y t h a n anecdotes about MAST suits or time schedules of patients a p p e a r i n g in emergency departments. i While we are t a l k i n g about our middle, we m u s t discuss education. Our concept of w h a t constitutes a valid residency experience in emergency medicine is beginning to crystallize. There are three ingredients t h a t appear critical: first, adequate p a t i e n t pathology in the emergency department; second, an adequate attending f a c u l t y in the emergency department, a n d I third , a n adequate n u m b e r of residents in the emeri gency department. If you don't control your own service, you cannot develop into a proper specialist. The one t h i n g t h a t has r e f i n e d my v i s i o n of emergency medicine more t h a n any other single factor is watching the evolution of self confidence, specialty awareness and poise of the emergency medicine resident who has acquired his t r a i n i n g i n the kind of residency described above. There is no substitute for online experience. You cannot learn emergency medicine on someone else's service. We don't do a good job of educating the undergraduate in emergency medicine. That, too, is something t h a t will require some time as well a s commitment from the medical schools, nor is it u n i q u e to emergency medicine. At present, our best effort is in the senior elective b u t even this m u s t be improved. Education for the practicing physician is also in its infancy. Despite our efforts to s t i m u l a t e c o n t i n u i n g medical education programs, there doesn't exist yet the slightest shred of evidence t h a t CME effectively alters b e h a v i o r , except i n m a k i n g c u r v e d p a r a l l e l turns on the ski slope. Again, I believe in addition to didactics, laboratories and workshops, we m u s t de-
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velop some in situ emergency d e p a r t m e n t teaching for the practicing physician. I cannot leave the middle w i t h o u t c o m m e n t on emergency medicine a d m i n i s t r a t i o n and service. J u s t as I b e l i e v e t h a t e d u c a t i o n b e s t occurs i n t h e emergency d e p a r t m e n t , I believe t h a t the field has suffered from too much a d m i n i s t r a t i o n divorced from the d e p a r t m e n t - - either because the director simply has not or does not now practice emergency medicine, or because he is assigned to the d e p a r t m e n t with no c o m m i t m e n t to the specialty. I cannot divorce service from a d m i n i s t r a t i o n , nor do I t h i n k anyone will ever comprehend the true responsibilities of the specialty unless they have a m a l g a m a t e d both areas.
AND F I N A L L Y . . . The END - - " t h a t which is n a t u r a l l y after somet h i n g itself, e i t h e r as its n e c e s s a r y or u s u a l consequent, and with n o t h i n g else after it;...,,1 W h e n involved i n the middle, it is always difficult to foresee an end. Perhaps there is no situation t h a t will negate emergency medicine's ever being a whole, short of a n u c l e a r holocaust destroying all m a n k i n d . But even should unforeseen technologies, sociologies, or economics produce an end to our specialty, we shall have had an u n p a r a l l e l e d opportunity for intellectual and emotional career growth and development. I shall close by quoting Oliver Wendell Holmes (Bartletts): "I find the great t h i n g in this world is not so much where we stand, as in w h a t direction we are moving: to reach the port of heaven, we m u s t sail sometimes with the wind and sometimes against it - b u t we m u s t sail, and not drift, or lie at anchor."
REFERENCES 1. P o e t i c s B o o k 2 - A r i s t o t l e .
Britannica Great Books, Ency-
clopaedia Britannica, 1952.
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The Biology of Emergency Medicine Peter Rosen, MD Denver, Colorado
Rosen P: The biology of emergency medicine. JACEP 8:280-283, July, 1979.
emergency medicine, specialty
INTRODUCTION Aristotle has often been misquoted as stating that all things must have a beginning, middle, and end. What he actually said 1 was, "A whole is that which has a beginning, middle, and end." I think it might be instructive to analyze emergency medicine as a whole to present my vision of the specialness of emergency medicine.
