- Email: [email protected]
What is past is prologue
EDITORIALS What is Past is Prologue Following is the text of a speech given by John P. McDade, MD, A C E P President, at the President's Awards Banquet, October 3, 1979 in Atlanta.
have changed over the years, a n d how in t u r n the p h y s i c i a n views the world a r o u n d him. My own memories go back to t h a t simpler time before World War II when we knew the physician as our ~'family doctor." We t h o u g h t of his professional org a n i z a t i o n with the same degree of t r u s t and respect. The organizations themselves were devoted almost tot a l l y to the a d v a n c e m e n t of scientific knowledge and physician education. The public was less cynical and more supportive. The news media and the g o v e r n m e n t were supportive as well. Since t h e n , we h a v e h a d Korea, V i e t n a m , the flower children, the drug culture, a n d Watergate. We have gone to the moon, we dial direct, we jet to the coast, we are spoonfed o u r n e w s by the boob tube. We have the Pill, the IUD, ERA, and now we have Ralph Nader, J i m m y Carter, we had Joe Califano a n d God knows, we have made L i b r i u m and Valium into household words. The complexity and pressures of today's society have a n impact on all areas of our lives and this includes our professional organizations. Today, medical organizations m u s t c o n t i n u e to strive for scientific excellence. They m u s t continue to promote medical education and m a i n t a i n dialogues a m o n g the clinician, researcher, and teacher. But in addition, they must respond to bureaucratic, legislative, a n d judicial influences. They m u s t s c r u t i n i z e the 25,000 bills introduced in the Congress every session. They m u s t deal with sections of state a n d federal b u r e a u c r a c y that produce regulations which often carry the force of law. T h e y m u s t cope w i t h such a c r o n y m i c m e n a c e s as HEW, FDA, FTC, OEO a n d OSHA. State governments are now creating hospital services cost review commissions; c o n s u m e r i s m has become a major industry. The power of the media has reached a level t h a t has i n v i t e d the a t t e n t i o n of the Supreme Court. The public is more sophisticated, more cynical, a n d more demanding. The i n v o l v e m e n t of medical organizations in all this strife - - and involved they m u s t be - - has made t h e m i n c r e a s i n g l y v u l n e r a b l e to attacks by all those forces t h a t have become a part of our daily lives. O t h e r n o n - g o v e r n m e n t a l i n f l u e n c e s which are b e i n g felt by physicians a n d their societies are organizations such as the J o i n t Commission on Accreditation of Hospitals, which promulgates new a n d more complicated regulations every month. The cost of complyi n g with these r e g u l a t i o n s increases proportionally. The A m e r i c a n Hospital Association, p a r t i c u l a r l y since the D a r l i n g Decision, has b e e n convincing the governi n g bodies of hospitals t h a t they m u s t exercise more a n d more control over the private physician and his practice. Each of these special i n t e r e s t groups - - and that's w h a t they are - - has one common focus: the a t t e m p t to exercise more control over the practice of medicine. W h e t h e r it takes the form of a hospital governing
t is wonderful to be a part of an e v e n i n g like this. A n d while I realize t h a t we are p r i m a r i l y here to honor some of our distinguished colleagues, what we are really doing t o n i g h t is celebrating a birthday. A new specialty of medicine has been born. A n d each of us is a godparent - - responsible for the u p b r i n g i n g a n d m a t u r a t i o n of this h e a l t h y infant. S t a n d i n g at this lectern, ready to follow the trail blazed by my distinguished predecessor, I a m h u m b l e d by the enormous achievements of the past 11 years. But more t h a n a n y t h i n g I have a sense of a n t i c i p a t i o n and confidence in the f u t u r e t h a t is like a powerful surge of electricity. Milestones such as we are celebrating tonight are n a t u r a l places in the life of a n organization to pause a n d take stock of where we have been a n d where we are going. It is simple to describe the status of A C E P t o d a y . . , a single word will do, a n d t h a t word is progress. B u t when we t h i n k of progress we m u s t t h i n k of it as two distinct entities: progress as fact, and progress as idea. Progress as fact is history. It is the record