Medical educators frequently remind trainees that half of what they learn as gospel in medical school and residency will be obsolete in 10 years. Few believe it. When I share my experiences from a career spanning 50 years in emergency medicine, students and residents are shocked to hear how recently EM adopted what is now standard medical treatment. Recognizing the rapidity of change in our profession can help us understand and adjust to how our specialty and practice will continue to mutate over the next decades, as we embrace new technologies, scientific breakthroughs, and novel modes of delivering care.
My involvement in EM began in 1967 on an ambulance service at the dawn of the modern emergency medical services era. I worked as a technician during medical school in the nation's first shock-trauma unit and later trained at the first EM residency, when such programs were almost nonexistent and the few EM textbooks were written by physicians with little real experience in emergency departments. I entered EM practice before the American Board of Emergency Medicine administered its first exam.
I eventually became the director of an EM residency program, and few specialties were interested in helping to educate our residents at that time. EM researchers were rare, and JACEP: Journal of the American College of Emergency Physicians was the only peer-reviewed journal. When I identified myself as an emergency physician in those early days, other physicians routinely asked, “What is that?” Even my mother continued to question when I would get an office and become a real doctor.
Radical changes have since altered our specialty's practices, improved patient outcomes, and transformed medicine and society, putting to rest any questions about the legitimacy of EM and its practitioners. Many advances in emergency care have been made over the past half-century, most notably in prehospital care, the ED milieu, personnel and equipment, EM residency training, standard procedures, diagnostic laboratory and imaging, available medications, and EM management and politics.
I joined the Wheaton (Maryland) Rescue Squad, a volunteer ambulance service, on my 18th birthday. This was long before EMS participation became a springboard into medical school. The squad ran on donations, and had a fleet of five “low-boy” ambulances, offering state-of-the-art training for its members: American Red Cross Advanced First Aid, an emergency childbirth film, and a new CPR technique advocated by the American Heart Association, which the American Red Cross refused to teach because of the obvious superiority of the Sylvester back-pressure-arm-lift method.
The silhouettes of our low-boy ambulances looked like hearses. In fact, the same companies made both, although ours were custom-fitted with extra interior lights and spaces to hold a rudimentary first aid kit packed in a large tool box, oxygen bottles, and various scoop stretchers. Aside from these, we carried only bandages, wood and metal splints, and an obstetrics kit, which I once used one moonlit night in a hospital parking lot. Performing CPR inside the ambulance required bending low over the stretcher and pushing hard because there was only a foot of space between your chest and the patient's. The 911 system was still only an idea. It would begin a year later, in 1968 in Alabama, so many calls came directly through the squad's landline.
The first emergency medical technicians were still several years away, so our state developed a similar program of classes and ED time, the Maryland State Hospital Corpsman course. After entering medical school (while still taking shifts with the squad), I passed an all-day exam that qualified me as one of the country's first EMT instructors. The local EMS was simultaneously participating in an ultimately unsuccessful paramedic-type project known as the Heartmobile, a single motor home-sized unit for the entire Washington, DC, metropolitan area.
A Typical ‘ER’ Case, 1967
Soon after a shift began, a horn blared outside the front door and a few nurses and orderlies with a wobbly gurney raced outside. From the open back door of the ambulance, bloody legs with open fractures poked out from a multiply injured motorcycle crash victim. As they rolled the patient into the ER, the front desk clerk sounded a buzzer, alerting a physician that a critical patient had arrived, and notified the hospital switchboard operator to page anesthesia and surgery.
Once the patient entered the resuscitation room, nurses started a peripheral IV connected to glass bottles of lactated ringer's solution, took his blood pressure using an upright mercury manometer, put him on oxygen, and set up intubation equipment for the anesthesiologist to use when he arrived. The physicians working in the ER requested type-specific blood and began plasma protein fraction (Plasmanate), balanced electrolyte solution (Poly-Sal), or human serum albumin. Only when the surgeon arrived could the operating room staff be notified. After hours, the OR staff often responded from home. Despite clinical evidence for a tension pneumothorax, the surgeon asked for multiple portable x-rays and fretted about the possibility of intraabdominal injury (ATLS had not been developed yet). Everyone then waited for the OR to be ready. As the chest x-ray arrived, the patient died.