THE WHOLE The BEGINNING - - "that which is not itself necessarily after anything else, and which has naturally something else after i t . . . , u The history of emergency medicine is not yet written. But less important than who were the first physicians to restrict their practice to emergency medicine are the reasons for the appearance of the specialty. It is hard to comprehend why it took so long for attention to be paid to the demands of the specialty. Certainly, since man took his first steps, there have been accidents and ailments that struck him down unawares. Doubtless, it takes a certain technology and willingness to intervene in natural disasters by an emergency response. Nevertheless, it is still an unaccountably late development in modern medicine. The beginning cannot, therefore, be the onset of those medical conditions that would mandate a professional emergency response. In fact, when one analyzes emergency medicine in terms of its case load, one is quickly struck b y the fact that true emergencies, ie, the life or limb threat, are .not what has produced the beginning of the field. Even the urgent cases (nonlife or limb threat but requiring a response to prevent deterioration into true emergency) probably would not have produced the field. In fact, I believe that two events coincided to produce the beginning: first was increasing numbers of nonemergency patients in the emergency department; second, the initial financial support for these cases in the emergency department. The cause of the increased workloads is multifactorial: the disappearance of primary physicians; the demise of the housecall, the growth of urban populations, the increased expectations of the public ("If you can put a man on the moon, why can't you cure my cold?"); the initial willingness of third party carriers to pay for emergency department visits but not office calls, and last, but not least, the captive presence of a physician in a predictable geographic area From Emergency Medical Services, Denver General:Hospital, Denver, Colorado. Presented at the Fifth Annual Rocky Mountain Regional Conference on Emergency Medicine in Keystone, Colorado, January 1979. Address for reprints: Peter Rosen, MD, Director, Emergency Medical Services, Denver General Hospital, West Eighth Avenue and Cherokee Street, Denver, Colorado 80204.
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~hen t h e p a t i e n t w a n t e d to be seen: the interface w i t h the medical d e l i v e r y system. I,m sure t h a t m a n y o t h e r factors can be offered to e x p l a i n this onset, b u t whatever the conglomeration of sociologic, technologic and sedical events, in the late 1960s the crisis became ~biquitous, a n d t h e r e s p o n s e p r o d u c e d e m e r g e n c y ~edicine. The MIDDLE - - " t h a t which is b y n a t u r e after one thing, a n d has also a n o t h e r after it. ''1 I It is h a r d l y a r g u a b l e t h a t e m e r g e n c y m e d i c i n e evolved along the only possible p a t h or even t h a t w h a t we recognize as emergency medicine t o d a y is the form that it will a s s u m e over the n e x t s e v e r a l decades. B u t as we a l l s t r u g g l e to define o u r roles a n d responsibilities, it is worthwhile to pause and ask: Is t h e r e anything u n i q u e a b o u t e m e r g e n c y medicine t h a t we can see in our struggle to define it as a special entity? That this was not done before the specialty h a d its beginning is not unique. While one can clearly distinguish b e t w e e n the allergist a n d t h e v a s c u l a r surgeon, and r e a d i l y u n d e r s t a n d the i n t e l l e c t u a l a n d t e c h n i c a l concerns t h a t s e p a r a t e them, the epistomological waters b e c o m e v e r y m u r k y w h e n t r y i n g to d e c i d e to whom to refer the facial fracture - - oral, plastic surgeon, or otolaryngologist.
vene in t h a t d e a t h t h r e a t , in fact, sets the limits of our field. L e t us e x a m i n e t h e d y i n g p a t i e n t . Despite t h e etiology, t h e r e a r e o n l y a s m a l l , finite n u m b e r of p a t h w a y s to death: f a i l u r e of r e s p i r a t i o n , f a i l u r e of circulation - - e i t h e r v i a t h e p u m p or via the volume of t h e s y s t e m , f a i l u r e o f t h e b r a i n , or f a i l u r e of metabolism. A l t h o u g h specific i n t e r v e n t i o n s m u s t be made for specific causes - - t h e response to the care coronary is different t h a n to the r e s p i r a t o r y failure from drug overdose -- our specialty establishes a d e q u a t e oxygenation, a n d does not teach b e t t e r t a b l e m a n n e r s to t h e former or p e r s o n a l i t y control to the l a t t e r . F u r t h e r m o r e , t h e p r o c e s s of d y i n g c a n be looked at grossly or microscopically. Not every p a t i e n t with low blood p r e s s u r e and r a p i d pulse has inadequate tissue perfusion. Correct a s s e s s m e n t h a