;)
Figure: retirement, EM history
FigureI retired from full-time clinical emergency medicine not long ago, and it made me think about what an amazing specialty it is and how it has evolved over 50 some years. Emergency medicine didn't really exist when I was an intern trying to decide my future. It was something you did while waiting for your real career to begin.
The ER (it wasn't called the ED then) was staffed by interns and a few begrudging attendings from other fields who viewed it as a punishment that had to be occasionally endured. Odd as it seems now, the most difficult field was handled by the least educated clinicians, and it was crazy to think it could ever be a lifelong calling.
I have tried to put my career into perspective over the years, with an acknowledgement of some of those spectacular clinicians who founded and developed the specialty, and it was interesting to contemplate my lowly journey through the most amazing specialty in modern-day medicine.
Thanks, everyone, for an amazing 45-year career, one that began at a time when I knew every residency-trained emergency physician in the world personally—all five of them. These are notes from my first 25 years in emergency medicine.
1972: I spoke to my medical school advisor today. He said, “You want to do what? Work full-time in the ER? You've got to be nuts.” He seemed like a smart guy, and was probably right by prognosticating that there's no future in the ER, but it is pretty exciting. Funny thing, though, nobody really knows what they're doing in the ER. Lots of weird stuff, adrenaline junkies work there, no real help from those consultants who offer just a lot of second-guessing and criticism. There's not even board certification in that “specialty.” Guess I'll go into OB/Gyn. That will make my mother happy.
1973: I'm an intern at Highland General Hospital in Oakland, CA. OB/Gyn sucks. Those Pitocin drips are the worst, and all you see are women who scream a lot. I can do a month in the ER if I want; will give it a try. Maybe I can find my calling there or at least decipher which internal medicine field is a fit.
But I kind of like this ER stuff. Heard about a doc named Bob Daley who does this full-time. Will give him a call, and will sign up for another month in the ER.
1974: Internship finished. Loved Berkeley but too many Quaaludes. You get them free from the pharmacy, and it's legal to grow pot here, but that will never catch on. Will miss the Filmore, Haight-Ashbury, sporting my ponytail, and all those cool California women and places, but time to think about a real job...not. Instead, I am going to Turkey. Got a VW bus, and drove to India. Did not like Pakistan; Afghanistan did not like us. Maybe it was my ponytail.
1975: Got a job in a local ER. Cool, but I don't know squat. Heard about this pseudoresidency at Medical College of Pennsylvania in emergency medicine. MCP used to be called Women's Medical College, but it went bankrupt; maybe that's where emergency medicine is headed, but I will check it out. They don't even need me to fill out a formal application, just show up July 1. This emergency medicine stuff is a lot different from internal medicine.
Met a doc named Dave Wagner and this guy George Schwartz, pretty smart guys. They think full-time ER just might work. Think I will do that “residency.” My mother wants to know when I will be a real doctor; she really wants to see my office.
I started EM residency in July. Might be a mistake, but will give it a try. Best part is that you can wear scrubs to work every day, no tie. Got to love that.
A patient stopped breathing, so I intubated him, just like I saw them do on my anesthesia rotation. It's not that hard; just put the tube into that little hole with those two white cords at the beginning. The head of anesthesia was furious and complained to Dr. Wagner. She said she would personally testify against me in court if I ever intubated again. That was the job of anesthesia, and I should call the nurse anesthetist. Dr. Wagner just laughed and told me to keep up the good work. I've got to be insane to put up with this garbage. Glad I can commiserate with a few other crazies out there.
The head of medicine said I was crazy: “Why don't you quit this ER nonsense and do a medicine residency?” Didn't like that guy. He actually told me that pulmonary edema should be treated only in the MICU; just call his resident and he would treat the patient the right way. Guess Lasix doesn't work in the ER, only the ICU. I did call that medicine resident, but I knew more than he did, and it took him an hour to call back.
Couldn't get the surgery resident to do anything for that guy with the icepick wound to the chest; he thought the hypotension was vagal. I did a pericardiocentesis when he left and got 50 cc of nonclotting blood and his blood pressure went up. The surgery attending did not know how to respond. What's an ER doc anyway? Never heard of such nonsense, but he took the patient to the OR to repair hole in the heart. Dr. Wagner just smiled.
Went to this meeting in Washington and met about 50 other docs who also thought this ER thing might take off. Called themselves the American College of Emergency Physicians. Met Ron Krome, John Wiegenstein, George Podgorny, Carl Mangold, Harris Graves, Gail Anderson, and Peter Rosen, all smart guys. They actually think they can get board certification. Talking about a real board exam. Fat chance. They've got to be nuts.
1976: Started going to East Lansing, MI, of all places, for meetings of the American Board of Emergency Medicine. The test being developed actually asked important stuff, nice idea, but EM will never fly, especially because the surgeons still hate us. Met Joe Waeckerle who started a residency group called EMRA with me, probably won't go anywhere. After all, only about 30 residents in the entire country, and I know most of them. We're a weird bunch.