of past accomplishments a n d it is appropriate t h a t we celebrate t h a t history tonight. But progress as idea concerns the future. It is the act of setting tomorrow's goals . . . of d e t e r m i n i n g how best to use the precious resources of this College for the greatest benefit of its m e m b e r s and the p a t i e n t s they serve. It is i m p e r a t i v e t h a t we give careful consideration to the p r u d e n t use of those resources. As we s t a n d on this threshold - - this doorway from the past to the f u t u r e - - it is clear t h a t the force t h a t has enabled us to travel this distance so swiftly has been the c o m m i t m e n t to excellence by this College. We have made a c o m m i t m e n t to excellence i n our educational programs; to excellence i n the certification of emergency physicians; to excellence in the provision of emergency care. We pledge to the future t h a t we will continue to honor a n d expand t h a t commitment. B u t as we travel this broad highway to the future, we m u s t take care not to t u r n off on one of the n a r r o w p a t h w a y s to super-specialization, where we become too much the scientist and too little the citizen. By d e m a n d i n g r e c o g n i t i o n as s p e c i a l i s t s , we h a v e acknowledged a responsibility to our fellow citizens to provide leadership in s e t t i n g standards for the q u a l i t y of education a n d of care i n our field. As leaders, we have a responsibility not only to those c o m m u n i t i e s of which we are a part, b u t to this College and to our colleagues. If we are to fulfill those responsibilities, we must, more t h a n ever before, be aware t h a t what is past is prologue. We m u s t be aware of how perceptions of the p h y s i c i a n a n d his professional o r g a n i z a t i o n
I
76/490
JACEP
8"11 (November) 1979
board, a s t a t e cost review commission, a federal h e a l t h care finance commission, or a h e a l t h systems agency, it all adds up to one serious a t t e m p t after a n o t h e r to t a k e control of y o u r freedom, and of your economic future. T h e r e can be no question t h a t this is t h e n e x t g r e a t c h a l l e n g e for this College. O u r o r g a n i z a t i o n must be involved in h e l p i n g to shape and focus the forces t h a t will affect our i n d i v i d u a l a n d collective a b i l i t y to practice q u a l i t y e m e r g e n c y medicine. The s t r e n g t h of our organization is the i n v o l v e m e n t of its m e m b e r s , a n d h e r e we h a v e a chance to b u i l d our strength. If we h a v e come so far in the past 11 years, i m a g i n e how much more we can accomplish in the future w i t h two, three, or four times as m a n y m e m b e r s actively involved in our struggle. If t h e r e is to be a watchword d u r i n g m y t e r m as P r e s i d e n t of this College, it will be involvement. We h a v e an obligation, you and I, to t h i s profession t h a t h a s been so good to us and so beneficial to the citizens of this country. If you believe, as I do, t h a t this country has the best system of medical care the world h a s ever seen; if you feel an obligation, as I do, to pass on to future g e n e r a t i o n s of physicians a s y s t e m founded on freedom of choice; if you feel an obligation,
as I do, to pass on to the children of your p a t i e n t s t h a t s a m e freedom of choice, a n d a system founded on a p r o p e r service d e l i v e r e d for a fair fee, then you m u s t become involved in the fight to preserve those freedoms. Those who go to the hospital, work t h e i r s h i f t , and then s h u t out the r e s t of the world while they r e t i r e to the security of h o m e or golf course a r e ignoring the problems in the h o s p i t a l or political world and are not c o n t r i b u t i n g , no m a t t e r how t a l e n t e d t h e y a r e a t diagnosis or t r e a t m e n t . To those who s a y the p a t t e r n is i r r e v e r s i b l e and t h a t n o t h i n g can be done, I say look back at the p a s t 11 years. It can be done, b u t if we are to preserve our r i g h t to call medicine a profession we m u s t become more t h a n colleagues; we m u s t become comrades. Tog e t h e r we can i n s u r e t h a t our p a t i e n t s will obtain t h e best possible care w i t h the least possible intervention of government. T o g e t h e r we can p r e s e r v e freedom in t h e medical profession. I a s k you to join with me in this struggle, and I pledge to you m y commitment, m y energy, my involvement. Together, we can.