s to be the most i m p o r t a n t r e s p o n s i b i l i t y of our specialty. Nor is our s p e c i a l t y confined to medical p a r a m e ters alone. E m e r g e n c y medicine h a s extended the a r m of t h e p h y s i c i a n to the field. In m a n y a r e a s we have been r e m i s s in a s s u m i n g t h e obligations of p r e h o s p i t a l care. But as one reviews t h e l i t e r a t u r e , it is s t r i k i n g how i n a d e q u a t e a n d i n a p p r o p r i a t e is the field medical control of the i n t e r n or of the coronary care unit. The education, function a n d q u a l i t y control of p r e h o s p i t a l c a r e m u s t , a n d w i l l , b e a s s u m e d by e m e r g e n c y medicine. In addition, t h e r e a r e the sociologic aspects of t h e acutely d y i n g to be d e a l t with. Much of the w o r k on d e a t h and d y i n g h a s b e e n in the context of chronic disease. All preconceived lessons m u s t be u n l e a r n e d w h e n calling out-of-state p a r e n t s to inform t h e m of t h e i r child's sudden death. To m y m i n d , t h e h a r d e s t t a s k in e m e r g e n c y medicine is the decision to send home a p o t e n t i a l l y life-threatened p a t i e n t . The p a t i e n t who is d i a p h o r e t i c w i t h clenched fist a n d an e l e c t r o c a r d i o g r a m (ECG) w i t h ST elevations p r e s e n t s no p r o b l e m in m a k i n g a decision. Not so the p a t i e n t who has had some chest pain, which is now gone, a n d no other clues to assist in the decision. Our awesome responsibility is deciding w h e t h e r to i n t e r v e n e in this p a t i e n t ' s life t h r e a t or to send h i m home. I w i s h I could say I have a l w a y s e r r e d on t h e side of safety for the p a t i e n t .
DEFINING THE SPECIALTY
Webster's Dictionary d e f i n e s a s p e c i a l t y as: " A branch of knowledge, science, a r t or business to which one devotes o n e s e l f w h e t h e r as a n avocation or a profession, and u s u a l l y to the p a r t i a l or t o t a l exclusion of related matters~. '' W h a t is there to e m e r g e n c y medicine to j u s t i f y this definition? First, t h e r e is the workload in and of itself. Not only did it produce the economic incentive for people to "exclude t o t a l l y or p a r t i a l l y r e l a t e d m a t t e r s , " b u t its l o g i s t i c s b e g a n to s h a p e t h e s p e c i a l n e s s o f emergency medicine. One of the specialty's responsibilities is not only to s e p a r a t e t h e sicker from the less sick b u t to j u g g l e several patients simultaneously. The emergency physician does not have the l u x u r y of devoting all of his energy to a single case at a time. To r e t u r n to the s e p a r a t i o n of emergency, u r g e n t , a n d n o n e m e r g e n c y , c l e a r l y m a n y of us c h o o s e emergency medicine because of t h e life or limb t h r e a t . The "cowboy case" m a k e s our a d r e n a l i n flow a n d combatting d e a t h is t h e i n t e l l e c t u a l and e m o t i o n a l challenge we sought in becoming physicians. But, in fact, as we e x a m i n e our response to t h e emergency, o u r res p o n s i b i l i t i e s a r e d e f i n e d less b y t h e d e f i n i t i o n of the disease s t a t e t h a n by the level of life threat. As an analogy, the role of e m e r g e n c y medicine is to catch the climber who is falling from a precipice and r e t u r n h i m to as much safety, as can be r e a d i l y achieved, b u t not necessarily to get h i m all t h e w a y b a c k down to the valley. Nor does it m a t t e r how he fell. The life t h r e a t of the fall m u s t be overcome before d e t e r m i n i n g t h a t his rope broke or t h a t he Was p u s h e d by a j i l t e d lover. A t times, t h a t i n t e r v e n t i o n can be lifesaving; a t times, m e r e l y stabilizing as in volume r e p l a c e m e n t in the h e m o r r h a g i n g patient. A n d as we define o u r r e s p o n s i b i l i t i e s , we g e t c a u g h t up i n t h e u n i q u e n e s s of o u r s p e c i a l t y . T h e dying o r g a n i s m b e h a v e s differently. W h e r e we inter8:7 (July) !979
EMERGENCY MEDICINE'S UNIQUE BIOLOGY To r e t u r n to the classic acute m y o c a r d i a l infarction, the biology of e m e r g e n c y medicine does not dem a n d proof of t h i s d i a g n o s i s in the e m e r g e n c y dep a r t m e n t ; it does d e m a n d stabilization. U n t i l this lesson is learned, lives will be lost while ECGs a r e being r u n prior to p l a c e m e n t of IV lines and a d m i n i s t r a t i o n of prophylactic lidocaine. For a n u m b e r of years, I have been s a y i n g t h a t the e m e r g e n c y p h y s i c i a n m u s t be as good as the cardiologist in r u n n i n g a n a r r e s t . After s e v e r a l r e c e n t experiences w a t c h i n g cardiologists in charge of a n arrest, I say they m u s t become as good as the e m e r g e n c y physician. It is t i m e t h a t we accept o u r role in m e d i c i n e without apology a n d w i t h the confidence t h a t we can do the job well w i t h o u t c a l l i n g for help u n t i l t h e n e x t phase of care by the a p p r o p r i a t e specialty. The d a y s w h e n the e m e r g e n c y p h y s i c i a n functioned as a referr i n g s e c r e t a r y a n d a s k e d p e r m i s s i o n before i n t e r v e n -