The ED Milieu
ED crowding is not a new phenomenon. Most hospitals had EDs (then called “ERs”) by 1970, although, as today, most were too small to accommodate their patient volume. Public hospital EDs cared for a huge population of medically indigent, homeless, and chronic psychiatric patients. Patient gurneys lined the hallways, many accommodating boarded psychiatric patients. Most gurneys allowed only the head to be raised and offered only straps, rather than side rails, to secure the patient.
Public hospital EDs also treated the most severe trauma cases, such as the one above, that were deemed too costly for private hospitals and interrupted their high-paying elective surgeries. As a result, the EDs received a constant stream of uninsured patients “dumped” in unstable condition from surrounding private hospitals. (Proc [Bayl Univ Med Cent] 2001;14:339; http://bit.ly/2POwZG8.) In response, EM physicians lobbied Congress to pass remedial legislation, which finally resulted in the 1986 Emergency Medical Treatment and Labor Act (EMTALA), with stiff penalties for violations, making dumping an historical anomaly. (42 USC 1395dd .)
Some private hospitals resisted offering emergency medical services, refusing to open EDs or providing admitting areas on upper floors that were difficult to find for ambulances and walk-in patients alike. Ambulances could only transport “preadmitted” patients to their loading dock at one private Washington, DC, hospital where we sometimes had to deliver patients; it took 10 minutes to roll an ambulance stretcher to the admitting room. By necessity, public hospitals frequently located and then expanded their EDs in repurposed spaces that were cramped and poorly lit, forcing staff to make whatever adaptations they could to treat patients. We had to crouch under a huge steam pipe to access the pediatric “asthma room” in one Baltimore university hospital, for example. Lumbar punctures, intubations, and pelvic exams often occurred in the hallways, with minimal patient screening. That's where I did my first (blind nasotracheal) intubation.
Far from a quiet environment, the ED's multiple buzzers and beeps were overlaid by the nearly constant blaring from the overhead paging system. These systems ruled lives throughout the hospitals before personal pagers became common. Even then, overhead paging remained the norm for decades, using code words to notify hospital teams to respond to cardiac arrests (e.g., “Dr. Blue, Room 308A”) and traumas (e.g., “Red Team One to ER”), as well as for general announcements such as “Visiting hours are now over.”
ED Personnel and Equipment
ERs had an often deservedly poor reputation in the late 1960s. Relatively few hospital ERs were staffed with full-time physicians interested in learning about and providing optimal emergency care, and there were no trained EM specialists. Physicians worked in ERs to earn money at the end of their career because they could not practice in their primary specialty or because they were required to work a shift or two each month as a member of the hospital staff. Fulfilling that common requirement led to internists and psychiatrists treating trauma, surgeons trying to diagnose and treat complex medical issues, and pathologists treating live patients. To make matters worse, teaching hospital EDs were staffed by interns, usually with little or no supervision, a tradition that stemmed from the earliest days of postgraduate medical education.
Given these conditions, it is little wonder that other clinicians questioned the ER physicians' professional competence. Gradually, EM-trained physicians staffed an increasing number of EDs, a process that occurred over decades and faster in areas with geographic proximity to EM residency programs. Initially, few minority or female physicians trained in EM, and osteopathic physicians usually had to develop their own residency programs. Into the 1980s, most ACGME institutions would not permit DOs in their training programs in any specialty.
Nursing staff, generally superbly trained graduates of three-year hospital programs, were the ED's most constant element. Dressed in starched white dresses with nursing school-specific caps and pins, they often had extensive acute care knowledge and experience. Yet, in most cases, as elsewhere in the hospital, ED nurse duties were confined to starting IVs, bag-ventilating patients, or pushing medications with an approving physician (or, in some cases, a medical student) present. Sporadic attempts were made to train specialty nurses in the mid-1970s, such as the suture nurses at Cincinnati General Hospital, but there were no advanced nurse practitioners for EM and the few physician assistants worked mostly in military settings.
ED equipment throughout the 1960s and 1970s conformed to the old joke about a bad meal: It was awful and there was never enough. The ED usually had the well-used monitors, sphygmomanometers, ophthalmoscopes/otoscopes, minor surgical sets, electrocardiographs, splints, stretchers, and even laryngoscopes that other hospital services had discarded as being less than adequate.