John P. McDade, MD President, ACEP
What's New in Academic Emergency Medicine? m e r g e n c y m e d i c i n e a d m i n i s t r a t i o n a n d clinical produced new techniques a n d new issues which are k e e p i n g pace with envisioned needs. F r o m a scientific standpoint, it is difficult to t a b u l a t e the u n i q u e a d v a n c e s in e m e r g e n c y medicine, for some academic and scientific a d v a n c e m e n t s in e m e r g e n c y medicine i n t e r d i g i t a t e with r e s e a r c h in t r a d i t i o n a l specialties. Even h a r d e r to t a b u l a t e are c u r r e n t r e s e a r c h trends a n d f u t u r e research challenges which a r e u n i q u e to academic e m e r g e n c y medicine. F r o m political a n d a d m i n i s t r a t i v e standpoints, the newest a d v a n c e m e n t in e m e r g e n c y m e d i c i n e is t h e development of a certifying board e x a m i n a t i o n . The A m e r i c a n Board of E m e r g e n c y Medicine (ABEM) has been formed a n d a Residency Review C o m m i t t e e will soon be active. New responsibilities and a u t h o r i t y for the Residency Review C o m m i t t e e promise to add considerable s t r e n g t h to residencies in e m e r g e n c y medicine from teaching, service and research standpoints. The a c r o n y m s of emergency medicine now h a v e a clearer identification and delineation t h a n in e a r l i e r years. U A / E M , ACEP, EDNA, STEM, EMRA, ACS/ COT, N E W / E M S , N A S / N R ~ , L R E C , A B E M , ATS, NREMT, N A E M T , I A F F , JACEP, and others h a v e in past y e a r s been s o m e w h a t i n d i s t i n g u i s h a b l e in t h e i r roles, purposes, and objectives. Now, however, each of these agencies is developing unique, clearly d e l i n e a b l e areas of responsibility. U A / E M d u r i n g the p a s t t h r e e years h a s clearly e s t a b l i s h e d itself as the only organization in which s t a t i s t i c a l l y significant research d a t a on e m e r g e n c y m e d i c i n e s u b j e c t s a r e r e p o r t e d to a a a t i o n a l forum of e m e r g e n c y medicine scientists who actively c r i t i q u e e x p e r i m e n t a l d e s i g n a n d i n t e r p r e tation of results. E s p e c i a l l y s i g n i f i c a n t a r e recent reports of h e a l t h services r e s e a r c h as t h e y r e l a t e to e m e r g e n c y medicine. D u r i n g t h e p a s t t h r e e y e a r s , t h e N a t i o n a l
C e n t e r for H e a l t h Sciences Research, u n d e r the able direction of J e r r y Rosenthal, MD, has funded a n u m b e r of projects in e m e r g e n c y medicine to e v a l u a t e h e a l t h s y s t e m s research. We are especially indebted to the h e a l t h systems r e s e a r c h now being reported by Rebecca A. H. A n w a r , PhD, of The Medical College of Pennsylv a n i a . The f i v e - y e a r s t u d y r e v i e w i n g r e s i d e n t s of e m e r g e n c y medicine, i n t e r n a l medicine, and s u r g e r y a n d t h e i r p r o g r a m d i r e c t o r s p r o m i s e s to h a v e farr e a c h i n g impact on a c a d e m i c e m e r g e n c y medicine and o t h e r specialties. Dr. A n w a r ' s e a r l y reports, as well as the extensive report g i v e n at t h e U A / E M m e e t i n g in Orlando in M a y 1979, are e x a m p l e s of scientific h e a l t h systems r e s e a r c h which serves as a model for others to follow. F r o m the s t a n d p o i n t of unsolved research problems in e m e r g e n c y medicine, the a c a d e m i c i a n m u s t be e s p e c i a l l y i n n o v a t i v e . The u n s o l v e d m e d i c a l chall e n g e s in e m e r g e n c y m e d i c i n e c a n be d i v i d e d into t h r e e areas: conceptual logistic problems, applied clinical research, and basic science research. F r o m a conceptual and logistic s t a n d p o i n t , a n u m b e r of studies should be initiated, including: d e v e l o p m e n t of outcome d a t a for i n t e r v e n t i o n s p e r f o r m e d in t h e p r e h o s p i t a l p h a s e b y p a r a m e d i c s a n d EMTs; cost effectiveness studies of a m b u l a n c e design, a i r a m b u l a n c e concepts, a n d advanced life support; the p h e n o m e n a of "psychic n u m b i n g " a n d ~ b u r n - o u t " in e m e r g e n c y m e d i c i n e p e r s o n n e l ; a n d f i n a l l y , r e s e a r c h on p r e v e n t i o n of h e a l t h problems and i n t e r f a c i n g with the emergency physician. Applied r e s e a r c h is limited only by the i m a g i n a tion of clinicians p r a c t i c i n g e m e r g e n c y medicine in the a c a d e m i c a r e n a . P s y c h i a t r i c disease, overdose, head injury, hypoxemia, w o u n d m a n a g e m e n t , r e s p i r a t o r y insufficiency, and g a s t r o i n t e s t i n a l bleeding are j u s t some of the a r e a s for clinical research. Research into