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ing in a p a t i e n t ' s life t h r e a t , must, should, a n d shall come to an end. P a t i e n t s do not '~belong" to p h y s i c i a n s or services. P a t i e n t s have p r o b l e m s t h a t r e q u i r e c a r e on m a n y levels. The quality, appropriateness and t i m e l i n e s s of the i n i t i a l care is the biology and r e s p o n s i b i l i t y of our specialty. No one who h a s n ' t t r a i n e d for it, or practiced it o t h e r t h a n full-time, is capable of r e n d e r i n g it. Merely because someone passed through an emergency medicine service as a student, intern, or medical r e s i d e n t does not give t h e m the expertise of our specialty. It t a k e s y e a r s of diligence, experience, and c o m m i t m e n t to gain t h a t expertise. The limit of our specialty is, therefore, set by its u n i q u e biology, and t h a t t i m e c o n t i n u u m w h e n other i n t e r v e n t i o n s b e c o m e a p p r o p r i a t e . These will v a r y w i t h the degree of life t h r e a t , the need for future care, or the need for i n p a t i e n t or follow-up care. But to a degree, to r e t u r n to our analogy, the type of intervention r e l a t e s to the distance to the valley. C e r t a i n life t h r e a t s c a n be s t a b i l i z e d d e f i n i t i v e l y w i t h i n t h e e m e r g e n c y d e p a r t m e n t . Others require special interventions, frequently dictated by how critical is time. F o r example, an extensive facial l a c e r a t i o n m u s t at t i m e s be referred to a surgeon because t h e r e are 20 o t h e r p a t i e n t s a w a i t i n g care.
of p a t i e n t s is not j u s t w h a t is h a p p e n i n g on the cellu. lar level b u t the interface b e t w e e n h e a l t h and disease, between p a t i e n t and system, and between emergency system and the i n p a t i e n t service. No e m e r g e n c y patient, w h a t e v e r the m a g n i t u d e of his problem, is free from fear. '~An emergency is a~ acute problem I have which I fear will t u r n into some. t h i n g worse," said a s t u d e n t to m e once. The sore t h r o a t t h a t seemed a mild a n n o y a n c e d u r i n g the day, becomes d i p h t h e r i t i c choking (to the patient) in the middle of the night. The blood p r e s s u r e check at 3 a~ is fear of i m p e n d i n g stroke. Moreover, the fear of the r e l a t i v e s m u s t be part of the interface. Who can forget the panic of a carihg person facing the awesome r e a l i t y of an acutely in. j u r e d and life t h r e a t e n e d relative? We all live on the b r i n k of d i s a s t e r and helping people on the wrong side L of t h a t b r i n k is one of e m e r g e n c y medicine's biologies. Even w h e n d e a l i n g with a nonemergency, it is s t i l l i n c u m b e n t u p o n t h e e m e r g e n c y p h y s i c i a n to e l i m i n a t e all possible life t h r e a t s a n d to t r y to discover w h a t m o t i v a t e d t h i s visit. Often, it is Something other t h a n the s t a t e d complaint. S o m e t i m e s the motive is never clear and the e m e r g e n c y d e p a r t m e n t has to ad. j u s t to p a t i e n t s who will not seek medical attention a n y w h e r e else. We h a v e f r e q u e n t l y s e e n t h e phe. nomenon of p a t i e n t s who relate to an institution, and specifically the e m e r g e n c y d e p a r t m e n t , r a t h e r than, and in preference to, a n i n d i v i d u a l physician. This is becoming true not j u s t for i n d i g e n t s who have been n u r t u r e d in a s y s t e m of r o t a t i n g h o u s e s t a f f but also in a d e q u a t e l y funded p a t i e n t s who s i m p l y possess what we call the s u p e r m a r k e t m e n t a l i t y of medical care. As one reviews the t o t a l c o m m i t m e n t of the field, a new responsibility emerges t h a t indeed requires special skills a n d knowledge - - the a b i l i t y to prioritize and a p p r o p r i a t e l y t r e a t each of t h e s e t h r e e categories. We are poorly t a u g h t in medical school and residencies to d i s t i n g u i s h sick from well. There are two g r e a t shocks for every e m e r g e n c y medicine resident: one, not every p a t i e n t is sick, and two, m a n y patients are much sicker t h a n t h e y first appear. Not only m u s t we l e a r n the specialized skill of sorting and t r e a t i n g these categories b u t we m u s t research the q u a l i t y and q u a n t i t y of care appropriate to each.