Personal protective equipment, now routine, was reserved for the OR, neonatal units, and isolation rooms. EM clinicians used gloves solely for sterile procedures, handling infected and weepy tissue, and genitourinary, rectal, and oral exams. That attitude only changed when the HIV epidemic intervened in the early 1980s. Until the late 1970s, EPs commonly saw patients with now-rare diseases: measles, mumps, rubella, epiglottitis, scarlet fever, and rheumatic fever. They had yet to encounter antibiotic-resistant gonorrhea, widespread herpes genitalia, Zika virus, MRSA, or bird flu in humans.
Little plastic equipment was used until the mid-1980s: Glass bottles were used for all suction devices, thoracostomy, and nasogastric drainage. Even the best endotracheal and nasogastric tubes and Foley catheters were made of thick red rubber with high-pressure cuffs. They were affixed to patients with heavy cloth adhesive tape, which was only gradually replaced by lighter “silk” tape and, ultimately, by paper tape and nonadhesive alternatives. Few ED gurneys could be raised or lowered, most wobbled on overused wheels, and few had IV poles attached.
Physicians used stethoscopes with relatively poor acoustics, reflex hammers supplied by drug companies, and narrow-vision ophthalmoscopes and otoscopes. They read ECGs by unrolling them as a long ribbon and checked intraocular pressures using Schiøtz tonometers. They intubated using a curved or straight blade: there were no fiberoptic devices or laryngeal mask airways, although esophageal obturator airways appeared around 1973. If the ED had a ventilator, it was generally a small green pressure-controlled box (the Bird ventilator) without PEEP or other fancy adjustments. EDs had manual BP cuffs, no pulse oximeters, or expired CO2 monitors, rarely had sophisticated IV drip controllers, and only had plaster bandages with which to fashion long-term casts and splints.
Until the new millennium and the arrival of the internet, EPs generally relied on pocket cards or notebooks as their portable brains. They supplemented these with a few, usually old and well-battered reference books at the doctors' station. Researchers relied on medical libraries, finding sources using Dewey Decimal card catalogues rather than PubMed.
EM Residency Training
I began my EM residency at the University of Cincinnati (then Cincinnati General Hospital) in 1976, and just eight programs were approved by the newly formed (and not yet recognized by the ACGME) Liaison Residency Endorsement Committee for Emergency Medicine. One of those programs would not accept residents for another decade.
Applicants—virtually all of whom were in a different specialty's residency or clinical practice—submitted paper applications to the programs. After interviewing, candidates were offered residency positions via a phone call, beginning at an agreed upon time and date. (Some fudged and offered positions during interviews.) I was running an ultimately successful cardiac resuscitation when a desk clerk stuffed a note into my pocket, presumably from the patient's family. Only as I was writing my post-resuscitation note did she remind me about it. To my surprise, it was an acceptance message from the EM residency program I most desired.
Embarking on residency in July 1976, we began with what was then a novel idea, a month of orientation on EM topics that was mixed with clinical time. (JACEP 1979;8:77.) We had almost no EM-trained faculty, however. A physician with mostly administrative experience initially led our program (and left to go into public health), surgeons directed most other early EM programs and scrounged their faculty from other specialties. Many years passed before programs could transition to an entire physician faculty that was either residency-trained or grandfathered in by passing the ABEM exam. Many more years passed before faculty worked overnight shifts with their residents.
EM residents primarily learned from off-service residents who came to the ED as consultants or who worked in special ED areas such as psychiatry, orthopedics, or pediatrics. We also learned by rotating on specialty services when not doing scut work. We had to resist, however, residents' and attendings' constant appeals to quit EM, “which isn't a real specialty” and to join their service. Neurosurgeons, orthopedic surgeons, and otolaryngologists seemed to be the most persistent supplicants.
Around 1978, a brief core EM curriculum outline was distributed nationally. Our program in Cincinnati used it as the basis for weekly resident-run teaching lectures, our only formal educational activity. Because ABEM was incorporated in 1976 and EM didn't win formal specialty recognition until 1979, early EM residents were not guaranteed—although all had a passionate belief—that they would eventually take a board examination. ABEM administered the first certification exam in 1980, and EM residents began taking an annual in-service exam in the early 1980s. The first EM subspecialties would not receive ABMS approval until the 1990s.