1977: Did some dog studies on endotracheal epinephrine with a guy named Mike Greenberg. It actually works; surprised nobody ever thought of it before. I knew those cardiologists had no clue about life in the ER, but I doubt if the American Heart Association will ever buy this concept.
Started working on this publication called Emergency Medicine News; met Jerris Hedges, another smart guy. We agreed that no standard textbook helps us in the ER, those guys just don't get it, might as well write our own, maybe concentrate on procedures. Started to read my first EM journal; can this specialty possibly take off? Worked with Steve Davidson, Brent King, Al Sacchetti, all such smart guys. I need to hit the books to keep up, but no good books out there that actually tell you what to do in an emergency.
1978: Went to a Society for Academic Emergency Medicine meeting, not many docs there, held in a Holiday Inn. The internists hold their meetings at the Marriott and all wear nice suits, even to work. Nice try, EM guys, better luck next time. Some of them seem as nuts as I am.
1979: The ABMS actually voted to accept emergency medicine as the newest specialty. Surgeons still hate us. Too bad, guys, get with the program. Thanks to Ben Munger, et al. I am actually intubating all ER patients now, still get grief with central lines and chest tubes. Head of anesthesia left, and we finally got succinylcholine in the ER.
Moved to University of New Mexico, same old hassles, glad Dennis Price, Dan Tandberg, and George Schwartz are there to give moral support. Might hire this guy Dave Sklar. Tried to start a residency, but no way. Guess 12 residencies in the country are enough. Met Tom Mayer, Ann Harwood, Harvey Meislin, Shelly Jacobson, Jon Glauser. They do the same stuff in other parts of the country.
1983: Heard about Lewis Goldfrank in New York. He is a legend in emergency medicine who has a fellowship in toxicology. Sounds like the same problems emergency medicine had to deal with; think I'll give it a try. Met Neal Flomenbaum, another smart guy. Had a moonlighting job in New Jersey where I put in a pacemaker on a patient with an acute MI in heart block, and I was asked to leave the medical staff by an irate cardiologist who could not be reached to put in the pacemaker. Seems like we should not tolerate waiting for prima donna consultants who do stuff I can easily do myself.
Somehow stayed on the medical staff. Same problems from an orthopod when I reduced a dislocated shoulder. Hey, guys, it's really not that hard, and you don't own the procedures. I better get cracking on that procedures book.
1985: Finished tox fellowship, feeling good. Heard that University of Cincinnati has an EM program and needed faculty. Met Richard Levy, Steve Dronen, Jerris Hedges again...that guy has potential. Mel Otten, Bill Barsan...all a whole lot smarter than I am, and those residents were awesome, like Mike Spadafora, Leslie Wolf, John Molnar, Scott Syverud, Carl Chudnofsky, Steve Huff, Brian Zink, Michelle Biros, Brian Gibler, Susan Stone, Sue Gin-Shaw, Rashmi Kothari, and a bunch more whose names escape me. I think these guys will be famous someday. Was asked to write regularly for Emergency Medicine News, a way to get something disseminated without waiting six months for a journal to respond. Started a column called InFocus where I get to pontificate.
1986:EMN had the first article in the literature about this weird immune deficiency syndrome, bad infections, Kaposi sarcoma, probably won't ever amount to much. I know I will never see it in the ER.
Met Louis Ling, Brooks Bock, John Gallagher, Joe Clinton, Mike Tomlanovich, Ernest Ruiz, Mike Callaham, Ellen Taliaferro, Dave Talan, Ken Iserson, Richard Braen, Bob Knopp, Blaine White, Tom Stair, Mark Smith, Bob Hockberger, Bob Schneider, Dan Danzl, and Kathy Delaney while giving the oral board exam. Getting harder to know everybody in EM, growing fast, some of the best medical students applying. These guys are really smart; hope they don't make me look bad.
The SAEM and ACEP meetings are getting bigger, no longer held at Holiday Inns. EMN writing about smoking cocaine, called crack. That will never catch on, trust me.
1987: Asked to resign by the chair of medicine in Cincinnati because I actually gave antibiotics to a septic patient before the medicine resident saw him. What nerve! But they were the correct antibiotics...still a long way to go. Asked to resign by pulmonary doc because I saw a patient in the ICU with carbon monoxide poisoning, and took him to another hospital for hyperbaric oxygen treatment. More residencies opening up, some getting full department status.
Got a call from Rick Bukata, might give a few talks, something about EM abstracts. Involved with Jerry Hoffman, Greg Henry, Neal Little, Mike Heller, Jim Ducharme, Peter Viccellio, Ron Walls, all clearly smarter than I am.