EMERGENCY MEDICINE IN THE FUTURE But is it enough to be involved in only one phase of life threat? The a n s w e r to t h a t question is the shape of emergency medicine in the future. The degree of satisfaction or dissatisfaction in a n y field is the price t a g or r e w a r d upon w h i c h c o n t i n u e d p a r t i c i p a t i o n hangs. I t h i n k e m e r g e n c y medicine "burn out" is more dependent on t h e psychic tension and stress of d e a l i n g w i t h d e a t h as a s t e a d y diet t h a n a lack of being able to "play in the valley." A second component o f our specialty is the u r g e n t patient. Here, too, is a special pathophysiology t h a t r e q u i r e s knowledge, technique and c o m m i t m e n t s - the pathophysiology in acute exacerbation of a chronic disease or l i m i t e d n o n l i f e - t h r e a t e n i n g disease. E v e n if t h e p a t i e n t is n o t s e r i o u s l y d e c o m p e n s a t i n g , t h a t t h r e a t m u s t be r u l e d out. The h a r d e s t m e n t a l change to create in new r e s i d e n t s is to ~'assume the worst e v e n if s t a t i s t i c a l l y i m p r o b a b l e . " N o w h e r e in i n p a t i e n t medicine does one l e a r n t h a t in early disease states, the t h r e a t to life, or well-being, hides itself. The responsibility is to describe or to deny t h a t life t h r e a t r a t h e r t h a n to place a specific label on a patient. M a n y p a t i e n t s c a n be t o t a l l y c a r e d for w i t h i n e m e r g e n c y medicine; m a n y will require some followup. Again, the degree of service will depend on f u t u r e definitions and m a y h a v e much less to do w i t h s t a t e d t u r f t h a n how care is p a i d t0r. For example, at the city h o s p i t a l or u n d e r n a t i o n a l h e a l t h i n s u r a n c e m a n y cases are, or will be, seen in the e m e r g e n c y departm e n t which had been m a n d a t o r y referrals to private offices. F i n a l l y , t h e r e is t h e price t a g of our specialty: the n o n e m e r g e n c y p a t i e n t . He, of course, t r i e s o u r patience, s t u l t i f i e s o u r d r e a m s of professional importance, produces voluminous letters of complaint, a n d of course, p a y s our e x t r a v a g a n t salaries. But t h e r e is still s o m e t h i n g unique about the p a t i e n t who d e m a n d s a blood p r e s s u r e check a t 3 am. But w h a t is unique t o the field in all t h r e e classes
RESEARCH E m e r g e n c y medicine h a s y e t to define to anyone's satisfaction its r e s e a r c h goals. T h a t is h a r d l y unique to emergency medicine in its p r e s e n t infancy. IS there a biochemical definition of d e a t h a n d dying? We still live w i t h the legacy of t h e 1950s which insisted all medicine fit into the Kreb's cycle. It will b e v e r y hard to produce t h i s k i n d of research, not only because we l a c k the t a l e n t (at p r e s e n t at any rate), b u t also because the big a n d e a s y basic r e s e a r c h dollar is now much h a r d e r to come by. Nevertheless, I do believe t h e r e is much basic l a b o r a t o r y r e s e a r c h p e r t i n e n t to our field, and given t i m e and support, we will have a m u c h e a s i e r t i m e d e m o n s t r a t i n g o u r own unique biology. For example, let someone discover a solution that will c a r r y and r e l e a s e oxygen a n d carbon dioxide and a t r i p to Stockholm awaits. U n q u e s t i o n a b l y , t h e r e is g r e a t room for viable clinical r e s e a r c h and inroads have been made. t personally believe t h a t m a n y of our most respectable clin-