E practice h a v e
8"11 (November) 1979
JACI=P
491/77
have changed over the years, a n d how in t u r n the p h y s i c i a n views the world a r o u n d him. My own memories go back to t h a t simpler time before World War II when we knew the physician as our ~'family doctor." We t h o u g h t of his professional org a n i z a t i o n with the same degree of t r u s t and respect. The organizations themselves were devoted almost tot a l l y to the a d v a n c e m e n t of scientific knowledge and physician education. The public was less cynical and more supportive. The news media and the g o v e r n m e n t were supportive as well. Since t h e n , we h a v e h a d Korea, V i e t n a m , the flower children, the drug culture, a n d Watergate. We have gone to the moon, we dial direct, we jet to the coast, we are spoonfed o u r n e w s by the boob tube. We have the Pill, the IUD, ERA, and now we have Ralph Nader, J i m m y Carter, we had Joe Califano a n d God knows, we have made L i b r i u m and Valium into household words. The complexity and pressures of today's society have a n impact on all areas of our lives and this includes our professional organizations. Today, medical organizations m u s t c o n t i n u e to strive for scientific excellence. They m u s t continue to promote medical education and m a i n t a i n dialogues a m o n g the clinician, researcher, and teacher. But in addition, they must respond to bureaucratic, legislative, a n d judicial influences. They m u s t s c r u t i n i z e the 25,000 bills introduced in the Congress every session. They m u s t deal with sections of state a n d federal b u r e a u c r a c y that produce regulations which often carry the force of law. T h e y m u s t cope w i t h such a c r o n y m i c m e n a c e s as HEW, FDA, FTC, OEO a n d OSHA. State governments are now creating hospital services cost review commissions; c o n s u m e r i s m has become a major industry. The power of the media has reached a level t h a t has i n v i t e d the a t t e n t i o n of the Supreme Court. The public is more sophisticated, more cynical, a n d more demanding. The i n v o l v e m e n t of medical organizations in all this strife - - and involved they m u s t be - - has made t h e m i n c r e a s i n g l y v u l n e r a b l e to attacks by all those forces t h a t have become a part of our daily lives. O t h e r n o n - g o v e r n m e n t a l i n f l u e n c e s which are b e i n g felt by physicians a n d their societies are organizations such as the J o i n t Commission on Accreditation of Hospitals, which promulgates new a n d more complicated regulations every month. The cost of complyi n g with these r e g u l a t i o n s increases proportionally. The A m e r i c a n Hospital Association, p a r t i c u l a r l y since the D a r l i n g Decision, has b e e n convincing the governi n g bodies of hospitals t h a t they m u s t exercise more a n d more control over the private physician and his practice. Each of these special i n t e r e s t groups - - and that's w h a t they are - - has one common focus: the a t t e m p t to exercise more control over the practice of medicine. W h e t h e r it takes the form of a hospital governing
t is wonderful to be a part of an e v e n i n g like this. A n d while I realize t h a t we are p r i m a r i l y here to honor some of our distinguished colleagues, what we are really doing t o n i g h t is celebrating a birthday. A new specialty of medicine has been born. A n d each of us is a godparent - - responsible for the u p b r i n g i n g a n d m a t u r a t i o n of this h e a l t h y infant. S t a n d i n g at this lectern, ready to follow the trail blazed by my distinguished predecessor, I a m h u m b l e d by the enormous achievements of the past 11 years. But more t h a n a n y t h i n g I have a sense of a n t i c i p a t i o n and confidence in the f u t u r e t h a t is like a powerful surge of electricity. Milestones such as we are celebrating tonight are n a t u r a l places in the life of a n organization to pause a n d take stock of where we have been a n d where we are going. It is simple to describe the status of A C E P t o d a y . . , a single word will do, a n d t h a t word is progress. B u t when we t h i n k of progress we m u s t t h i n k of it as two distinct entities: progress as fact, and progress as idea. Progress