EM Standard Procedures
Many of my Friday and Saturday nights during medical school were spent with the anesthesia department as they helped resuscitate patients in the shock-trauma unit admitting area. Most of these patients received chest tubes and peritoneal lavages (there were no clinical CT scanners, and FAST exams were many decades in the future). On Monday mornings, I watched the medical examiner inspect the “chest” tubes that had inadvertently entered the patients' livers or spleens. ATLS protocols would be instituted in 1980, based, in part, on the feedback that surgeons received from autopsies.
A few years later, our EM residency group took a newly designed weekend course on cardiac resuscitation. We were comfortable with intubation, CPR, and the basic cardiac medications, but imagine our surprise when, in rapid succession, we encountered a disturbingly wide range of dysrhythmias, seemingly the whole pharmacopeia, and novel acid-base formulas. That was our introduction to Advanced Cardiac Life Support, first published in 1974. Subsequently, as ACLS instructors, we helped teach structured cardiac resuscitation to many thousands of physicians and other providers. Pediatric Advanced Life Support courses did not appear until 1988.
EM procedures now considered rare or antique included gastric lavage, culdocentesis, cervical traction tongs, Schiøtz tonometry, peritoneal lavage, blind nasotracheal intubation (since paralytics were not permitted), precordial thumps as initial treatment for cardiac arrest, transtracheal aspirations for pneumonia diagnosis, Vaseline gauze packing to treat anterior epistaxis (no premade balloons existed), venous cutdowns (IO lines did not exist), and often blind placement of transvenous (no external available) pacemakers. Emergency physicians slowly forced the use of cricothyrotomies in emergencies after they were shown to have no more risk of tracheal stenosis than tracheostomies. (J Thorac Cardiovasc Surg 1976;71:72.) Internal jugular lines and Swan-Ganz catheters were only introduced in the mid-1970s.
A Typical ED Case, 1976
A 22-year-old sexually active woman presented with lower abdominal pain. She had a normal urinalysis, including dipstick, wet slide, and gram stains, all done by the ED physician. A urine sample was sent for a pregnancy test because the patient related that her menses were always abnormal. Due to the time it took for specimen transport, test setup, and performance (usually two hours or more) and reporting, it could take as long as six hours to receive the results.
The physician did a culdocentesis in the meantime to avoid complications from a possible ruptured ectopic pregnancy. This involved elevating the cervix using a single-toothed tenaculum and inserting a spinal needle into the rectouterine pouch, posterior to the cervix. The goal was to obtain either nonclotting blood from a probably ectopic pregnancy or serous fluid indicating no bleeding. Unfortunately, in most cases, the painful procedure resulted in either no fluid or clotted blood, both of which were nondiagnostic. This patient was eventually discharged with a diagnosis of nonspecific lower abdominal pain.
Laboratory and Imaging
Blood glucose and urine dipsticks were the only bedside lab tests, and emergency physicians performed other tests in their basic ED lab. A typical ED lab in 1981: “A small, well-equipped, well-lighted laboratory with microscopes, centrifuges, Bunsen burners, dyes, testing papers and solutions, slides, applicators, and filter paper should be adjacent to the emergency room. Use of such a laboratory should be confined to physicians working in the emergency room, and examinations should be limited to blood counters, urinalysis, sputum stains, examination of urethral and vaginal discharges, stool examinations and examinations of cerebrospinal fluid.” (Carter JH. Planning and operation of the emergency room. In: Emergency-Room Care. Boston: Little, Brown. 1981:15-31.) The 1988 Clinical Laboratory Improvement Amendments removed the ability of EPs to do most bedside testing until the modern handheld blood analyzers appeared. (Fed Regist 1992;57:7002.)
In the late 1970s, there were no rapid pregnancy tests or clinical tests for lactate. CPK and SGOT were the only cardiac enzymes to help diagnose myocardial infarctions. Eventually, LDH, CK-MB, and troponins sequentially appeared. Little other infectious disease screening was done although blood for transfusion had been screened for syphilis since 1938, and voluntary blood donors and screening had reduced post-transfusion hepatitis since 1970. Anti-HIV screening assays only began in 1985, but blood banks assured clinicians that the blood they were transfusing was fully screened for pathogens in the early 1980s when AIDS appeared. (Blood 2008;112:2617; http://bit.ly/2PfsmYR.)
