The only thing an emergency room doctor needs to know is how to pick up a phone and dial it. — Legendary trauma surgeon, circa 1985
I was teaching at an ultrasound course a few weeks ago when I ran into an academic emergency physician who taught with us several years ago. He left our specialty to do residency training in anesthesia. Emergency medicine was a bad fit for him, and he decided to pursue something that provided more personal satisfaction. It was a courageous move.
He was now trained in ultrasound-guided nerve blocks, and I hoped that he would help develop a curriculum for us. One of our EM faculty had already created some lectures, but it would be great to get some additional editing, content, and expertise. Multiple papers by emergency physicians have been done on the topic, so it is not a novel idea.
After teaching with us for a few days, he said he had reservations about emergency physicians doing ultrasound. He is entitled to his opinion. After all, who would know better? He was an expert in emergency medicine, anesthesia, and ultrasound.
I began working in EDs three decades ago as a medical student with no clue of what I was getting into. It was a vastly different specialty then, with few board certified EPs, nearly all of whom struggled for respect. I remember a chief EM resident correcting me when I said “emergency room.” “We are not a room,” he said. “We are a department.”
Professional esteem was not that important to me in those days. I wasn't even sure how I got into medical school. My college performance was fairly pedestrian. Derogatory comments from other specialists did not bother me much either. It was no surprise when I entered residency in 1990 that my attendings were at war with the anesthesiologists about using drugs for rapid sequence induction. Anesthesia would say, “Just nasally intubate them. These drugs are too complicated for you.”
That is how I did most intubations as an intern. None of us knew how uncomfortable a nasal intubation was. It seems ironic now because I cannot remember the last time I saw this procedure performed. Over time, intubation skills became a cornerstone of emergency medicine training, including using those complicated drugs.
Collaboration, not Confrontation
Surgeons did not want us near the trauma bay in those days either. I remember tiptoeing around pontificating surgical attendings spewing condescending comments. I still hear about hospitals where the trauma patients roll through the emergency department into trauma bays exclusively staffed by trauma teams, but my experience over the past 15 years has been one of collaboration with surgical colleagues, not confrontation. Now there are even PAs extensively involved with trauma resuscitations, an idea that would have made previous generations of trauma surgeons apoplectic.
I began to use and promote bedside ultrasound for emergency physicians in the 1990s. As you might guess, the radiologists were peeved. One attacked me over the salad bar in the doctor's lounge about how he studied ultrasound for four years during residency and why EPs should not be using it. My reply was, “You really want to do this over the salad bar?” It seemed to me that he was a slow learner if all he studied during his four years of training was ultrasound.
Cardiologists and obstetricians were unhappy about emergency physicians using ultrasound as well, and battles were waged on national stages as professional organizations shot out policy statements that sought to secure long-held turf. Their lobbyists asked the government and insurance companies to withhold payments for any ultrasound study not performed by traditional users. Rumors circulated about radiology groups that physically removed ultrasound machines from EDs and locked them in closets. The idea of an angry radiologist running from the ED pushing an ultrasound machine and locking it up is pathetic. Maybe this was an isolated occurrence or an urban myth, but the story is still recited as a cautionary tale.
Nonetheless, EM wore them all down. We kept pushing to do more of everything because we have to. We are charged with meeting the demands for timely emergency care of complex pathologies in the absence of traditional specialists. We cannot wait for a cardiologist to begin managing a STEMI or a neurologist to treat acute stroke. They need us to begin management immediately to improve the quality of care. Fortunately, we also have the talent to accomplish this—the ranks of EM residency programs are loaded with the most accomplished graduates in the country. Consultants subsequently capitulated by giving up once-sacred turf because of the demand for improving patient outcomes and preserving their own wellness.
Be aware that you will be told that you cannot do something or that you lack the necessary qualifications, but the legacy of our specialty is to push the envelope. Given what emergency medicine has proven in such a short time, it is apparent that the emergency physician's role will continue to expand at its current meteoric pace as more and more specialists are forced to recognize that improved care requires us to be even more involved.
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