as fact is history. It is the record of past accomplishments a n d it is appropriate t h a t we celebrate t h a t history tonight. But progress as idea concerns the future. It is the act of setting tomorrow's goals . . . of d e t e r m i n i n g how best to use the precious resources of this College for the greatest benefit of its m e m b e r s and the p a t i e n t s they serve. It is i m p e r a t i v e t h a t we give careful consideration to the p r u d e n t use of those resources. As we s t a n d on this threshold - - this doorway from the past to the f u t u r e - - it is clear t h a t the force t h a t has enabled us to travel this distance so swiftly has been the c o m m i t m e n t to excellence by this College. We have made a c o m m i t m e n t to excellence i n our educational programs; to excellence i n the certification of emergency physicians; to excellence in the provision of emergency care. We pledge to the future t h a t we will continue to honor a n d expand t h a t commitment. B u t as we travel this broad highway to the future, we m u s t take care not to t u r n off on one of the n a r r o w p a t h w a y s to super-specialization, where we become too much the scientist and too little the citizen. By d e m a n d i n g r e c o g n i t i o n as s p e c i a l i s t s , we h a v e acknowledged a responsibility to our fellow citizens to provide leadership in s e t t i n g standards for the q u a l i t y of education a n d of care i n our field. As leaders, we have a responsibility not only to those c o m m u n i t i e s of which we are a part, b u t to this College and to our colleagues. If we are to fulfill those responsibilities, we must, more t h a n ever before, be aware t h a t what is past is prologue. We m u s t be aware of how perceptions of the p h y s i c i a n a n d his professional o r g a n i z a t i o n
I
76/490
JACEP
8"11 (November) 1979
board, a s t a t e cost review commission, a federal h e a l t h care finance commission, or a h e a l t h systems agency, it all adds up to one serious a t t e m p t after a n o t h e r to t a k e control of y o u r freedom, and of your economic future. T h e r e can be no question t h a t this is t h e n e x t g r e a t c h a l l e n g e for this College. O u r o r g a n i z a t i o n must be involved in h e l p i n g to shape and focus the forces t h a t will affect our i n d i v i d u a l a n d collective a b i l i t y to practice q u a l i t y e m e r g e n c y medicine. The s t r e n g t h of our organization is the i n v o l v e m e n t of its m e m b e r s , a n d h e r e we h a v e a chance to b u i l d our strength. If we h a v e come so far in the past 11 years, i m a g i n e how much more we can accomplish in the future w i t h two, three, or four times as m a n y m e m b e r s actively involved in our struggle. If t h e r e is to be a watchword d u r i n g m y t e r m as P r e s i d e n t of this College, it will be involvement. We h a v e an obligation, you and I, to t h i s profession t h a t h a s been so good to us and so beneficial to the citizens of this country. If you believe, as I do, t h a t this country has the best system of medical care the world h a s ever seen; if you feel an obligation, as I do, to pass on to future g e n e r a t i o n s of physicians a s y s t e m founded on freedom of choice; if you feel an obligation,
as I do, to pass on to the children of your p a t i e n t s t h a t s a m e freedom of choice, a n d a system founded on a p r o p e r service d e l i v e r e d for a fair fee, then you m u s t become involved in the fight to preserve those freedoms. Those who go to the hospital, work t h e i r s h i f t , and then s h u t out the r e s t of the world while they r e t i r e to the security of h o m e or golf course a r e ignoring the problems in the h o s p i t a l or political world and are not c o n t r i b u t i n g , no m a t t e r how t a l e n t e d t h e y a r e a t diagnosis or t r e a t m e n t . To those who s a y the p a t t e r n is i r r e v e r s i b l e and t h a t n o t h i n g can be done, I say look back at the p a s t 11 years. It can be done, b u t if we are to preserve our r i g h t to call medicine a profession we m u s t become more t h a n colleagues; we m u s t become comrades. Tog e t h e r we can i n s u r e t h a t our p a t i e n t s will obtain t h e best possible care w i t h the least possible intervention of government. T o g e t h e r we can p r e s e r v e freedom in t h e medical profession. I a s k you to join with me in this struggle, and I pledge to you m y commitment, m y energy, my involvement. Together, we can.