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ical notions, doctrines and fads will be overturned in the next t e n years as appropriate emergency medical clinical t r e a t m e n t schedules are devised. S y s t e m s r e s e a r c h is p r e s e n t l y f a s h i o n a b l e in ~Vashington b u t hopefully will produce something of a little higher q u a l i t y t h a n anecdotes about MAST suits or time schedules of patients a p p e a r i n g in emergency departments. i While we are t a l k i n g about our middle, we m u s t discuss education. Our concept of w h a t constitutes a valid residency experience in emergency medicine is beginning to crystallize. There are three ingredients t h a t appear critical: first, adequate p a t i e n t pathology in the emergency department; second, an adequate attending f a c u l t y in the emergency department, a n d I third , a n adequate n u m b e r of residents in the emeri gency department. If you don't control your own service, you cannot develop into a proper specialist. The one t h i n g t h a t has r e f i n e d my v i s i o n of emergency medicine more t h a n any other single factor is watching the evolution of self confidence, specialty awareness and poise of the emergency medicine resident who has acquired his t r a i n i n g i n the kind of residency described above. There is no substitute for online experience. You cannot learn emergency medicine on someone else's service. We don't do a good job of educating the undergraduate in emergency medicine. That, too, is something t h a t will require some time as well a s commitment from the medical schools, nor is it u n i q u e to emergency medicine. At present, our best effort is in the senior elective b u t even this m u s t be improved. Education for the practicing physician is also in its infancy. Despite our efforts to s t i m u l a t e c o n t i n u i n g medical education programs, there doesn't exist yet the slightest shred of evidence t h a t CME effectively alters b e h a v i o r , except i n m a k i n g c u r v e d p a r a l l e l turns on the ski slope. Again, I believe in addition to didactics, laboratories and workshops, we m u s t de-
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velop some in situ emergency d e p a r t m e n t teaching for the practicing physician. I cannot leave the middle w i t h o u t c o m m e n t on emergency medicine a d m i n i s t r a t i o n and service. J u s t as I b e l i e v e t h a t e d u c a t i o n b e s t occurs i n t h e emergency d e p a r t m e n t , I believe t h a t the field has suffered from too much a d m i n i s t r a t i o n divorced from the d e p a r t m e n t - - either because the director simply has not or does not now practice emergency medicine, or because he is assigned to the d e p a r t m e n t with no c o m m i t m e n t to the specialty. I cannot divorce service from a d m i n i s t r a t i o n , nor do I t h i n k anyone will ever comprehend the true responsibilities of the specialty unless they have a m a l g a m a t e d both areas.
AND F I N A L L Y . . . The END - - " t h a t which is n a t u r a l l y after somet h i n g itself, e i t h e r as its n e c e s s a r y or u s u a l consequent, and with n o t h i n g else after it;...,,1 W h e n involved i n the middle, it is always difficult to foresee an end. Perhaps there is no situation t h a t will negate emergency medicine's ever being a whole, short of a n u c l e a r holocaust destroying all m a n k i n d . But even should unforeseen technologies, sociologies, or economics produce an end to our specialty, we shall have had an u n p a r a l l e l e d opportunity for intellectual and emotional career growth and development. I shall close by quoting Oliver Wendell Holmes (Bartletts): "I find the great t h i n g in this world is not so much where we stand, as in w h a t direction we are moving: to reach the port of heaven, we m u s t sail sometimes with the wind and sometimes against it - b u t we m u s t sail, and not drift, or lie at anchor."
REFERENCES 1. P o e t i c s B o o k 2 - A r i s t o t l e .
Britannica Great Books, Ency-
clopaedia Britannica, 1952.
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