ED imaging primarily consisted of plain radiographs (with many useless skull radiographs), occasionally supplemented with fluoroscopy, intravenous pyelograms, nuclear scans, and, in some locations, stereoscopic radiographs in the late 1970s. Computerized tomography specifically for the head had only recently become available in a few locales. Magnetic resonance imaging did not exist, and ultrasound was not used clinically outside neonatal units. Some patients received cerebral angiography for possible bleeds, but it was not yet being used to treat acute pelvic or abdominal bleeding.
A Typical ED Case, 1979
A 24-year-old man arrived with the sudden onset of palpitations and a rapid pulse. His other vital signs were found to be normal, and he was attached to a green-screen cardiac monitor, had an IV line placed, and an ECG done. The ribbon of ECG paper showed PSVT. His blood pressure was normal, so the EP tried to increase vagal tone first using a Valsalva maneuver, and then induced gagging with tongue depressors and finally carotid massage, all to no effect.
The EP then administered 10 mg IV edrophonium chloride (Tensilon), and repeated the Valsalva and gagging maneuvers when there was no resolution within three minutes. The EP then administered 1 mg phenylephrine IV, and the PSVT resolved. The next alternatives would have been to give 10 mg methoxamine HCL IV or metaraminol (Aramine) as a continuous drip. If those failed, the patient would be digitalized with intravenous digoxin, isolanid (Lanatoside C), or ouabain.
EM's formulary changed radically over the past decades. We replaced many older medications with newer (often more effective and certainly costlier) ones, discovered new uses for old medications (e.g., aspirin), and added entirely new medication classes to lessen our patients' morbidity and mortality.
Analgesia remains the backbone of EM practice, and morphine continues to be the go-to drug for powerful parenteral analgesia. Hydrocodone (Dilaudid) continues in use, and EM only slowly adopted fentanyl after its 1968 FDA approval. Other opioids have almost completely disappeared. One example is meperidine (Demerol), which for several decades was promoted by the pharmaceutical industry as being safer, less addictive, and more effective than morphine; it isn't. It's now deleted from most ED formularies.
Around 1980, our NSAIDs (a term first used in 1960) consisted only of aspirin and indomethacin (Indocin). Narcotics such as codeine, combined with acetaminophen or aspirin, were the most prescribed oral analgesics. Aspirin was used primarily as an analgesic rather than preventing clots or treating myocardial infarctions, a use that has greatly diminished since the introduction of the costlier NSAIDs. We had no parenteral versions, and COX inhibitors did not arrive until the 1980s. From 1999 until 2004, COX-2 inhibitors (rofecoxib, valdecoxib) were the primary analgesics dispensed to ED patients on discharge; after being tied to serious cardiac events, all except celecoxib were withdrawn from the U.S. market.
Conscious sedation usually meant a trip to the OR for many ED patients until at least the late 1980s. Early on, EPs used benzodiazepines (i.e., diazepam), short-acting barbiturates, and morphine for sedation in adults and the erratic chloral hydrate for children. Some EDs had ketamine, nitrous oxide, and short-acting barbiturates, but anesthesia-generated hospital rules often prevented their use to sedate patients. (Leonard F. Pain control: anesthesia and analgesia. In: Rosen P, et al. (eds). Emergency Medicine: Concepts and Clinical Practice. St. Louis: CV Mosby, 2983:192-203.) No flumazenil was available.
Lidocaine was our main antidysrhythmic agent, although magnesium sulfate and procainamide were occasionally used. Bretylium tosylate became popular for ventricular dysrhythmias in the 1970s, but it had been discarded by 2000. We could use atropine, isoproterenol, or a transvenous pacer, only occasionally guiding the pacing wire via cardiac electrical patterns using a lead connected to an ECG for bradycardia and A-V block. Sodium bicarbonate was used liberally for patients in shock and cardiac arrest, and cardiac resuscitations often included generous amounts of calcium chloride.
Patients in shock received isoproterenol, norepinephrine, and eventually dopamine. Norepinephrine went out of favor, and then was reintroduced.