John P. McDade, MD President, ACEP
What's New in Academic Emergency Medicine? m e r g e n c y m e d i c i n e a d m i n i s t r a t i o n a n d clinical produced new techniques a n d new issues which are k e e p i n g pace with envisioned needs. F r o m a scientific standpoint, it is difficult to t a b u l a t e the u n i q u e a d v a n c e s in e m e r g e n c y medicine, for some academic and scientific a d v a n c e m e n t s in e m e r g e n c y medicine i n t e r d i g i t a t e with r e s e a r c h in t r a d i t i o n a l specialties. Even h a r d e r to t a b u l a t e are c u r r e n t r e s e a r c h trends a n d f u t u r e research challenges which a r e u n i q u e to academic e m e r g e n c y medicine. F r o m political a n d a d m i n i s t r a t i v e standpoints, the newest a d v a n c e m e n t in e m e r g e n c y m e d i c i n e is t h e development of a certifying board e x a m i n a t i o n . The A m e r i c a n Board of E m e r g e n c y Medicine (ABEM) has been formed a n d a Residency Review C o m m i t t e e will soon be active. New responsibilities and a u t h o r i t y for the Residency Review C o m m i t t e e promise to add considerable s t r e n g t h to residencies in e m e r g e n c y medicine from teaching, service and research standpoints. The a c r o n y m s of emergency medicine now h a v e a clearer identification and delineation t h a n in e a r l i e r years. U A / E M , ACEP, EDNA, STEM, EMRA, ACS/ COT, N E W / E M S , N A S / N R ~ , L R E C , A B E M , ATS, NREMT, N A E M T , I A F F , JACEP, and others h a v e in past y e a r s been s o m e w h a t i n d i s t i n g u i s h a b l e in t h e i r roles, purposes, and objectives. Now, however, each of these agencies is developing unique, clearly d e l i n e a b l e areas of responsibility. U A / E M d u r i n g the p a s t t h r e e years h a s clearly e s t a b l i s h e d itself as the only organization in which s t a t i s t i c a l l y significant research d a t a on e m e r g e n c y m e d i c i n e s u b j e c t s a r e r e p o r t e d to a a a t i o n a l forum of e m e r g e n c y medicine scientists who actively c r i t i q u e e x p e r i m e n t a l d e s i g n a n d i n t e r p r e tation of results. E s p e c i a l l y s i g n i f i c a n t a r e recent reports of h e a l t h services r e s e a r c h as t h e y r e l a t e to e m e r g e n c y medicine. D u r i n g t h e p a s t t h r e e y e a r s , t h e N a t i o n a l
C e n t e r for H e a l t h Sciences Research, u n d e r the able direction of J e r r y Rosenthal, MD, has funded a n u m b e r of projects in e m e r g e n c y medicine to e v a l u a t e h e a l t h s y s t e m s research. We are especially indebted to the h e a l t h systems r e s e a r c h now being reported by Rebecca A. H. A n w a r , PhD, of The Medical College of Pennsylv a n i a . The f i v e - y e a r s t u d y r e v i e w i n g r e s i d e n t s of e m e r g e n c y medicine, i n t e r n a l medicine, and s u r g e r y a n d t h e i r p r o g r a m d i r e c t o r s p r o m i s e s to h a v e farr e a c h i n g impact on a c a d e m i c e m e r g e n c y medicine and o t h e r specialties. Dr. A n w a r ' s e a r l y reports, as well as the extensive report g i v e n at t h e U A / E M m e e t i n g in Orlando in M a y 1979, are e x a m p l e s of scientific h e a l t h systems r e s e a r c h which serves as a model for others to follow. F r o m the s t a n d p o i n t of unsolved research problems in e m e r g e n c y medicine, the a c a d e m i c i a n m u s t be e s p e c i a l l y i n n o v a t i v e . The u n s o l v e d m e d i c a l chall e n g e s in e m e r g e n c y m e d i c i n e c a n be d i v i d e d into t h r e e areas: conceptual logistic problems, applied clinical research, and basic science research. F r o m a conceptual and logistic s t a n d p o i n t , a n u m b e r of studies should be initiated, including: d e v e l o p m e n t of outcome d a t a for i n t e r v e n t i o n s p e r f o r m e d in t h e p r e h o s p i t a l p h a s e b y p a r a m e d i c s a n d EMTs; cost effectiveness studies of a m b u l a n c e design, a i r a m b u l a n c e concepts, a n d advanced life support; the p h e n o m e n a of "psychic n u m b i n g " a n d ~ b u r n - o u t " in e m e r g e n c y m e d i c i n e p e r s o n n e l ; a n d f i n a l l y , r e s e a r c h on p r e v e n t i o n of h e a l t h problems and i n t e r f a c i n g with the emergency physician. Applied r e s e a r c h is limited only by the i m a g i n a tion of clinicians p r a c t i c i n g e m e r g e n c y medicine in the a c a d e m i c a r e n a . P s y c h i a t r i c disease, overdose, head injury, hypoxemia, w o u n d m a n a g e m e n t , r e s p i r a t o r y insufficiency, and g a s t r o i n t e s t i n a l bleeding are j u s t some of the a r e a s for clinical research. Research into
E practice h a v e
8"11 (November) 1979
JACI=P
491/77