1989: Back to Philadelphia. The residency has grown to 36 residents, can't possibly get bigger. Most of the old problems solved; getting almost impossible for me to do nights anymore. Dr. Wagner still working more shifts than I am. My textbook on procedures is in its second edition; some great contributors who really know their stuff. Started my own toxicology fellowship, graduating Dave Cone, Dave Lee, Suzanne Doyon, Chris King, Sue Farrell.
1995: These residents take intubating, chest tubes, central lines, pacemakers, and conscious sedation for granted. They don't realize how hard we worked to get them to this point. Must be getting old; definitely can't do nights anymore. Met a whiz named Billy Mallon. Also Diane Birnbaumer, Peter Sokolove, Rita Cydulka, John Marx, Jeff Runge. I hear Johns Hopkins, Harvard, and the University of Pennsylvania—Ivy League schools—are actually starting emergency medicine residencies. Who would have thought that would ever come to pass? Bob McNamara and Howard Blumstein started the American Academy of Emergency Medicine. They have to be crazy if they think they can change ACEP.
1998: These ACEP and SAEM meetings sure are getting bigger, so many smart people, very intimidating research, where do they find the time and energy? Bob Hoffman sure is smart. EM residencies up to 50, and the applicants actually wear suits for interviews, not like the old days. The residents sure are smart these days, a lot smarter than I was. Anthony Dean and Tom Costantino think they can do ultrasound at the bedside. Ed Sloan and Andy Jagoda started the Foundation for Education and Research in Neurological Emergencies, another niche for emergency medicine.
2000: Wish I could give a talk like Tim Erickson, or knew as much tox-related music as Leon Gussow, or work a PDA phone like Rich Hamilton. Do I really have to learn PowerPoint? I just mastered email.
2001: Lots of new names showing up, impressive bunch, Rick Bukata, Billy Mallon, and Mel Herbert still whizzes at meetings. These guys are real stars, as are Knox Todd, Ed Newton, Judd Hollander, Sarah Stahmer, Cathy Custalow, Arjun Chanmugam, and Jeanmarie Perrone. How are they so productive? Residents now are very competitive. Med students suck up on rotation to get a good letter from the old fox; nice homage, but I'm onto them. But they all know PowerPoint and can work a Palm. They think EM is a cool specialty; they will never understand what it took to get here. If my mother could only see me now. Now I really do have an office. My medical school advisor was right: “You've got to be a bit nuts to do this ER thing.”
2002: Just finished a bedside ultrasound course. Doubt if this procedure will ever be done in the ED, but somehow we got it past radiology and even convinced administration to buy the machines. The residents, of course, take it for granted. Malpractice, crowding, countless meaningless meetings, lack of resources, money issues, no time for reading, research, or teaching. But at least the surgeons, internists, and anesthesiologists are off my back. They actually think we do just fine, especially Saturday at 2 a.m.
The medical staff knows how hard this is. Getting less second-guessing and criticism. We actually tell them who to admit. They are probably happy to stay in bed, and they know their patients are being well cared for and that we can actually teach their residents. Took a long time. The residents make us all look good. Finally realized how hard it is to do full-time emergency medicine when you are older. My medical school advisor is still right; you've got to be a bit crazy to do this ER thing. But I was wrong, it did take off.
2022: Emergency medicine has changed dramatically since 2002. It is now one of the most popular residencies, and emergency physicians are involved in many activities outside the run-of-the-mill ED patient visit.
I was wrong about cocaine; crack became tremendously popular and devastating to many who used it. Opioids began to wreak havoc on the population in the 2000s, and the organizations that earlier made pain a vital sign and advocated for aggressive use of opioids now criticized physicians who prescribed them, even for severe pain. Heroin was displaced on the street by fentanyl around 2015, and now it is difficult to find pure heroin.
Hospital labs finally started to test for fentanyl around 2020, but many variations are available to drug dealers. I was also wrong about HIV; it is omnipresent and something we see daily in the ED, but new drugs are now effective. Emergency physicians are now involved in buprenorphine treatment for opioid addiction, diagnosing and treating excited delirium, and using ultrasound, now a basic ED technique.
EM education is booming, and the quality of conferences is astonishing, thanks to emergency physicians like Richard Bukata and Mel Herbert. The number of stellar physicians involved in EM education is overwhelming. To name just a few who have impressed me and make me feel totally inadequate: Christopher Carpenter, Ilene Claudius, Stephen Colucciello, David Glaser, Jessica Mason, Ken Milne, Richard Pescatore, Jan Shoenberger, Michael Hayoun, Maria Raven, Christopher Colwell, Richard Shih, Peter DeBlieux, Michael Winters, Michael Callaham, Corey Slovis, Amal Mattu, Todd Thomsen, Stuart Swadron, and hundreds more.
Dr. Robertsis a professor of emergency medicine and toxicology at the Drexel University College of Medicine in Philadelphia. Read his past columns athttp://bit.ly/EMN-InFocus.