There were no calcium channel blockers, beta blockers (other than propranolol), thrombolytics, immediate cardiac catheterization, or CABG for ED patients with acute myocardial infarctions. The only parenteral antihypertensive in the mid-1970s for those with hypertensive emergencies was alpha-methyl-dopa (Aldomet), which took at least six hours to work. Parenteral diazoxide appeared in the late 1970s, but it is no longer available parenterally because it immediately crashed patients' blood pressure.
Antibiotics were still widely effective against most infections, though public health officials warned of looming antibiotic resistance even back in the 1970s. Asthmatic patients received subcutaneous epinephrine and theophylline (usually without cardiac monitoring), rather than aerosolized beta agonists and anticholinergics. We had to reconstitute the dangerous (and slow-acting) apomorphine to reverse opioid overdoses rather than using naloxone (Narcan) into the late 1970s. EPs often used topical 4% cocaine to numb the nasal mucosa before packing patients with epistaxis, and, until the early 1980s, those needing post-rabies exposure treatment got the dreaded duck-embryo-derived rabies vaccine (DEV): 21 shots in abdomen and back followed by two boosters.
Until 1997 when 4-methylpyrazole (Fomepizole) was approved in the United States, often-ineffective ethanol (drips or oral) or hemodialysis was used to treat toxic alcohol ingestions. Acutely agitated psychiatric patients received the powerful and orthostatic hypotension-inducing chlorpromazine (Thorazine) or haloperidol (Haldol). Those who weren't as violent received trifluoperazine HCL (Stelazine) or fluphenazine (Prolixin).
Management and Politics
The EM practice milieu differed markedly during the late 1970s and into the 1980s. The many public hospital EDs rarely asked for or received patient payments. Even when emergency patients had insurance, there often was no mechanism to bill or collect for ED services. Nearly all hospitals ran their own internal services (cafeteria, laundry, laboratory, housekeeping, parking, security, etc.) rather than outsourcing them. Of course, there were no computers or EMRs, and all records were handwritten, often illegible, and difficult to obtain for ED patients.
A prominent emergency physician once refused to allow me to pay for my office computer with faculty funds, proclaiming, “No physician will ever need a computer to do his job!” Physicians responded to pocket pagers or overhead pages. Emergency physicians, nurses, and everyone else (except for those near oxygen sources) smoked cigarettes throughout the ED.
Malpractice suits were common, but EPs were rarely sued. (Perhaps we should be asking why that changed.) Throughout that period, ethical issues in emergency medicine were rarely discussed. When the first EM ethics text appeared, one of the fathers of EM facetiously asked me, “Do you really think that EM has ethics?” (Iserson KV, Sanders AB, Mathieu D (eds). Ethics in Emergency Medicine, 2nd ed. Tucson, AZ: Galen Press, 1986.) Getting ACEP and SAEM to create an ethics committee was an uphill struggle, but both are now among the largest and most active in both organizations.
Three national EM organizations existed in the United States by the late 1970s: the American College of Emergency Physicians, the Society of Teachers of Emergency Medicine, and the University Association of Emergency Medicine. STEM's membership was almost entirely composed of those who would become EM's leading educators. Their relatively small annual meetings were devoted to improving the specialty's educational techniques and opportunities, and often were collocated with those of the surgeon-dominated UAEM, where new research could be presented.
Eventually, emergency physicians became the dominant force in UAEM, and the two organizations melded in 1989 to become the Society for Academic Emergency Medicine. The Liaison Residency Endorsement Committee morphed into the Residency Review Committee for Emergency Medicine when EM was officially recognized.
ACEP has, since its inception, concentrated on promoting the specialty through publications, public relations, professional action in the American Medical Association and the American Board of Medical Specialties (eventually producing ABEM), and legislative activities (most prominently the EMTALA legislation). Eventually, other EM organizations emerged, the most notable being the Emergency Medicine Residents' Association, the American College of Osteopathic Emergency Physicians, the American Osteopathic Board of Emergency Medicine, and the American Academy of Emergency Medicine.
Shakespeare's phrase, “what's past is prologue,” suggests that the last half-century of emergency medical development is just the first act in our specialty's dramatic evolution. We can learn from our past, setting the scene for the great achievements that lie ahead. Where we go and what we do rests in our hands. Let's look to a future of great accomplishments in EM, just as did our forebears.Copyright © 2018 Wolters Kluwer Health, Inc. All rights reserved.